THE CARE-BY-PARENT UNIT

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(Received July 15; revision accepted October 26, 1967.)

Supported in Part by Grant H160, the Children’s Bureau, Department of Health, Education and Welfare.

ADDRESS: Department of Pediatrics, University of Kentucky Medical Center, Lexington, Kentucky 40506. PEm.riucs, Vol. 43, No. 4, Part I, April 1969 488

ARTICLES

THE

CARE-BY-PARENT

UNIT

Vernon L. James, Jr., M.D., and Warren E. Wheeler, M.D.

Department of Pediatrics, University of Kentucky Medical Center, Lexington, Kentucky

ABSTRACT. A preliminary report was made of 2

years’ experience with hospitalization of children in the Care-By-Parent Unit. A surprising number of mothers can, with supervision, take complete care of their ill children in an area of the hospital de-signed for this, releasing registered nurses to work elsewhere. The authors are convinced that this plan lessens the emotional trauma of

hospitaliza-tion to the child. Most importantly, it greatly im-proves the learning experience for mothers who are

interested in their child’s illness and its manage-ment at home. The learning experience of medical students and house staff is enhanced. Certainly, hospitalization in this manner is economical as far as personnel and money are concerned. In spite of lower costs, the authors feel that patients on this unit receive superior care. Pediatrics, 43:488, 1969,

HOSPITALIZED CHILD, PARENT-CHILD RELATIONS,

HOSPITAL PLANNING AND CONSTRUCTION, CARE BY

PARENT.

C

HILDREN in hospitals are cared for by

their parents throughout most of the

world. Only in our culture do we give this

responsibility to professional nurses and

aides, who are strangers to the children.

Realizing that our hospitalization practices

are far from ideal, we, ftt the University of

Kentucky, tried an adaptation of the ways

of the so-called underdeveloped countries.

We established a Care-By-Parent Unit in

the Department of Pediatrics; and, after 2

years’ experience, we feel that this unit is a

major step forward in the operation of a

teaching hospital which deals with

chil-dren. This paper reports our experience in

establishing the unit, its methods of

opera-tion, its advantages, and its problems. An

evaluation of the interaction of parents,

pa-tients, and personnel will be reported later.

PROBLEMS OF HOSPITALIZATION

As pediatricians are well aware, the

hos-pitalization of a child is often a traumatic

experience for the child, as well as an

ex-pensive one for the parents. The child all

too often feels that he is being kept from

those he loves while being attacked by

strangers in white. He is watched over by a

continuous procession of unfamiliar faces,

while being subjected to new and

frighten-ing experiences. He often becomes

with-drawn or rebellious.

The astronomical rise in hospital costs

has become a major problem for the

par-ents-one which calls for thoughtful

consid-eration by physicians and hospital

adminis-trators. In an effort to counteract both the

emotional and economic disadvantages of

admitting the child to the hospital,

ambula-tory pediatrics has grown to specialty

pro-portions. However, pediatric outpatient

clinics all too often have inefficient facilities

for the diagnosis of complex problems of

children, especially if the children must

come from long distances. To combine the

advantages of both inpatient and outpatient

services while reducing the disadvantages

of both, forward-thinking pediatricians,

such as Dr. Morris Green of Indiana, have

suggested a ward where the parent would

stay with the child and provide for his care.

CARE-BY-PARENT OPERATION

Physical Plant

The Care-By-Parent Unit is much like a

motel. It is located on the same hospital

floor as the other pediatric facilities and is

adjacent to the outpatient clinic. The

facili-ties of the clinic, such as the treatment

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SCALE

08 16 32

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ARTICLES

Fic. 1. Schematic plan, Care-By-Parent Unit.

There are 14 comfortable, attractively

fur-nished private rooms, each with shower and

toilet (Fig. 1). Each has an appropriate

bed for the child and a couch that makes

into a bed for the mother.

A common utility room is in the unit

with refrigerator, stove, washing machine,

dryer, bathinette, iron, and ironing board

available to all parents, providing them

with facilities that are necessary for a stay

away from home. The utility room has

be-come an area where parents get together

for coffee and socializing. We have

pur-posely placed no television set in the unit in

an attempt to encourage parents and

chil-dren to find activities that increase the

par-ent-child interaction. Meals are served from

a hot cart to the mother and child in their

room. If a child’s condition permits, meal

tickets are available for the patient and his

mother to go to the general hospital

cafete-ria for their meals, if they prefer to do so.

Administration

Administratively, the unit is a part of the

pediatric clinic, although all

Care-By-Par-ent patients are inpatient admissions. It is

important to emphasize that these patients

are inpatients and their hospitalization is

properly paid for by insurance or any other

form of third-party payment.

Fewer hospital personnel are required to

run the Care-By-Parent Unit than a

con-ventional hospital ward. There are no

nurses assigned to the ward; the parent

provides complete care. If a professional

nurse is needed, a clinic nurse responds

during clinic hours. She makes chart rounds

with the Care-By-Parent staff each morning

before clinic opens, serving as a consultant

and making pertinent suggestions regarding

patient management. She assists the

physi-cians in special procedures such as bone

marrows, lumbar punctures, and so forth.

Perhaps most important, she plays a vital

role in the teaching of parents.

The director of the unit is a member of

the pediatric faculty and is director of the

pediatric clinic. He is responsible for the

operation of the ward and for developing

new procedures and methods of operation.

A child care supervisor functions as the

unit manager and is responsible for the

ad-ministrative functions of the unit. She is the

liaison person between the patient, the

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490

care assistants and works closely with the

director in the development of procedures

and methods.

Three child care assistants are former

nursing aids who have been given training

and experience in many areas of the

hospi-tal such as the premature nursery, the

pedi-atric ward, the outpatient department, and

the physical therapy department. They

have a good working knowledge of hospital

procedures, treatments, and care, with

ad-ditional “on-the-job” training given by the

child care supervisor and the clinic nurse.

The assistants are able to provide a great

deal of instructions to the parents about the

care of sick children.

The social worker is shared with the

pe-diatric clinic. She provides an evaluation of

the parent and social work assistance when

needed. Her contact with parents is so

close that she often serves as a “trouble

shooter” for the unit. She deals with such

problems as anxiety, fear, hostility, and

other emotional reactions which need

immediate help.

The medical students, interns, and

pedi-atric residents assigned to the pediatric

clinic are also responsible for the patients

on the Care-By-Parent Unit. This adds a

welcome new dimension to the usual

outpa-tient training program. House staff and

medical students must make their rounds in

the early morning prior to going to the

clinic and again in the afternoon after the

clinic closes. This routine is much like that

of a physician in private practice and

en-courages the student to coordinate

inpa-tient and outpatient care. Students and

house staff originally see the patient in the

pediatric clinic and follow him throughout

his hospital stay in the unit, providing a

continuity of care which is greatly

appre-ciated by the patient, parent, and physician.

There is no supervisory person in the

unit from 10:30 P.M. until 6:30 A.M. We

en-courage all mothers and their children to be

in bed by 10:30 P.M. when the evening

child care assistant leaves. A red telephone

without a dial is placed on the desk in the

common room at that time and any mother

who needs assistance during the night picks

up the phone and talks to the paging

opera-tor, who immediately sends a pediatric

in-tern or resident. This phone was used seven

times during 1 year of operation; but, no

calls represented a true medical emergency.

Criteria for Patient Admissions

It was originally felt that only those

pa-tients who were minimally ill or needed a

“diagnostic workup” would be admitted.

However, this criteria for admission has

gradually changed to “the ability of a

mother to stay and to care for the child.”

Children who need professional nursing

care are admitted to the general pediatric

ward; the transfer of patients between the

ward and the unit is an easy and simple

procedure and occurs frequently. Patients

with transmissable, infectious diseases are

excluded from the unit.

Role of the Parent

It is important to note that the critical

element which makes this unit a successful

venture in child care is the role of the

par-ent. These are not just private rooms where

a parent can stay and push a button

expect-ing an instant nurse to appear; these are

rooms where complete responsibility for

care lies with each parent, just as it does

when a child is cared for at home.

It is indeed remarkable just how much the

parents can learn and do. The collection of

a 24-hour urine has proven to be much

eas-ier for the mother to do correctly than a

se-ries of nurses. This is true even for small

babies, and frequently the mother adapts

for her child variants of the technique we

suggest for collection. Parents have also

been very successful in “ambulating” a child

after surgery, or getting a “chest case” to

cough. With careful instructions they can

accurately observe and record the effects of

drugs and other therapy.

In cases where the child is recovering

from anesthesia, the patient is kept in the

post-anesthetic recovery room a little longer

than usual-until he is well awake-before

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ARTICLES

TABLE I

PATIENT ADMISSIONS, DECEMBER 1, 1966, THROTJGII NOVEMBER 30, 1967

Month Admitted. _.4Daily

rerage Patient Days Average Slay (da) 1966

December (open days)

1967 January February March April May June July August September October November Total 34 55 6! 57 38 8 85 75 84 73 81 64 739 7.6 7.9 10.2 9.1 6.7 10.0 11.4 10.4 10.0 10.1 9.1 10.7 189 36 85 336 34’2 3l 3l2 308 307 38 3,442 6.0 4.3 4.5 4.9 5.0 4.0 4.0 4.0 3.6 3.7 3.1 4.5

Monthly averages 63.3 9.4 86 .8 4.3

Unit. At this time the nurse from the

pedi-atric clinic is called and the nurse checks

the patient and chart to be sure that

every-thing is in order, that the patient is in good

condition, and that the mother understands what to do. To date, this procedure has worked so well that we see the Care-By-Parent Unit as an excellent recuperating place for the more minor types of pediatric

surgery such as biopsies, mole removals,

herniorrhaphy, plastic repaid of cleft palate,

eye surgery, dental operations, and so forth.

Occasionally, more than one child is

ad-mitted with a parent. There were, for

exam-ple two boys, age 7 and 9, who had measles

pneumonia and developed bronchiectasis.

The boys were admitted with their mother.

Bronchograms revealed extensive disease

and the older boy was taken to surgery for a lobectomy. After surgery he was in the in-tensive care unit, then the general pediatric

ward, and, after 4 days, back to the

Care-By-Parent Unit. At this time, the younger

child went to surgery and followed the

same course. With careful daily instructions

by

the physical therapist, the mother

be-came an “expert” in postural drainage and

chest percussion. She learned the value of

medications and provided these boys with

excellent emotional support through a

diffi-cult hospital course. The entire hospital

stay was less than 2 weeks. Other instances

where more than one child was admitted

with a parent have been cases of mental

re-tardation, multiple congenital anomalies,

diabetes, and PKU. Occasionally, both

mother and father have stayed.

In the Care-By-Parent Unit the mother is

asked to keep a daily diary sheet which is

given to her each night by the child care

assistant. The assistant writes on the sheet

any appointments and tests that are

sched-uled for the next day. This helps the

mother know what to expect, and in many

cases prepare the child emotionally for the

next day. The parent records on this sheet

the medication she gives the child, special

activities of the child, temperature, weight,

bowel movements, and so forth. Except for

an occasional injection by the clinic nurse,

all medications are given by the parent

and

recorded on the daily diary sheet. The

sheet is picked up each night, and the

in-formation is tranferred to the medical

rec-ord. Medications are recorded as “given by

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CARE-BY-PARENT

TABLE II

ADMIssIoNs BY SERVICES

JUNE 1-NOVEMBER 30, 1967

(6MONTHS)

Illness Number. of

r’atienls

Mental retardation program 67

Cardiac 53

Neurology 52

General pediatrics 51

Urology 47

Premature infants 36

Hematology 24

Renal 23

Neurosurgery 22

Birth defects 15

Surgery (general) 14

Ophthalmology 8

Plastic surgery 6

Allergy 3

in the order book in the form of outpatient

prescriptions, and the mother receives a

bottle of medication with instructions just

as she would in a physician’s office. She

keeps the drugs in a locked medicine

cabi-net in the bathroom in her room.

The absence of full-time, professional

nurses increases the staff’s concern for

teaching the mother about her child’s

ill-ness and how she can help her child. We

feel this is one of the outstanding benefits

that has been realized from this unit. The

following three cases illustrate the variety

of activities of accomplishments that

moth-ers can learn:

CASE 1: Jenifer, a 4-month-old infant, had

a tracheotomy performed at age 1 month.

The mother, who is uneducated, started

caring for the tracheotomy tube with

care-ful instructions by the professional nurses

on the general acute ward. A suction pump

and other equipment were obtained for her

and the child was transferred to the

Care-By-Parent Unit. Here the mother learned to

assume full responsibility of the use of

this equipment under the watchful eye of

the Care-By-Parent staff.

CASE 2 Mary Lou was an 18-day-old

baby detected on a routine examination as

having a positive PKU screening test. The

mother had one severely retarded child at

home. It was difficult for this frightened

and overwhelmed family to understand

what was wrong with their child. With the

combined efforts of the social worker,

doe-tor, public health nurse, and nutritionist,

she was taught about PKU, the dietary

management of her baby, and the necessity

for a carefully controlled diet. She was

also taught to do “heel sticks” and mail the

blood sample to the medical center at

reg-ular intervals so that we could monitor the

dietary management. At 18 months of age

the child was developing normally.

CASE 3: Bobby, a 6-year-old boy, had

leukemia. He received a number of blood

transfusions in the Care-By-Parent Unit

where the mother was taught how to

moni-tor the infusion and watch for reactions.

She kept a meticulous record of the hourly

progress of the infusion; and, after his

tran-fusions, they stayed over night so he could

be re-evaluated in the morning to see if he

needed further transfusions.

CASES AND PROCEDURES

In the second year of operation there

were 739 patients admitted to the ward,

covering all of the pediatric specialties and

many of the surgical specialties (Table I).

The variety of patients who were admitted

under their mother’s care is illustrated in

Table II. The number of procedures that

have been performed while the patient was

in the Care-By-Parent Unit is illustrated in

Table III. Since many of these patients are

admitted for “diagnostic workups,” the

number of procedures per patient is more

than on the general, acute pediatric ward.

ADVANTAGES OF THE

CARE-BY-PARENT UNIT

We feel the most significant advantages

of the Care-By-Parent Unit are:

1. It is significantly more economical to

operate than a conventional ward. In the

fiscal year July 1, 1966, through June 30,

1967, the comparative cost for operation of

the two units, including meals, is as

fol-lows: Care-By-Parent Unit-2,932 patient

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TABLE III

PROCEDURES ACCOMPLISHED

JUNE 1-NOVEMBER 30, 1967

(6MONTHS) 104 53 47 42 39 23 21 19 17 12 11 11 9 8 6 6 6 5 3 3 2 2 2 0 18 5 7 4 1 1 ARTICLES

pediatric ward-12,667 patient days at

$33.93 per patient day. These figures do not

reflect any cost incurred for drugs,

labora-tory determinations, x-rays, and so forth.

The cost of direct personnel services is

sig-nificant when one takes into account that

60% of the hospital budget is reflected in

personnel charges. During a typical

4-month period in 1966, the personnel cost on the acute, general pediatric ward was

$10.31 per patient day in comparison with

the Care-By-Parent Unit which was $3.81 per patient day. For

1967 a

typical 4-month

period shows a rise in hospital personnel

cost to $17.99 per patient day on the acute

general pediatric ward and to $5.09 per

pa-tient day on the Care-By-Parent Unit.

Though it has been impossible to apply a

completely accurate cost accounting system

to the unit, the hospital administration is

satisfied that the Care-By-Parent Unit costs

40%

less than the acute, general pediatric

ward. The charge to the patient is a room

fee, including meals for the mother and

child, of $17.50 per patient day, which is

$10.00 less than the charges for the general

pediatric ward.

2. The Care-By-Parent Unit makes

avail-able more pediatric hospital beds regardless

of nursing shortages. The removal of some

non-acutely ill patients from the ward al-lows the pediatric nurses to concentrate on

those patients needing professional nursing

care.

3. By keeping the parent and the child

together, the trauma of mother-child sepa-ration is eliminated.

4. The 24-hour availability of the parent

provides an excellent opportunity to teach

the parent about the child’s condition and allows her to try her newly acquired

child-care skills under careful supervision. A

good example of double advantage is seen

when a premature infant is transferred to

the Care-By-Parent Unit for the last 2 or 3

days of his hospitalization. During these

few days before taking the baby home, the

mother, under supervision, assumes

com-plete care of her child. If necessary, she is

taught how to bathe the baby, to prepare

the formula, and so forth. Frequently the

Procedure Number of Patients

Electroencephalogram Electrocardiogram Lumbar puncture Intravenous pyelogram Cardiac catheterization Dental treatments Pneumoencephalogram Cystoscopy Ophthalmic treatment Cardiac radiograph Electromyogram

Speech and hearing evaluation

Barium swallow Carotid angiogram Bone marrow Brain “scan” Sweat electrolytes Cerebral arteriogram Bronchoscopy Subdural tap Lymphangiogram Myelogram

Pulmonary function study

Radioactive iodine uptake

Biopsy renal muscle rectal skin testes

public health nurse from the mother’s home

county visits and participates in these

in-structions given by the clinic nurse. This

2-or 3-day period gives our social worker,

clinic nurse, child care assistants, and

phy-sicians sufficient time to work with the

mother so that she can take her baby home

with considerable confidence in her ability

to care for it.

5. The medical students and house staff

who work closely with the parent have an

excellent opportunity to develop skills in

handling patients and parents. In contrast

to the outpatient department, there is

ample opportunity to observe which of

many instructions a parent has understood

clearly. This indicates to the staff how well

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non-494 CARE-BY-PARENT

medical personnel. It is often a sobering

ex-perience for the young physicians in train-ing.

6. The Care-By-Parent Unit has been

especially useful for a multidisciplinary

ap-proach to general diagnostic evaluations.

We are able to schedule in advance all

nec-essary consultations and diagnostic

proce-dures, concentrating a very complete

workup in a short period of time. The

aver-age stay for all patients on the unit is 4.2

days, in contrast to an average of 9 to 11

days on the conventional ward. This is also

in contrast to the numerous visits to the

outpatient clinic that would be required to

accomplish the same evaluation.

7. The Care-By-Parent staff and

physi-cians can observe parent-child interaction,

making appropriate suggestions regarding

management when indicated.

8. This unit could be considered a

labo-ratory, where new medical or

administra-tive methods and techniques can be tried

and where the availability of parent and

child together offers an unsurpassed

oppor-tunity for clinical research.

A small but interesting example of an

ad-ministrative problem is thermometer

break-age. The cost of replacement of

thermome-ters on a large pediatric ward runs about

$300.00

a year. In the Care-By-Parent Unit

we sell each mother a thermometer of her

own and teach her how to use it. She uses

this thermometer throughout her stay and

takes it home with her when the child is

discharged. The breakage is almost nil!

Many homes, for the first time, now have

thermometers and mothers who can read

them.

This unit serves as a laboratory for

ob-serving the interaction of the parents while

they are on the unit. We have families from

all social classes, a variety of religions, and,

of course, members of the Caucasian and

Negro races. It is not uncommon to see any

or all of the mothers help each other

ac-tively, taking a temperature or baby sitting

while the mother is

being

interviewed or is

out of the hospital for an hour or so for a

walk or a respite from her “nursing” care.

Mothers also commonly support each other

during emotionally stressful moments when

their children are in the operating room or

catheterization laboratory.

The social worker frequently utilizes the

group interaction in a therapeutic manner

to help a specific problem or mother.

EVALUATION

To determine if our subjective

evalua-tions indicating significant advantages of

the Care-By-Parent Unit are indeed correct,

several research projects are now underway

and will be reported in the near future.

Three of these projects are:

(

1

)

physician-parent communication in the

Care-By-Par-ent Unit and its impact on the parent; (2)

the impact on the family of Care-By-Parent

hospitalization of child and parent; (3) the

impact of the Care-By-Parent Unit on the

education of medical students.

PROBLEMS ENCOUNTERED

We had expected we would have

prob-lems with some mothers’ acceptance of the

around-the-clock responsibility for the care

of her child and perhaps with mothers not

getting along with each other. These

situa-tions have been very infrequent.

The hospital administration was at first

concerned with a widely fluctuating census.

Since the average stay is only 4.3 days and

most of the admissions are on Sunday or

Monday, bed occupancy at the end of the

week drops precipitously. We now attempt

to avoid this by scheduling elective,

short-stay surgical, dental, and ophthalmological

patients on Thursday and Friday.

We find both students and house staff

have difficulty in answering demands from

both the outpatient department and the

Care-By-Parent Unit at the same time. Both

areas are very busy and we probably need

a larger house staff to deal with this unit

and the outpatient department.

Occasionally a parent becomes

unexpect-edly ill and we have found it

administra-tively difficult to care for her since she is

not a hospital patient. The visit to the

emergency room is not always satisfactory

and clinic visits prove to be excessively

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1969;43;488

Pediatrics

Vernon L. James, Jr. and Warren E. Wheeler