How safe is newborn early discharge?
No study reveals optimal postpartum stay
By Elgin K. Kennedy, MD
Editor, The Assertive Utilization and Quality Report
We live in a time of heavy pressures for cost-containment. Payers stand to gain substantially when hospital stays are shortened. Postpartum stays have decreased dramatically over the years. Two generations ago a woman stayed in the hospital for 10 to 14 days after giving birth. Fifteen years ago it was down to four days. Initially the decline was due to the public demand to demedicalize childbirth. More recently the incentive is pressure by third-party payers to contain costs.
Recent federal and state legislation reflect widespread public opinion that "drive-through" deliveries are not acceptable. The legislation requires automatic reimbursement for stays up to 48 hours.
Two recent investigations looked at the safety of newborn early discharge.1,2 One looked at infant rehospitalization in the first month of life for newborns discharged 30 to 78 hours after birth. Those discharged early had an increased risk for rehospitalization, and the risk was greatest in the first week after discharge. The second did not find an increased risk, but it used a more restricted outcome of readmission for feeding-related problems. An editorial accompanying the studies points out that while the discharge of a healthy infant at 48 hours seems reasonable, there's presently no conclusive proof that it's safe.3
The conditions most likely to require readmission after a 48-hour discharge are neonatal jaundice, dehydration, and feeding difficulties. When healthy newborns are discharged on or before two days, state the editorial authors, mothers should receive specific follow-up services in the home or in the clinic setting on the third or fourth postpartum day. (See related article on follow-up services, below.) At present, such follow-up visits are not required by law and are often not reimbursed by payers.
References
1. Liu LL, Clemens CJ, Shay DK, et al. The safety of newborn early discharge. JAMA 1997; 278:293-298.
2. Edmonson MB, Stoddard JJ, Owens LM, et al. Hospital readmission with feeding-related problems after early postpartum discharge of normal newborns. JAMA 1997; 278:299-303.
3. Braveman P, Kessel W, Egerter S, et al. Early discharge and evidence-based practice: good science and good judgment. JAMA 1997; 278:334-336.
[Editor's note: The preceding article was first published in the September 1997 issue of The Assertive Utilization and Quality Report - $60 per year (12 issues). For more information, contact Elgin Kennedy, MD, at 204 Second Ave., # 334, San Mateo, CA 94401. Telephone: (415) 348-3647.]
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