Association releases new pediatric discharge guides
Traditional guidelines are inadequate, says AAP
Existing discharge guidelines for high-risk newborns are inadequate because they can't be tailored to individual cases, according to an expert panel convened by the Elk Grove Village, IL-based American Academy of Pediatrics (AAP).
Traditionally, preterm infants were considered eligible for discharge when they achieved a set weight, usually 5 or 5.5 pounds. But, according to the panel headed by James A. Lemons, MD, a single criterion or even a single set of criteria isn't enough to account for all the different types of high-risk infants. The panel's own guidelines, endorsed by the AAP, appear in the August 1998 issue of Pediatrics.1 They identify four categories of high-risk newborns:
1. the preterm infant;
2. the infant who requires technological support;>
3. the infant at risk because of family issues;
4. the infant whose irreversible condition may result in an early death.
In its proposed guidelines, Lemon and his colleagues acknowledge that timely discharge can be beneficial for newborns, because "decreasing the period of separation from the parents may lessen the subsequent adverse effect on parenting. Early discharge also cuts the risk of "hospital-acquired morbidity," they say. Nevertheless, infants released too early may be placed at risk for increased morbidity and mortality.
Indeed, past research shows preterm low birth weight infants who needed intensive care are much more likely than other infants to be readmitted to the hospital or die within one year. Because of those grim facts, it's vital that case managers and other members of the discharge team spend adequate time preparing parents and other caregivers for the challenges ahead.
According to the AAP panel, the pediatric discharge team should include parents, the primary care physician, the neonatologist, neonatal nurses, and the social worker or case manager. Other professionals should be brought in as needed: surgical specialists, pediatric subspecialists, occupational, physical and respiratory therapists, infant educators, nutritionists, and home health care liaisons.
The panel stresses that although the exact date of discharge may not be entirely predictable for this patient population, you should begin the discharge planning process when it's clear that the infant will survive. The discharge plan should include the following components:
r Parental education.
The panel suggests developing a written checklist of the specific areas or tasks that parents should master before the infant is discharged. Checklists make it more likely that more than one caregiver receives complete instruction in the care of the infant. According to the panel, "return demonstrations, parent rooming-in, and telephone follow-up have all been reported to facilitate parental education."
r Implementation of primary care.
Preparing the infant for the transition to primary care involves immunizations, metabolic screening, and assessment of hearing, among other tests.
r Evaluation of unresolved medical problems.
"Review of the hospital course and the active problem list of each infant and careful physical assessment will reveal unresolved medical issues," the panel states. The results of such a review give a better picture of the infant's clinical status and may suggest changes to the management plan.
r Development of the home care plan.
The content of the home care plan will vary by individual infant, but common elements include: identification and preparation of in-home caregivers, development of a comprehensive listing of required equipment and supplies, identification of necessary home care personnel and support services, a home assessment, development of an emergency care and transport plan, and assessment of the family's financial resources.
r Identification and mobilization of surveillance and support services.
Before and after discharge, members of the discharge planning team should review the family's needs, coping skills, use of available resources, financial problems, and progress toward established goals.
r Determination and designation of follow-up care.
Identify a primary care physician as early as possible, "to facilitate the coordination of follow-up care planning between the primary care setting and the subspecialty center-based discharge planning staff," according to the panel. If possible, the primary care physician should meet the parents before discharge and examine the infant in the hospital.
The panel recommends the following as a framework to consider when discharging high-risk infants:
r Infant readiness for hospital discharge.
In the judgment of the responsible physician, there has been:
- a sustained pattern of weight gain of sufficient duration;
- adequate maintenance of normal body temperature with the infant fully clothed in an open bed with normal ambient temperature;
- competent suckle feeding, breast or bottle, without cardiorespiratory compromise;
- physiologically mature and stable cardiorespiratory function of sufficient duration.
r Home care readiness.
All appropriate disciplines should contribute to the creation of an individualized home care plan. "The plan for infants with complex multiple system problems, and particularly for those requiring technological assistance, must be specific and detailed," according to the plan. "For infants at psychosocial risk, arrangement for appropriate psychological surveillance and family support is essential."
r Family and home environmental readiness.
- identification of at least two family caregivers, one of whom is an adult, and assessment of their ability, availability, and commitment;
- psychosocial assessment for parenting risks;
- a home environmental assessment that may include an on-site evaluation, including the availability of 24-hour telephone access, electricity, an in-house water supply, and heating;
- review of available financial resources and identification of adequate financial support.
Parents and caregivers should be able to demonstrate the ability to provide the following components of care:
- feeding, whether breast, bottle, or an alternative technique, including formula preparation as required;
- basic infant care including bathing; skin, cord, and genital care; temperature measurement; dressing; and comforting;
- infant cardiopulmonary resuscitation and emergency intervention as indicated;
- assessment of clinical status, including understanding and detection of the general early signs and symptoms of illness, as well as the signs and symptoms specific to the infant's condition;
- infant safety precautions including proper infant positioning during sleep and use of car seats;
- specific safety precautions for an artificial airway, feeding tube, ostomy, infusion pump, and other mechanical and prosthetic devices as indicated;
- administration of medication, specifically proper dosage and timing, storage, and recognition of the signs and symptoms of toxicity;
- equipment operation, maintenance, and problem solving for each mechanical support device required;
- the appropriate technique for each special care procedure required, including special dressings for infusion entry site, ostomy, or healing wounds, maintenance of an artificial airway, chest physiotherapy, oropharyngeal and tracheal suctioning, and infant stimulation and physical therapy, as indicated.
r Community and health care system readiness.
Before discharge, the team should develop an emergency intervention and transportation plan, and identify emergency services providers. Other criteria include:
- primary care physician identified, and responsibility for care accepted;
- surgical specialty and pediatric subspecialty follow-up care requirements identified and appropriate arrangements made;
- neurodevelopmental follow-up requirements identified and appropriate referrals made;
- home nursing visits for assessment and parent support arranged as indicated by the complexity of the infant's clinical status and family capability and the home care plan transmitted to home health agency.
For more information, contact the American Academy of Pediatrics in Elk Grove Village, IL. Telephone: (847) 228-5005.
Reference
1. American Academy of Pediatrics. Hospital discharge of the high-risk neonate - proposed guidelines. Pediatrics 1998; 102:411-417.
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