A new approach to early discharge

By Allan R. LaReau, MD

A hospital in Michigan has developed a program to aid compliance with AAP guidelines on newborn discharge. Its plan could serve as a model for other institutions.

Pediatricians have struggled in recent years with the issue of lengths of stay for normal newborns. Those in practice in the 1970s and 1980s recall four-day newborn stays, which provided an opportunity to examine newborns on successive days in the inpatient setting. Monitoring for evidence of sepsis, jaundice, congenital heart disease, and other neonatal conditions was much easier than it is now, and newborn care was clearly an inpatient experience for the baby, the family, and the pediatrician. With the shortening of the newborn length of stay, we have been forced to think of newborns less as inpatients and much more as patients to be seen in our offices and outpatient clinics.

The American Academy of Pediatrics (AAP) lent its expertise, force, and credibility to this new approach when it published guidelines for care of the newborn discharged after a short length of stay.¹ In spite of the wisdom of the AAP's recommendations, disseminating, discussing, and implementing the guidelines has not been an easy task. Our hospital has instituted a program that addresses this issue. It helps to ensure that newborns have appropriate outpatient follow-up. The heart of our program is a redesigned discharge order sheet that emphasizes follow-up evaluation. The plan is supplemented with a new approach to management of newborn jaundice and stepped-up efforts to increase rates of breastfeeding.

Who we are and what we did

The Children's Hospital at Bronson is part of a community hospital. It is the tertiary care pediatric hospital for southwest Michigan, serving a population of approximately 900,000 people, and has been an associate member of the National Association of Children's Hospitals and Related Institutions since 1994. We have a 50-bed neonatal intensive care unit and a high-risk perinatal service. About 2,700 babies are delivered each year at Bronson. About 90% of these newborns are cared for by pediatricians, the remainder by family practitioners. All attending physicians are required to use standard preprinted admission and discharge orders.

To develop our program, we gathered background information, reviewed available literature, and devised a plan. We sought input from practicing pediatricians, house officers, neonatologists, nursing staff, laboratory staff, outcomes coordinators, and the departments of process improvement and nursing education. We found that between 25 and 35 newborns per month who were discharged at or around 48 hours of age left the hospital without a documented plan for follow-up that was consistent with the AAP guidelines. We also tracked the number of newborns who were being readmitted for management of neonatal jaundice at between six and 12 per year. The percentage of our newborns who were breastfed at the time of discharge in 1997 and 1998, when we were developing the program, was about 65%.

With this background information in hand, we began to institute some changes. We redesigned our discharge order sheet and instructions for parents, giving the AAP's recommendations a prominent position (Figure 1). We also added notes to emphasize the importance of sleep position and tobacco avoidance.

We sought to improve our approach to neonatal jaundice, reduce variability of clinical practice, decrease the need for readmission, and assure patient safety. Clinically estimating the degree of jaundice has always been challenging since it is affected by lighting, skin color, and other factors. Infants now reach their peak bilirubin levels when they are no longer in the hospital, on approximately day 4, with perhaps a later peak in infants of Asian ethnicity. A promising approach to these problems appeared in a landmark article by Bhutani and colleagues published in Pediatrics in early 1999, when we were developing our program.² The investigators advocated drawing a bilirubin in all newborns at the time of their newborn metabolic screen. By plotting the hour-specific bilirubin on a graph, one can predict with some accuracy which infants need more extensive evaluation and closer follow-up.

We adapted the Bhutani approach for our nursery and developed laminated cards (yellow, of course) for all of the physicians. The card included the percentile-based bilirubin nomogram for the first week of life that the investigators constructed from hour-specific predischarge and postdischarge total serum bilirubin levels of healthy newborns (Figure 2). The card also contains the AAP guidelines for treatment of hyperbilirubinemia.³ We then began to have a bilirubin drawn on all newborns at the time of their newborn screen, between 24 and 48 hours of age. We did a cost-benefit analysis that showed that the additional cost of bilirubin assays would probably be offset by a reduction in readmissions for jaundice.

In October 1999 I presented the program at the pediatric department meeting for additional input, questions, and suggestions and then presented the "finished product" at pediatric Grand Rounds, and nursing staff meetings. As part of the Grand Rounds, our lactation consultant, who sees about 95% of mothers at our hospital, provided pediatricians with an update on breastfeeding. We also made other efforts to improve our rate of breastfeeding at discharge. Mothers are now nursing more frequently during the day, and we strongly discourage supplementation for normal newborns.

Promising outcomes

Our program has been extremely well received by community pediatricians, parents, and the nursing staff. Thus far, we have been most successful at documenting plans for follow-up care. The number of infants discharged from the hospital without an appropriate follow-up plan has fallen significantly (Figure 3). We also have seen a reduction in the number of newborns readmitted for treatment of hyperbilirubinemia. Eleven infants were readmitted in 1997, 13 infants in 1998, and seven from January to October of 1999. From November 1999, when the program was initiated through July 2000, however, only two infants were readmitted for jaundice. A few infants may have been treated with home phototherapy, but it is clear that we have made progress in this area. Our breastfeeding rate at discharge, already quite high when we began the program, has risen to more than 70%. Another regional hospital has adopted our approach to issues relating to current newborn discharge practices.

REFERENCES

1. AAP Committee on Practice and Ambulatory Medicine: Recommendations for preventive pediatric health care. Pediatrics 1995;96(2):Insert

2. Bhutani VK, Johnson L, Sivieri EM: Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics 1999;103(1):6

3. AAP Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia: Practice parameter: Management of hyperbilirubinemia in the healthy term newborn. Pediatrics 1994;94:558

THE AUTHOR practices pediatrics with Rambling Road Pediatrics and is Medical Director, Children's Services, Children's Hospital, Bronson Methodist Hospital, Kalamazoo, MI.

The author wishes to thank Ms. Peg Malnight, Ms. Cindy Duff, and the newborn nursery staff at Bronson Methodist Hospital for their assistance. Dr. LaReau can be reached at 252 Lovell St., Kalamazoo, MI 49007 or by e-mail at lareaua@bronsonhg.org.

 

Allan LaReau. A new approach to early discharge. Contemporary Pediatrics 2000;10.