Reconceptualizing children's complex discharge with health systems theory: novel integrative review with embedded expert consultation and theory development

AIM: To report a novel review to develop a health systems model of successful transition of children with complex healthcare needs from hospital to home. BACKGROUND: Children with complex healthcare needs commonly experience an expensive, ineffectual and prolonged nurse-led discharge process. Children gain no benefit from prolonged hospitalization and are exposed to significant harm. Research to enable intervention development and process evaluation across the entire health system is lacking.DESIGN:Novel mixed-method integrative review informed by health systems theory. DATA SOURCES: CINAHL, PsychInfo, EMBASE, PubMed, citation searching, personal contact. REVIEW METHODS:Informed by consultation with experts. English language studies, opinion/discussion papers reporting research, best practice and experiences of children, parents and healthcare professionals and purposively selected policies/guidelines from 2002-December 2012 were abstracted using Framework synthesis, followed by iterative theory development.RESULTS: Seven critical factors derived from thirty-four sources across five health system levels explained successful discharge (new programme theory). All seven factors are required in an integrated care pathway, with a dynamic communication loop to facilitate effective discharge (new programme logic). Current health system responses were frequently static and critical success factors were commonly absent, thereby explaining ineffectual discharge. CONCLUSION: The novel evidence-based model, which reconceptualizes 'discharge' as a highly complex longitudinal health system intervention, makes a significant contribution to global knowledge to drive practice development. Research is required to develop process and outcome measures at different time points in the discharge process and future trials are needed to determine the effectiveness of integrated health system discharge models.