Guidelines cover high-risk newborns’ early discharge
New rules aimed at technology-dependent infants
How strong are the discharge plans for your preterm infants? After sweeping through adult critical care, the early-discharge juggernaut is hitting pediatric and neonatal ICUs with the same intensity: NICU nurses are also getting queasy feelings about patient safety.
The trend toward identifying certain high-risk preterm newborns for transfer to lower-intensive settings — including home-based programs — is growing, nurses report. Yet, it’s unclear whether physicians and nurses are choosing correctly. Most are using their own sets of standards for decision making.
But what standards should be used to determine the readiness of high-risk babies for discharge? critics ask.
"We’ve needed a positive statement that addresses the early discharge of high-risk but moderately healthy preterm babies. There’s been a lot of pressure to get these infants out of costly acute-care settings," says Carole Kenner, RNC, DNS, director of education and programs at the National Association of Neonate Nurses (NANN) in Des Plaines, IL.
The membership organization has done that with a series of evidence-based guidelines for NICUs published last year in collaboration with the American Academy of Pediatrics in Elk Grove Village, IL.
Rules cover uncharted territory
The guidelines cover discharge-planning criteria for high-risk preterm infants.1 (See Critical Care Management, October 1998, pp. 118-120, for details on those guidelines.)
Last month, NANN issued directives that cover the early discharge of a far more delicate group of newborns: The technology-dependent preterm baby scheduled for a home care discharge.
The guidelines define the technology-dependent infant and identify the minimum physiological benchmarks to qualify a newborn for discharge to a home situation.
The technology-dependent infant is defined as a baby who is "physiologically stable with the assistance of some technology." (The guidelines do not cover incubator-bound preemies.)
The guidelines also cover in detail the prerequisites for the care of the infant at home, including the education and training of the primary caregiver, provisions for home health nursing services and life-supporting equipment, and nutritional and community-based social services.
Other provisions encompass the necessary financial resources to support the homebound infant’s care and preparations for the home environment to facilitate a smooth hospital-to-home transition.
For example, the guidelines recommend a multidisciplinary discharge planning team to oversee the baby’s transfer to home care. The team should consist of NICU staff nurses, case managers, discharge planner/utilization reviewer, community-based health coordinator (home health nurse), attending neonatologist, nutritionist, and pediatrician.
Guidelines offer ample wiggle room’
Allied health professionals should include an audiologist, respiratory therapist, social worker, developmental specialist, and pastoral care staff.
Although specific enough to provide nurses with ample, useful information, NANN officials say the guidelines also are sufficiently broad to allow individual units flexibility in their application.
But nurses should use the guidelines to establish internal protocols for discharge planning, advises Sandra Swanson, RN, MSOD, a neonatal nurse at Loyola University Medical Center in Maywood, IL, who co-authored the guidelines.
In the past, the discharge criteria for this population were based on the baby’s weight and gestational age, Swanson says. "The criteria has shifted," she adds. "They’re now based on indicators of physiologic stability."
For example, here are the physiologic criteria for home discharge:
• Thermal stability in an open-air environment with a maintained axillary temperature of 36.5°C to 37.5°C.
• Stable cardiopulmonary status with or without external supports, which does not require interventions other than gentle touching, apnea/bradycardia; saturations of >95 for oxygen-dependent infants.
• Stable neurologic status as determined for each individual neonate.
• Successful mode of enteral feeding with a positive pattern of weight gain for several days prior to discharge. (Parenteral feeding may be a successful mode of feeding for selected neonates for whom other physiologic criteria are met and who have stable access via a broviac or percutaneous intravenous catheter.)
• Hyperbilirubinemia that can be treated with home phototherapy. (Some institutions use the rule of requiring no more than two lights and total bilirubin of less than 12 mg/dl, declining after day three of life. However, there is debate as to whether such prescriptive are necessary. At this time, it is best to refer to current institutional policy and to be consistent within an institution.)
• Suspected sepsis that can be treated at home with stable access such as percutaneous catheters. (First, the infant would meet the above criteria for stability, such as thermal and cardiopulmonary stability.)
Yet, despite these baseline physiological indicators, the discharge plan for technology-dependent infants isn’t complete without a thorough evaluation of the family and community supports, Kenner cautions. "Look carefully at the family and its ability to care for the infant. Also, what community support services are available? What access will the baby have to good home health nursing?"
Expect pediatricians to oppose idea
In the past, Kenner says discharge nurses have encountered stubborn resistance from pediatricians. Surprisingly, finding one who will accept the care of the high-risk infant will be one of the most difficult aspects of the planning. Pediatricians, by and large, do not want responsibility for the patient. Therefore, begin looking for a willing provider as soon as possible.
Discharge planning for technology-dependent newborns can be a workable solution, Kenner adds. Nevertheless, if neonatal nursing officials had their preference there would be no need for the discharge guidelines.
Infants would be allowed to remain in the NICU without restrictions until they were assured a more appropriate transfer to another setting. "Unfortunately, this is all a response to what is happening in the policy environment in Washington as well as in managed care," Kenner says.
Reference
1. American Academy of Pediatrics. Hospital discharge of the high-risk neonate — proposed guidelines. Pediatrics 1998; 102:411-417.
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