Overnight Care Research Articles

Responding to concerns about a study of infant overnight care postseparation, with comments on consensus: Reply to Warshak (2014).

© 2015 American Psychological Association. Richard Warshak (2014) published a report in this journal (Vol. 20, No. 1) documenting a policy position on infants and overnight care following parental separation. He asserts that [t]here is no evidence to support postponing the introduction of regular and frequent involvement, including overnights, of both parents with their babies and toddlers (p. 60). To support this assertion, Warshak presents a series of detailed concerns about an Australian study the authors conducted, some of which involve serious misrepresentations of our aims, methodology, and findings. In this reply, we clarify the purpose, context, and limitations of our study, and refute one of Warshak's central theses: that our study's design and results favor primary maternal care of young children and discourage overnights and shared parenting for fathers. We appraise the Warshak article, and consider whether other approaches to consensus statements and to policy dialogue might better serve families involved in the family law system, particularly when emotive debates such as the overnight care of young children cannot yet be resolved by science.

Sleep deprivation in parents caring for children with complex needs at home: a mixed methods systematic review.

A significant number of children with a range of complex conditions and health care needs are being cared for by parents in the home environment. This mixed methods systematic review aimed to determine the amount of sleep obtained by these parents and the extent to which the child-related overnight health or care needs affected parental sleep experience and daily functioning. Summary statistics were not able to be determined due to the heterogeneity of included studies, but the common themes that emerged are that parents of children with complex needs experience sleep deprivation that can be both relentless and draining and affects the parents themselves and their relationships. The degree of sleep deprivation varies by diagnosis, but a key contributing factor is the need for parents to be vigilant at night. Of particular importance to health care professionals is the inadequate overnight support provided to parents of children with complex needs, potentially placing these parents at risk of poorer health outcomes associated with sleep deprivation and disturbance. This needs to be addressed to enable parents to remain well and continue to provide the care that their child and family require.

Will Rest for the Weary Wear Everybody Out?

Will Rest for the Weary Wear Everybody Out?

Parental Separation and Overnight Care of Young Children, Part I: Consensus Through Theoretical and Empirical Integration

The AFCC Think Tank on Research, Policy, Practice, and Shared Parenting was convened in response to an identified need for a progression of thinking in the family law field, removed from the current polarizing debates surrounding the postseparation care of infants and very young children. We share this goal as our research and commentaries have been centrally implicated in the current controversies. Our collaboration over this empirical paper and its clinical counterpart endorses the need for higher‐order thinking, away from dichotomous arguments, to more inclusive solutions grounded in an integrated psycho‐developmental perspective. We first critically appraise the theoretical and empirical origins of current controversies relevant to attachment and parental involvement research. We then describe how attachment and parental involvement contribute complementary perspectives that, taken together, provide a sound basis from which to understand the needs of very young children in separated families. As a companion piece, Part II offers a collective view of a way forward for decision making about overnights for infants and young children, toward the integration of theoretical and empirical with clinical wisdom. Key Points for the Family Court Community: An integrative perspective suggests that the goals of attachment and early parental (typically paternal) involvement with very young children after separation are mutually attainable and mutually reinforcing rather than exclusive choices. An optimal goal for the family is a “triadic secure base” developed through a co‐parenting environment that supports the child's secure attachment with each parent and the recognition by each parent of the other's importance to the child. Cautions against overnight care during the first three years are not supported. The limited available research substantiates some caution about higher frequency overnight schedules with young children, particularly when the child's relationship with a second parent has not been established and/or parents are in frequent conflict to which the child is exposed.

Parental Separation and Overnight Care of Young Children, Part II: Putting Theory into Practice

This article is a companion piece to the empirical and theoretical perspectives on infant overnight care arrangements offered in Part I. Grounded in an integrated psycho‐developmental perspective, the paper provides a set of clinical assumptions and a related chart of practical considerations, to guide decision making about infant overnight care, both in the individual case and in broader policy contexts. At all levels of decision making, we endorse the need for developmentally sensitive resolutions that protect both the vulnerabilities of early childhood and support lifelong parent–child relationships, whenever possible. Key Points for the Family Court Community: Parenting orders or plans for children 0–3 years of age should foster both developmental security and the health of each parent–child relationship, now and into the future. From a position of theoretical and empirical consensus, we provide an integrated set of assumptions and considerations to guide decision making about overnight parenting plans. These considerations apply equally to planning in the individual case and to policy level decisions.

Overnight care patterns following parental separation: Associations with emotion regulation in infants and young children

Children living in a shared-time parenting arrangement following separation (also known as joint physical custody or dual residence) spend equal or near-equal amounts of day and night time with each parent. Little data exist regarding developmental sequelae of such arrangements for infants. The current study examined a theoretically driven question: Are there associations between quantum of overnight stays away from a primary resident parent and the infant’s settledness, or emotion regulation with that parent? Nationally representative parent report data from the Longitudinal Study of Australian Children (LSAC) were used Three age bands were studied and three level of overnight care contrasted. When parenting style, parental conflict and socio-economic factors were controlled for, greater number of shared overnight stays for the 0–1 year old and the 2–3 year old groups predicted some less settled and poorly regulated behaviours, but none for the 4–5 year old group. Limits of these data are discussed, including application to the individual case. Findings suggest emotional regulation within the primary infant-parent relationship is one useful index of infant adjustment to parenting time arrangements.

Effectiveness of written hospitalist sign‐outs in answering overnight inquiries

Hospitalists are key providers of care to medical inpatients, and sign-out is an integral part of providing safe, high-quality inpatient care. There is little known about hospitalist-to-hospitalist sign-out. To evaluate the quality of hospitalist/physician-extender sign-outs by assessing how well the sign-out prepares the night team for overnight events and to determine attributes of effective sign-out. Analysis of a written-only sign-out protocol on a nonteaching hospitalist service using prospective data collected by an attending physician survey during overnight shifts. Yale-New Haven Hospital, a 966-bed, urban, academic medical center in New Haven, Connecticut with approximately 13,700 hospitalist discharges annually. We recorded 124 inquiries about 96 patients during 6 days of data collection in 2012. Hospitalists referenced the sign-out for 89 (74%) inquiries, and the sign-out was considered sufficient in isolation to respond to 27 (30%) of these inquiries. Hospitalists physically saw the patient for 14 (12%) of inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]), and clinical changes (26 [21%]). Ninety-five (77%) inquiries were considered to be "somewhat" or "very" clinically important by the hospitalist. Overall, we found that attending hospitalists rely heavily on written sign-out to address overnight inquiries, but that those sign-outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign-out is needed to help improve the safety of overnight care.

P1-237 Post-separation parenting arrangements: patterns and developmental outcomes

IntroductionChanges in family law in many countries have preceded research addressing the developmental impacts of different patterns of parenting after separation. We use data from the Longitudinal Study of Australian...

Sleeping at Home: A New Model for a Hospital Teaching Service

The traditional marriage between teaching hospitals and residents pivots on a central prenuptial agreement: residents offer their hospitals round-the-clock patient care, and, in exchange, hospitals provide an experiential learning modality. This long-held covenant may require an update due to 3 significant changes: the increased spotlight on protecting resident education from excessive service demands; the development of hospital medicine as a specialty; and the need to provide more experiential learning in ambulatory care settings for primary care programs, including family medicine. The rapid growth of hospitalist care—84% of all teaching hospitals in the United States have at least 3 hospitalists1—has been sparked in part by pressure placed on primary care doctors to increase outpatient visits and on hospitals to reduce length of stay.2 The desire to have better work/life balance coupled with fewer inpatient admissions and increased financial demands have resulted in a decline in family medicine physicians who provide both inpatient and outpatient care. Many hospitals are moving to hospitalist care, citing improved care and decreased cost.,3,4 In 2006, the year before we implemented our new model of inpatient teaching, 62.5% of our program's new graduates entered into practice without an inpatient component. We describe a unique adult inpatient teaching service in a family medicine residency program that integrates resident teaching with hospitalist care. The novelty stems from the use of hospitalists, not residents, as the primary workforce in the hospital. By uncoupling the educational experience of teaching residents how to care for hospitalized patients from the service demands of the hospital, it is possible to achieve both of these goals and comply with duty hour limits. The added advantage of our system is that residents are able to spend more time in the outpatient setting. This gain in ambulatory training aligns with most of our residents' postgraduation plans to work as primary care physicians in the outpatient setting.

The Impact of an Early-Morning Radiologist Work Shift on the Timeliness of Communicating Urgent Imaging Findings on Portable Chest Radiography

The aim of this study was to assess the potential impact of staggered radiologist work shifts on the timeliness of communicating urgent imaging findings that are detected on portable overnight chest radiography of hospitalized patients. The authors conducted a retrospective study that compared the interval between the acquisition and communication of urgent findings on portable overnight critical care chest radiography detected by an early-morning shift for radiologists (3 am to 11 am) with historical experience with a standard daytime shift (8 am to 5 pm) in the detection and communication of urgent findings in a similar patient population a year earlier. During a 4-month period, 6,448 portable chest radiographic studies were interpreted on the early-morning radiologist shift. Urgent findings requiring immediate communication were detected in 308 (4.8%) studies. The early-morning shift of radiologists, on average, communicated these findings 2 hours earlier compared with the historical control group (P < .001). Staggered radiologist work shifts that include an early-morning shift can improve the timeliness of reporting urgent findings on overnight portable chest radiography of hospitalized patients.

Carers' Experiences with Overnight Respite Care. A Qualitative Study

Aim The aim of this study was to explore experiences with overnight respite care (ORC) of Norwegian carers who provided care to frail elderly awaiting nursing home placement.Background In many Western countries respite care has become part of health care service provision, and various types of respite care are available. The intent with respite care can be twofold; caring for the care receiver and supporting the carer.Methods This was a descriptive qualitative study. Interviews were conducted with 15 carers, transcribed and analysed by qualitative content analysis.Findings The carers described various experiences with ORC. If ORC supported the family unit, it was welcomed by carers and experienced as supportive. If ORC did not support the family unit, many carers rejected ORC, and it was experienced as non-supportive. Two categories were constructed: 'experiencing ORC as supportive for the family as a unit' and 'not experiencing ORC as supportive for the family as a unit'.Conclusion To support more carers, nurses have to listen to carers’ experiences about ORC. Nurses need to take responsibility for the family as a unit and provide more flexible ORC services based on both carers’ and elderly’s needs.

Practices and Provisions for Parents Sleeping Overnight with a Hospitalized Child

To describe practices affecting parents' overnight stays, provisions for parents sleeping overnight and parents' involvement in overnight care of their hospitalized child. A cross-sectional telephone survey of Canadian and American hospitals with more or equal to 50 acute pediatric beds and more or equal to two pediatric wards was conducted. Surveys were completed by 135 hospitals (77% response rate). All general pediatric units allowed parents to sleep at the bedside overnight; higher acuity units limited parental stays. The majority of hospitals limited overnight visitors at the bedside to one parent, and few hospitals routinely allowed siblings to sleep overnight. One hundred and thirty-three (99%) hospitals reported parental involvement in their child's care at night, with 52 (39%) stating this was an expectation. In general, parents are given the opportunity to stay at the bedside overnight, but barriers exist that limit opportunities for sleep during their child's hospitalization, and serve to separate families who have a hospitalized child.

Part-Time Fostering: Recruiting and Supporting Carers for Short-Break Schemes

Although most local authorities provide or commission home-based short-break services to support families with a disabled child, such schemes have been much slower to develop as a form of support for families where children are in need for reasons other than disability. June Statham and Margaret Greenfields draw on a study of barriers to the development of ‘support care’ schemes in England, focusing in particular on the motivation and experiences of those who undertake this part-time fostering work and the skills and support they require. Since childminders can now be registered to provide overnight care, and some already provide daytime care for children placed with them by social workers, the potential for childminders to expand their service into short-break care is also considered. The paper concludes that although local authorities have sometimes been reluctant to develop short-break schemes because they fear diverting potential carers from mainstream fostering, in practice such fears are not well founded. Support care schemes can offer a way for those who might be interested in fostering to ‘dip a toe’ in the water, as well as helping to retain existing foster carers who might otherwise leave the service. This kind of service also fits well with the current policy emphasis on early intervention to support children and families who are experiencing difficulties and on promoting flexibility in the social care workforce.

Using an anesthesia information management system (AIMS) for documentation in a day care unit for ambulatory surgery

From January 1997 until June 1999, the complete durations of stay of 3152 outpatients were entered into a computerized documentation system. The scope of the data entry went from patient admission to patient release. The objective was to determine the usefulness of the anaesthesia information management system (AIMS) in producing complete and high-quality documentation in the field of outpatient operations. Some aspects and results from routine work are presented here. The system was installed in eight bedside computers, in addition to a further client connected to the existing AIMS via Ethernet. Patient medical courses were documented both preoperatively and postoperatively in outpatient bedsides until their discharge or admission. The online documentation software NarkoData (Version 4, Imeso GmbH, Hüttenberg, Germany) was used to document and store patient data in a database. This program contains all relevant information concerning the course of anaesthesia and outpatient duration of stay, including application of drugs, vital signs, observation times, and medical findings as well as the data sets of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), ICD, and ICPM. Data was analyzed by exporting from the database into a statistical program using "structured query language." Data sets of 3152 outpatients were entered into the online documentation software. Most (54.2%) of the ambulatory surgical procedures were performed by the Department of Traumatology. General Surgery followed with 16.0%, and Urology managed 9.5% of the cases. The most frequent ambulatory surgical procedures were: diagnostic arthroscopy (923, 31.2%), removal of osteosynthetic material (410, 13.8%), and circumcision (250, 8.4%). Anesthesia procedures consisted of inhalative (38.6%, n = 1218) and intravenous anesthesia (IVA) (29.9%, n = 938). In 22.6% (713) of the cases, regional anaesthesia was performed. The average postoperative observation time was 289.2 +/- 140.1 minutes. One hundred sixty-nine patients (5.4%) were unexpectedly admitted to overnight care. The decision to admit patients to normal wards took place within the first 3 postoperative hours in 51.9% of the cases. The AIMS described above is sufficient in documenting the entire care process of patients in a day care unit. Integration into the existing AIMS was an important prerequisite for the integrity of the documentation chain. This allowed for a sensitive communication with other clinical data processing systems. The quality of documentation and flow of information at the workplaces in the day care unit were increased, similarly to other anaesthesiological workplaces in the hospital. Medical and administrative data and information for analyses of clinical processes are possible with such tools.

Matching short break services for children with learning disabilities to family needs and preferences.

Short breaks or respite care is a much-valued service by families and the demand for it is likely to exceed supply. It is all the more imperative that the services provided are matched to the needs and preferences of families. A census was undertaken within one Health and Social Services Board in Northern Ireland of families who received short break services for their child with disabilities during a 12-month period. Information was also collected on pertinent child and family characteristics. This enabled profiles to be drawn up of the recipients of six types of short-term breaks: (1) hospital-based overnight care; (2) overnight stays in a residential home; (3) domiciliary service in the family home; (4) breaks provided in another family home; (5) residential holidays; and (6) breaks provided through leisure schemes organized after-school or during holidays. A second study entailed interviews with families who were resident in one area served by a Health and Social Service Trust regarding their usage and preferences for each type of service noted above. This too identified variations in parental preferences and usage. This information gathered should assist commissioners in developing cost-beneficial short break services although further research is needed to validate the possible predictors for each service.

Standardized clinical care pathways for major thoracic cases reduce hospital costs

Background. Standardized clinical care pathways have been developed for postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this study was to assess the effect of these pathways on length of stay, hospital charges, and outcome for major thoracic surgical procedures. Methods. All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for length of stay, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Common to both pathways are early mobilization and prudent x-ray and laboratory analysis. In addition, the pathway for esophagectomies emphasizes overnight intubation with 24-hour intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is early postoperative extubation with overnight intensive care unit management. The discharge goal was postoperative day 7. Results. Group I esophagectomies (n = 56) had significantly greater hospital charges compared with group II (n = 96) ($21,977 ± $13,555 versus $17,919 ± $5,321; p < 0.04, in actual dollars) and ($29,097 ± $18,586 versus $19,260 ± $6,000; p < 0.001, in dollars adjusted for inflation) and greater length of stay (13.6 ± 6.9 versus 9.5 ± 2.8 days; p < 0.001). Group I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 ± 6.2 versus 6.4 ± 3.8 days; p < 0.002); although charges trended downward ($13,113 ± $10,711 versus $12,404 ± $7,189; not significant) in actual dollars, charges were significantly less in dollars adjusted for inflation ($17,103 ± $13,211 versus $13,432 ± $8,056; p < 0.01). The most significant decreases in charges for esophagectomies were in miscellaneous charges (61% in dollars adjusted for inflation), pharmaceuticals (60%), laboratory (42%) and radiologic (39%) tests, physical therapy charges (35%), and routine charges (34%). For lung resections the greatest savings occurred for pharmaceuticals (38%), supplies (34%), miscellaneous charges (25%), and routine charges (22%). Mortality was similar (esophagectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not significant). Conclusions. Introduction of standardized clinical pathways has resulted in a marked reduction of length of stay for all major thoracic surgical procedures. Total charges were reduced for both esophagectomies (34%) and lung resections (21%) with continued quality of outcome.

Anesthesia for carotid endarterectomy: a survey.

Indications for carotid endarterectomy (CEA) have been expanded recently, and a consensus statement has been made regarding these changes. However, the debate regarding the "ideal" anesthetic for CEA remains on-going. This study was designed to evaluate the actual anesthetic techniques used by anesthesiologists for CEA. A total of 426 1-page questionnaires were mailed to all current (1995) members of the Society of Neurosurgical Anesthesia and Critical Care (SNACC). Of these, 216 (50.7%) were completed and returned. The majority of these respondents (84.7%) administered general anesthesia (GA) for CEA. Regional anesthesia (RA) was the anesthetic method of choice for 16.7%, whereas 2.8% each chose either local anesthesia (LOC) or a combined regional/general (RA/GA) technique. Despite the controversial role of nitrous oxide in neuroanesthesia, 74.6% of those returning the survey use nitrous oxide during CEA. Intraoperative neuromonitoring use was reported by 90% of the respondents, with the electroencephalography (EEG) the favored modality (67.5%). Specific intraoperative neuroprotective measures were provided by only 22.2% of all respondents, with barbiturates as the favorite method (50.0%). The technique of intraoperative hypertension is practiced by a majority of those surveyed (61.1%), with the most common target blood pressures being either preoperative baseline or preoperative baseline plus 20%. Although there is some trend towards nonintensive care setting for postoperative care, the intensive care remains the location of choice for overnight care of CEA patients (71.8%). The results of this study show that despite arguments for RA over GA, the majority of anesthesiologists surveyed choose GA for CEA.

Day-Case Laparoscopy: Patient Preferences, Adjustment and Management

The psychological effects of shorter hospital stay for surgery is a neglected subject of multidisciplinary research. A study is presented which examines the relative impact of overnight or day-case care. Data are presented of 75 women undergoing minor gynaecological surgery (laparoscopy) who were randomly allocated to day-case care (n = 43) or to a 2-overnight stay condition (n = 32). They were interviewed 7 times before and after surgery including 1 and 6 weeks after the operation. The results show that day-case care is associated with more anxiety before the operation, but not more pain or anxiety after the operation. Day-case patients had faster recover and fewer complications while in hospital, but this was confounded by the finding that day-case patients were scheduled for surgery earlier in the day. Patients tended to prefer the type of care to which they had been allocated. Overnight stay cases stress the positive aspects of having a rest in hospital, but economic and social considerations did not appear to influence patients’ preferences. Twenty day-case patients over-stayed one night and these patients tended to have slightly later surgery than day-case patients who were discharged home immediately. They also had more complications and more analgesia. Patients who over-stayed had less previous experience of operations. Discussion is provided of the implications of the study for the preparation of patients for day-case admission.