Nurse-Led Discharge Education and Readmission Risk in Medically Complex Pediatric Patients

Introduction

Children with medical complexity, defined by the presence of serious chronic conditions affecting multiple organ systems, dependence on medical technology, and substantial functional limitations, represent a small proportion of pediatric inpatients but account for a disproportionate share of hospital days, costs, and unplanned readmissions (Berry et al., 2011; Cohen et al., 2011). Discharge from an inpatient stay marks a period of concentrated risk for this population, as caregivers assume responsibility for complex medication regimens, medical equipment, and symptom monitoring tasks that were previously managed by trained clinical staff (Coller et al., 2015).

Nurses are typically the clinicians most directly responsible for delivering discharge education and confirming caregiver understanding prior to a child’s transition home. Teach-back methodology, in which caregivers are asked to demonstrate or restate key information in their own words rather than simply acknowledging instructions, has been associated with improved retention and self-management confidence in general pediatric and adult populations (Kornburger et al., 2013; Peter et al., 2015). However, comparatively less prospective evidence has directly linked structured, nurse-led discharge education completion with subsequent readmission specifically among medically complex pediatric patients, or has identified which readiness domains and readmission reasons are most closely tied to gaps in discharge teaching within the same cohort.

Clarifying whether structured discharge education completion is associated with lower readmission risk, and identifying the readiness domains most strongly linked to early readmission, has direct implications for how pediatric nursing units prioritize discharge workflow redesign, staffing for discharge teaching, and standardization of teach-back practices. The purpose of this prospective cohort study was to examine the association between nurse-led discharge education bundle completion and 30-day unplanned readmission among medically complex pediatric patients, and to characterize the caregiver-reported readiness domains and readmission reasons most strongly associated with early return to hospital.

Methods

Design. This study used a prospective cohort design with caregiver enrollment at the time of inpatient discharge and structured telephone follow-up at 30 days post-discharge.

Setting and participants. Eligible participants were caregivers of children (age 0–17 years) meeting criteria for medical complexity, defined as dependence on a medical device (e.g., tracheostomy, gastrostomy tube, ventilator), a complex chronic condition affecting two or more organ systems, or a technology-dependent care plan, discharged from inpatient units of a tertiary pediatric hospital. Of 356 eligible discharges, 331 caregivers completed 30-day follow-up (93.0%), with enrollment occurring over a five-month period in 2024–2025.

Intervention and measures. Bedside nurses used a structured discharge education bundle incorporating teach-back methodology across five domains: medication management, equipment and device care, symptom recognition, follow-up coordination, and emergency action planning. Bundle completion was recorded as full (all five domains completed with documented teach-back confirmation) versus partial or none. Caregiver-reported discharge readiness was measured using the Readiness for Hospital Discharge Scale (RHDS), a validated instrument scored 0–10 per domain, administered at the time of discharge (adapted from Weiss & Piacentine, 2006; Weiss et al., 2008). The primary outcome, unplanned readmission within 30 days of discharge, was ascertained through hospital records and caregiver report at follow-up. Caregivers who experienced a readmission were asked to identify contributing factors from a fixed list with an open-text option, with the option to select more than one factor.

Statistical analysis. Mean RHDS domain scores were calculated and ranked. The difference in 30-day readmission rate between discharges with full versus partial/no bundle completion was examined using chi-square test. The association between full bundle completion and 30-day readmission was examined using multivariable logistic regression adjusting for number of chronic conditions, device dependence, and length of index admission, yielding an adjusted odds ratio. Contributing factors for readmission were summarized descriptively as the proportion of applicable respondents selecting each factor. A two-sided p value of less than .05 was considered statistically significant.

Results

Of 331 caregivers with complete follow-up (Table 1), 61.9% received a fully completed discharge education bundle with confirmed teach-back across all five domains. Mean caregiver-reported readiness scores by domain, ranked lowest to highest, are shown in Figure 1.

Comparing discharges with full versus partial or no bundle completion, full completion was associated with a substantially lower 30-day unplanned readmission rate, as shown in Figure 2.

Overall, 47 of 331 discharges (14.2%) resulted in an unplanned readmission within 30 days. Among these, the distribution of self-reported contributing factors is shown in Figure 3.

Discussion

In this prospective cohort of medically complex pediatric patients, full completion of a structured, nurse-led discharge education bundle incorporating teach-back was associated with a substantially lower 30-day unplanned readmission rate, and this association persisted after adjustment for chronic condition burden, device dependence, and length of index admission. This pattern is consistent with prior evidence linking teach-back-based discharge teaching to improved caregiver retention and self-management confidence, and extends that literature by directly connecting bundle completion to a readmission outcome within a medically complex pediatric cohort (Kornburger et al., 2013; Coller et al., 2015).

Caregiver-reported readiness scores were lowest in the symptom recognition and emergency action planning domains, and these same themes, delayed recognition of worsening symptoms and uncertainty about when to contact the care team versus present to the emergency department, were also the most frequently cited contributing factors among caregivers who experienced a readmission. The convergence of the lowest-scoring readiness domains with the most commonly cited readmission factors suggests that these two domains, rather than medication management or equipment care alone, may represent the most consequential gaps in current discharge teaching practice for this population (Berry et al., 2011; Desai et al., 2016).

Medication administration error or confusion was also commonly cited, despite medication management showing the highest mean readiness score among the five domains assessed. This apparent discrepancy may reflect that medication regimens for medically complex children are often more numerous and more frequently adjusted after discharge than other aspects of the care plan, such that even relatively strong baseline teaching may not fully anticipate the complexity caregivers encounter once home, an interpretation that warrants further prospective evaluation (Desai et al., 2016).

Several limitations should be considered. Bundle completion was documented by nursing staff and readiness was self-reported by caregivers, both of which may be subject to social desirability or recall bias, and the prospective cohort design, while stronger than a purely retrospective approach, does not eliminate the possibility that units or nurses with more complete discharge teaching also differed in other unmeasured ways associated with lower readmission risk. Readmission ascertainment relied on hospital records supplemented by caregiver report, which may not capture care sought at outside facilities not linked to the study hospital’s records. Finally, this study was conducted within a single tertiary pediatric hospital, and the relative weight of readiness domains and readmission contributing factors may differ in settings with different discharge staffing models or care coordination infrastructure.

Future research should evaluate targeted interventions addressing symptom recognition and emergency action planning specifically, such as structured symptom-based action plans or simulation-based caregiver training, using controlled or pre-post designs, and should incorporate objective readmission ascertainment across health systems to reduce the risk of missed out-of-network encounters. Extension of this approach to additional pediatric health systems with differing discharge workflows, and closer examination of the post-discharge medication adjustment period specifically, would help clarify which readiness gaps are broadly generalizable versus setting-specific. Taken together, these findings suggest that strengthening nurse-led teaching around symptom recognition and emergency action planning, alongside continued attention to medication management as regimens evolve after discharge, represents a priority target for reducing readmission risk among medically complex pediatric patients.

References

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