College of Nursing PhD Program 99 Jonathan Lucas Street/Room 215 MSC 160 Charleston, SC 29425-- 1600 Tel 843 792 3815 Fax 843 792 9258 AACN Award for Outstanding Doctoral Dissertation Catherine Cox, AACN Faculty Programs Director October 10, 2013 Dear Ms. Cox and Award Selection Committee Members, On behalf of the Medical University of South Carolina (MUSC) College of Nursing, I enthusiastically nominate Shannon Hudson, PhD, RN, CCRN for the 2014 American Association of Colleges of Nursing (AACN) Award for Outstanding Doctoral Dissertation. Dr. Hudson was a BSN to PhD student at the Medical University of South Carolina (MUSC) College of Nursing with a background in pediatric critical care nursing. She successfully defended her dissertation entitled Risk and Protective Factors for Hospital Admissions and Emergency Department Visits among Children with Complex Chronic Conditions in February 2013. She conducted the dissertation under the advisement of her mentor, Marilyn Laken PhD, RN, FAAN and a committee comprised of four additional experts in areas essential to successful completion of the dissertation. The South Carolina Nurses Foundation Nursing Capacity Initiative Stipend funded Dr. Hudson s doctoral studies and her dissertation was supported by a Sigma Theta Tau Gamma Omicron at-large Chapter research grant. Purpose The purpose of this dissertation was to explore the factors associated with hospital admissions and emergency department (ED) visits among infants and young children up to 4 years of age with complex chronic conditions, a population that typically has high rates of utilization. An integrative literature review was conducted to identify how previous studies examined hospital readmissions and repeat ED visits and to expose gaps in the published literature. Methods Convergent parallel mixed methods design was used, which promoted a more comprehensive understanding of the risk and protective factors associated with hospital admissions and ED visits. Social ecological theory and the risk and protective factors model were the theoretical frameworks for the study. The qualitative and the quantitative phases of the study were conducted concurrently. 1
For the qualitative phase, interviews with 13 parents/primary caregivers of 8 children and 3 focus groups with a total of 24 health care providers were conducted. A qualitative descriptive approach guided the interviews and focus groups, which were audio recorded and transcribed verbatim. Directed content analysis was conducted using an ecological risk and protective factors model as the framework for analysis. Data from interviews and focus groups were arranged into ecological themes using NVivo9; the themes were refined as analysis progressed. Similarities and differences between parents/caregivers and health care providers perceptions were noted. The quantitative phase of the study was conducted using descriptive retrospective cohort design with medical record review. Over 1000 electronic medical records of children with at least one ICD9 code for a complex chronic condition were hand-searched to identify medical records for children meeting the inclusion criteria. Data from the sample of records (n = 216) were entered into a REDCap database and exported to SPSS for analysis. Descriptive statistics were calculated. Stepwise multiple regression analyses with backwards deletion were conducted to identify the demographic and clinical factors associated with measures of hospital admissions and ED visits (number of occurrences, days between occurrences, length of stay). Findings After individual qualitative and quantitative analyses were complete, findings from quantitative linear regression modeling and qualitative directed content analysis were merged using a side-byside comparison to determine convergence and divergence and to create a comprehensive risk profile. The main outcome of the dissertation was a comprehensive risk and protective factors model for hospital admissions and ED visits among children with complex chronic conditions. The mean number of hospital admissions and/or ED visits following the index hospitalization was 2.8, the mean number of days between the index hospitalization and the first subsequent admission or ED visit was 112.1 days, and the mean index admission LOS was 27.2 days. During interviews, parents and caregivers reported using multiple hospitals and EDs, which indicated these figures were an underestimation of true utilization. Key risk factors identified were: conditions with greater complexity, younger age, a greater number of siblings, lacking resources such as transportation, telephone access, and income, having public insurance or self-pay status, ineffective parent-provider communication, and lacking community resources. Having a greater number of siblings, for example, resulted in more communicable diseases leading to increased hospital and ED use. This is a new finding and one amenable to an intervention. Key protective factors identified included: parents ever-growing knowledge and experience, parents vigilance over the child, family member support, open parent-provider communication, strong parentprovider relationships, and community support. Rural residence was also identified as a risk factor since findings suggested rural disparities in access to primary and outpatient care. Implications The risk and protective factors model that resulted from the dissertation study can inform current nursing practice, but more importantly, has implications for future work. Research questions and areas for further exploration stemmed from the dissertation and included questions pertaining to patterns of utilization among this population, barriers to care coordination and continuity of care encountered by parents and health care providers, and system-wide challenges to efficient health 2
care access and utilization. The dissertation may lead to the development of a care coordination intervention. Care coordination has historically been a nursing function and is currently an area of great interest to policy-makers, providers, and patients. An understanding of the patterns of utilization, decision-making processes, and barriers and resources encountered by patients and families is essential to creating an evidence-based care coordination intervention that can be disseminated, implemented, and sustained. Prospective studies are needed to confirm the hypothesized risk and protective factors, and studies with larger samples and wider age ranges are needed to improve the generalizability of the findings. Future studies should also incorporate a wider perspective of health care utilization including other hospitals/eds, primary care, and outpatient services. Finally, interventions should be designed or refined to minimize the effect of risk factors and strengthen the impact of protective factors on hospital/ed utilization among children with CCC. Findings from this dissertation are significant for nurses and other health care providers because they allow for a more complete understanding of the issues faced by children with CCC and their families necessary to take steps to decrease rates of hospital/ed utilization. Dr. Hudson gained expertise not only in using a mixed methods research design, but also in research-related activities throughout the dissertation. She obtained IRB approval from MUSC and McLeod Health, the study site. She sought resources available through the South Carolina Translational Research Institute, including guidance with submitting an electronic IRB application and using REDCap, a web-based system for creating and maintaining surveys and databases. She recruited participants, collected quantitative and qualitative data, and analyzed the data with the support of her dissertation committee. Dr. Hudson s dissertation work is consistent with the Mission of the AACN by serving public interest. She is working to help set the standard for ethically conducting research with vulnerable children. Dissemination of her work related to risk and protective factors for children with complex problems demonstrated her leadership capacity to advance nursing research, change practice, and inform policy. I believe Dr. Hudson is an excellent candidate for the 2014 American Association of Colleges of Nursing (AACN) Award for Outstanding Doctoral Dissertation. Her enthusiasm for teaching and building workforce competency for this vulnerable population is contagious. I believe that her work has the potential to make a significant difference in how we manage mealtimes for PWD and I fully support her nomination. Nominator Contact Information: Gail Gilden, ScD, RN Director of PhD Program Associate Professor Medical University of South Carolina, College of Nursing 99 Jonathan Lucas Street, MSC 160, Charleston, SC 29425-1600 (F) 843.792.9258 barbosag@musc.edu 3
Personal Statement The dissertation study arose from my observations as a pediatric critical care nurse when I noticed that certain populations of children with complex chronic conditions had frequent hospital readmissions and emergency department (ED) visits. I sought to better understand the factors underlying these admissions and ED visits and conducted an integrative literature review to explore published studies on hospital readmissions and ED visits among children with complex chronic conditions. The purpose of the integrative review was to identify gaps in the literature and implications for nursing practice. I designed a dissertation study to address the gaps in the literature and to develop a comprehensive understanding of the factors associated with hospital readmissions and ED visits by using mixed methods analysis in a regional hospital serving rural- and urban-dwelling populations. The dissertation was composed of five manuscripts: the integrative review, a report of the quantitative phase of the study, a report of the qualitative phase of the study, a report of the merged quantitative and qualitative findings, and a report of a sub-study examining rural residence as a potential risk factor. Of these manuscripts, the integrative review was published in the Journal of Pediatric Nursing in July 2013, the qualitative manuscript is in press in Issues in Comprehensive Pediatric Nursing, the quantitative and mixed methods manuscripts will be submitted for publication by the end of October, 2013, and the rural residence manuscript will be revised and submitted for publication by the end of November 2013. I will also be presenting the findings of the dissertation in a poster presentation at a regional conference on October 12, 2013. One of my long-term goals is to develop an intervention that can be widely disseminated to improve systems of care for children with complex chronic conditions, which will include working toward any necessary policy changes that may arise. It will be essential that I achieve many shorter-term goals leading to the long-term goal. First, I will collect additional pilot data to better understand patterns of health care utilization among infants and children with complex chronic conditions and parents decision-making processes contributing to these patterns of utilization. In September 2013, as the Co-PI with an interprofessional team, I submitted an intramural grant proposal to collect this additional pilot data. Second, I will conduct additional pilot work to map out primary, secondary, and tertiary care utilization among children with complex chronic conditions and will identify areas with the greatest likelihood for discontinuity of care and in greatest need of intervention. Third, building on my dissertation work, I will gather additional data on the protective factors that may mediate or moderate the effect of risk factors on the outcomes. I believe I can develop an intervention that will lead to improved systems of care for children with complex chronic conditions and better health outcomes through a combined understanding of protective factors and knowledge of the vulnerable points in the health care system. Additional contributory work in the area may include testing the risk and protective model and developing a tool for providers to facilitate identification of children with complex chronic conditions at risk for frequent hospital admissions and ED visits. 4
Shannon M. Hudson, PhD, RN, CCRN 99 Jonathan Lucas St. Charleston, SC, 29425 843-792-9379 hudsonsm@musc.edu Education Doctor of Philosophy in Nursing, Medical University of South Carolina, 2007-2013 Bachelor of Science in Nursing, Magna Cum Laude, University of North Florida, 1997-1999 Associate of Arts, Magna Cum Laude, St. Johns River Community College, 1994-1997 Professional Experience Instructor, 2013- present Medical University of South Carolina College of Nursing, Charleston, SC Quality Improvement Professional (QIPro), 2012-present Care Coordination Institute, Greenville Hospital System, Greenville, SC Advanced Cardiovascular Life Support Course Director, 2012-2013 McLeod Regional Medical Center, Florence, SC Educator, 2009-2010 Pee Dee AHEC, Florence, SC Clinical Instructor, 2006-2007 Francis Marion University, Florence, SC Pediatric Advanced Life Support Course Director, 2006-2013 McLeod Regional Medical Center, Florence, SC Staff Nurse, 1999-2013 McLeod Regional Medical Center, Florence, SC 5
Honors and Awards 2008 South Carolina Nurses Foundation Palmetto Gold Award for Nursing Excellence 2006 McLeod Regional Medical Center Unit Nurse of the Year for Pediatric Intensive Care Unit 2005 McLeod Regional Medical Center Unit Nurse of the Year for Pediatric Intensive Care Unit Grants 2012-2016 Centers for Disease Control and Prevention Community Transformation Grant 50% effort for quality improvement education, primary care systems of care education, and Healthcare Lean Six Sigma training (QIPRO) 2012 Sigma Theta Tau Gamma Omicron-at-Large New Investigator Award Dissertation Study: Risk and Protective Factors for Hospital Admissions and Emergency Department Visits among Children with Complex Chronic Conditions 2009-2012 South Carolina Nurses Foundation Nursing Capacity Initiative Grant Publications Hudson, S. M. (2013). Hospital readmissions and repeat emergency department visits among children with medical complexity: An integrative review. Journal of Pediatric Nursing, 28(4), 316-339. doi: 10.1016/j.pedn.2012.08.009 Hudson, S. M., Newman, S. D., Hester, W. H., Magwood, G. S., Mueller, M., & Laken, M. A. (2013). Factors influencing hospital admissions and emergency department visits among children with complex chronic conditions: A qualitative study of parents and providers perspectives. Issues in Comprehensive Pediatric Nursing. In press. Laken, M. A., & Hudson, S. M. (2013). Use of the PERT chart to improve efficiency of the dissertation. Manuscript submitted for publication. 6
Works in Progress Hudson, S. M., Laken, M. A., Magwood, G. S., Mueller, M., Newman, S. D., & Hester, W. H. (2013). A mixed methods analysis of the risk and protective factors for hospital admissions and emergency department visits among children with complex chronic conditions. Hudson, S. M., Magwood, G. S., Laken, M. A., Mueller, M., Newman, S. D., & Hester, W. H. (2013). The influence of rural versus urban residence on hospital admissions and emergency department visits among children with complex chronic conditions. Hudson, S. M., Mueller, M., Laken, M. A., Hester, W.H., Magwood, G. S., & Newman, S. D., (2013). At-risk characteristics for hospital admissions and ED visits. Presentations Hudson, S. M. & Watson, M. L. (2013, April). Missed follow-up visits among patients with TRH. Poster presented at 2013 OQUIN Community- Based Practice Research Network Symposium, Columbia, SC. Hudson, S. M. & Watson, M. L. (2013, April). Dissemination of survey results. Poster presented at 2013 OQUIN Community-Based Practice Research Network Symposium, Columbia, SC. Hudson, S. M. (2013, October). Using Lean Six Sigma as a practical method for identifying research opportunities. Sigma Theta Tau Pi Lambda and Beta Omicron Chapter 4th Annual Nursing Research and Evidence Based Practice Conference. Podium presentation at Augusta, GA. Hudson, S. M. (2013, October). Factors associated with hospital utilization among children with complex chronic conditions. Poster at Sigma Theta Tau Pi Lambda and Beta Omicron Chapters 4th Annual Nursing Research and Evidence Based Practice Conference, Augusta GA. Hudson, S. M. & Laken, M. A. (2013, October). The intersection between QI and research. Poster at Sigma Theta Tau Pi Lambda and Beta Omicron Chapters 4th Annual Nursing Research and Evidence Based Practice Conference, Augusta GA. 7
Hudson, S. M., Laken, M. A., Hester, W. H., Magwood, G. S., Mueller, M., & Newman, S. D. (2012, April). Children with complex chronic conditions: A formative study to support development of care coordination initiatives. Poster presented at the 2012 OQUIN Community-Based Practice Research Network Symposium, Columbia, SC. Bissinger, R. L., Harmon, E., & Hudson, S. M. The Role of Nursing in Quality Improvement and Practice-Based Research. 2012 OQUIN Community- Based Practice Research Network Symposium [Conference]. Columbia, SC. 14 April 2012. Panel Discussion. Hudson, S. M., & Laken, M. A. (2011, September). Physical activity in rural schools. Poster presented at the First Annual Medical University of South Carolina College of Nursing Student Research Day, Charleston, SC. Service and Involvement Medical University of South Carolina Faculty Senate, Senator for College of Nursing, October 2013-present Sigma Theta Tau Gamma Omicron at-large Chapter, Governance Council Member, October 2013- present American Heart Association, South Carolina Regional Faculty for Pediatric Advanced Life Support, 2010-2012 term; 2012-2014 term American Heart Association, South Carolina Regional Faculty for Basic Life Support, 2010-2012 term; 2012-2014 term South Carolina Public Health Association, member, 2012-present South Carolina Nurses Association and the American Nurses Association, member, 2011-present American Telemedicine Association, member, 2010- present Southern Nursing Research Society, member, 2009-present Sigma Theta Tau International, Gamma Omicron at-large Chapter, member, 2008-present American Association of Critical-Care Nurses, member, 2007-present 8
Licensure, Certifications, and Training Lean Six Sigma Green Belt Certification, July, 2013 Lean Six Sigma Green Belt Training, November, 2012 Lean Six Sigma Yellow Belt Certification, November, 2012 Lean Six Sigma Yellow Belt Training, August, 2012 Lean Six Sigma White Belt Training, July, 2012 American Association of Critical-Care Nurses Pediatric Critical Care Nursing Certification, December, 2007 American Heart Association Advanced Cardiovascular Life Support Instructor, December, 2009 American Heart Association Pediatric Advanced Life Support Instructor, May, 2004 American Heart Association Basic Life Support Instructor, December, 2002 Registered 9