The pediatric nurse as linking pin between pediatrics and youth health care: is it effective and efficient?

In their diagnosis and care for children Dutch pediatricians face a wide
variety of problems. Beside biological problems they face social- and
psychosocial problems. The type of complaints within these problems varies. The
Dutch Society of Pediatrics distinguishes six main groups:
1) Somatic diseases which give rise to psychosocial problems
2) Psychosocial problems that play a role in the development and cure of
diseases
3) Somatic complaints that hide psychical problems
4) Development problems
5) Threatening of safety and health due to parental functioning
6) Specific referral because of psychical and social problems
According to the literature the incidence of the entire group of complaints
varies between 6.3% (Central Bureau of Statistics) and 10% (Dutch Society of
Pediatrics).

Because of the above mentioned complaints pediatricians feel the need to a more
intensive collaboration with youth healthcare. This need has become even
stronger since the decentralization of youth healthcare. Moreover, the
pediatricians that are involved in the working method of this study, expect
that the incidence of the above mentioned complaints is higher than described
by the Central Bureau of Statistics and Dutch Society of pediatrics. This
expectation is based on their experience with this study group.
From studies into collaborations between youth healthcare and hospitals, we
distinguish a few cooperation forms. From 2014 on doctors working in youth
healthcare have the possibility to directly refer children to specialized care.
Also there are initiatives in which pediatricians and doctors working in youth
healthcare have agreements concerning the transfer of information of children
with health risks. In addition there are examples of joint thematic meetings,
which encourage informal acquaintance, knowledge exchange and alignment of
referral patterns. It is expected that such collaborations, if implemented
correctly, contribute to the quality of care for children. However, at current
these collaborations are still limited in nature and scale and scarcely aimed
at making psychological support available in pediatrics. Finally, from
literature studies it appears that the collaboration between youth healthcare
and pediatrics is slow and difficult. Sauer et al. Showed that youth healthcare
and pediatrics have drifted apart in the last decades. He therefore pleads for
a different, integral model for the organization of care for children in which
both youth healthcare and pediatrics collaborate in patientcare, education and
research.
The Amphia hospital (a hospital with establishments in Breda, Etten-Leur and
Oosterhout, the Netherlands) has started with an integrated model of care for
children with complaints in which social and psychosocial factors are involved.
In this model there is an intensive collaboration between pediatricians and
pediatric nurses. Since August 2015, pediatric nurses are seconded at the
pediatric outpatient clinic during one shift per week. They are in close
collaboration with children and their parents, pediatricians and other
professionals in the youth- and social domain. In this way they are the linking
pin between pediatrics and social domain.
The purpose of this working method is to accompany children with (psycho)social
problems to the best fitting support in a faster way than can be done according
the regular route. From the evaluation of a pilot study that was performed in
2016 there are indications that by the timely addition of the pediatric nurse
and the quick reference to the best fitting support, worsening of problems can
be prevented. The next step in the scientific foundation of this working method
is to study the effectivity in terms of children*s and parental satisfaction
with the intervention as well as the efficiency in terms of shortening the
throughput time to the best fitting support.

This study is aimed at optimizing the bridge between medical curative care and
care that comes from the social domain, for children and adolescents. The
primary goal is to offer the best fitting care to children with psychosocial-
and social problems by a direct collaboration between pediatric nurses and
pediatricians at the outpatient clinic. It is expected that by this
collaboration, the throughput time to the best fitting care can be shortened
and children and parents become more satisfied with the entire process. In
addition it is expected that this working method contributes to the reduction
in psychosocial- and social problems in children in the long-term. The
secondary goal of this study is to gather insight into the costs of the new
working method and the way this working method can be funded on a regular base.
In this study the goals will be evaluated comparing the added value of the new
working method at process- and effect level to *care as usual*. The evaluation
will be performed following the next research questions:
Primary questionnaires:
* Are parents/children from the intervention group more satisfied than
parents/children that received *care as usual*?
* What are the effects of the intervention (the new working method), in terms
of throughput time in comparison with *care as usual*?
Secondary questionnaires
* How do involved professionals experience the process (effectivity and
efficiency) of the new working method in comparison to *care as usual*?
* How and where can the intervention be improved?
* Is there (from the perspective of the professional and the parents/children a
difference in the development of problem severity in children that received the
intervention compared to children that received *care as usual*?
* Is there (from the perspective of the parents) a difference in the
development of parenting stress in families that received the intervention
compared to families that received *care as usual*?
* What are the considered costs from the intervention and how can this be
funded on a regular base?

As mentioned before this study is aimed at optimizing the bridge between
medical curative care and care that comes from the social domain, for children
aged 0-19 years. The primary goal is to offer fitting care to children with
social- and psychosocial problems by a direct collaboration between pediatric
nurses and pediatricians at the outpatient clinic. It is expected that by this
collaboration, the throughput time to the best fitting care can be shortened
and children and parents become more satisfied with the entire process. In
addition it is expected that this working method contributes to the reduction
in social- and psychosocial problems in children in the long-term.
Because of the relatively short duration of the study (2 years) it is yet not
possible to study the effectiveness of the ultimate goal, lowering problem
severity. However parental/children*s satisfaction with the new working method
is indicative for the eventual effectivity of the care received. Therefore one
the primary outcome measures of this study is parental/children*s satisfaction
with the new working method. The other primary outcome measure is the
throughput (the time between the reference by the pediatrician to the moment
the best fitting *follow-up* care) of the new working method compared to *care
as usual*.

This study is directed to demonstrate effects as well as to understand these
effects. The best fitting design to answer the research questions is a
randomized controlled trial (RCT).The argumentation for this is as follows:
We study an experimental intervention, the new working method in the Amphia
hospital. The intervention is performed with an experimental group
(intervention group) which is compared to a group that receives *care as
usual* (control group). To assure that by the start of the study there are no
(prognostic) differences between the groups which may influence the results,
the children will be randomly allocated to the intervention- or control group.
The pediatricians as well as the researchers cannot influence the randomization
process.
The content and execution of the study will be monitored by the researchers. In
this way it is possible to perform a process evaluation in parallel to the
effect evaluation. The process evaluation reveals insight in the question
whether the new working method works, whether this method shows unexpected
outcomes and how and where this method can be improved.

Intervention
The intervention consists of the procedure that started in 2015 at the Amphia
hospital, Breda, The Netherlands. In this procedure, pediatric nurses act as
the linking pin between pediatrics, Dutch youth healthcare and youth counselors
within the social domain.
Pediatric nurses are present at the outpatient clinic of the Amphia hospital
during one shift/week for the execution of the intervention. In addition as
part of the intervention, they have the availability to pay visits to other
locations (i.e. the clients home) during 1.5 day/week.
The procedure starts at the moment a child (and its parents) consults a
pediatrician. If it appears from the anamnesis by the pediatrician that the
child suffers from problems in which (psycho)social factors are involved, the
child can be considered for inclusion in the study. If so, the pediatrician
explains the study to the child and its parents, hands them over the research
information as well as an informed consent form. If so, the pediatrician
explains the study to the child and its parents, hands them over the research
information as well as an informed consent form. Once the informed consent form
is signed, the child is included in the study and allocated by randomization to
the intervention group, the child is referred to the pediatric nurse for
(psycho)social problems. The pediatric nurse contacts the family by telephone
within two weeks after the consultation with the pediatrician. In consultation
with the child and the parents an appointment is made at the parents* house or
at the outpatient clinic. During this consultation the pediatric nurse
clarifies the problem and together with the parents and the child she considers
which care fits best to the child. This procedure can take several
consultations. If necessary, the pediatric nurse connects the child to other
professional authorities in the field as for example the infant welfare center
(i.e. teaching in upbringing) or specialized youth assistance. When it becomes
clear that the family is able to go on by itself or when they are transferred
to another professional authority the pediatric nurse closes the contact after
a written feedback to the family, the pediatrician and (with parental consent)
the general practitioner and other professional parties involved. Three months
after closing down the contact with the pediatric nurse the child visits the
pediatrician for a control consultation. This consultation is not part of the
intervention, but necessary for the scientific study.
Whenever the child suffers from somatic problems which need attention of a
pediatrician, the pediatrician takes care of these problems.

*Care as usual*
For the control group the procedure starts with a consultation to the
pediatrician as well. If it appears from the anamnesis by the pediatrician that
the child suffers from problems in which (psycho)social factors are involved,
the child can be considered for inclusion in the study. If so, the pediatrician
explains the study to the child and its parents, hands them over the research
information as well as an informed consent form. Once the informed consent form
is signed, the child is included in the study and allocated by randomization to
the control group, the child is offered *care as usual*. In this study *care as
usual* implies that the parents/child get the advice to contact youth
healthcare or their general practitioner. Whenever the child suffers from
somatic problems which need attention of the pediatrician, the pediatrician
takes care of this. Six months after the consultation with the pediatrician
there is a control consultation with the pediatrician.

The study is non-invasive with respect to diagnostics and treatment. Medical
treatment will not be denied or postponed and it does not involve medical
risks. The study is an evaluation of a possibility to offer psychosocial care.
Nevertheless, whenever a child suffers from a serious adverse event (SAE), this
will be reported immediately to the employer A. van der Zijden, principal of
GGD West-Brabant, and to the pediatrician A.A.P.H. Vaessen-Verberne, Amphia
Hospital, Breda. The employer reports the SAE by the web portal
*Toetsingonline* to the METC Brabant within seven days after she has taken
knowledge of an SAE that resulted in the death or a life-threatening situation
of a child that is included in the study. This report will be followed by an
initial report within eight days. All other SAEs will be reported within a
period of a maximum of 15 days after the employer has taken knowledge of the
SAE. In case of a SAE that doesn*t need to be reported directly to the
employer, this SAE will be reported to the pediatrician A.A.P.H.
Vaessen-Verberne, Amphia hospital, Breda.*