Early discharge from a neonatal intensive care unit and rates of readmission

Background: Increasing admissions to neonatal intensive care units (NICUs) demand early discharge from the units. Our hospital aims to early discharge patients who meet the following requirements: they are able to regulate body temperature; neither apnea nor bradycardia is observed; and bodyweight increases with lactation. We studied the real state of this strategy. Methods: We looked at postmenstrual age, bodyweight, complication at the time of discharge and the readmission rate in 609 patients with gestational age of less than 34 weeks, who were discharged from our NICU between January 2000 and March 2008. Results: The postmenstrual age and bodyweight at discharge decreased with the increase of gestational age. This tendency was stronger in cases with gestational age of less than 26 weeks. A comparison was made between two patient groups with a gestational age of less than 26 weeks and with the age of 26 weeks or longer. Many patients with a gestational age of less than 26 weeks suffered frequently from complications and were on home oxygen therapy. The readmission rates within 3 months and 1 year of NICU discharge were 10.4% and 26.9% in patients with gestational age between 22 and 25 weeks, respectively, while those rates were 2.8% and 7.4% in patients with gestational weeks of 26 to 34, respectively. Conclusion: The postmenstrual age and bodyweight at NICU discharge decreased in inverse proportion to gestational age, especially less than 26 weeks. Our requirements for early discharge were verified by the readmission rate in this investigation.     

Risk factors for hyperbilirubinemia in breastfed term neonates

Increased breastfeeding was suggested as a contributing factor to significant hyperbilirubinemia. The aim of this study was to identify the risk factors associated with jaundice in exclusively breastfed term neonates. We retrospectively reviewed all consecutively live-born neonates from August 2009 to July 2010 who had complete outpatient department (OPD) follow-up at ≤14 days old. Hyperbilirubinemia was defined as a transcutaneous bilirubin (TcB) value of ≥15 mg/dl. During the study period, there were 718 deliveries, of which 152 neonates were transferred to the special care nursery or neonatal intensive care unit; 566 neonates were discharged from the nursery, and 243 neonates were excluded: 83 did not return to the OPD, 46 were older than 14 days at OPD follow-up, 44 were <37 weeks of gestational age, and 70 had been fed formula. In total, 323 neonates were enrolled and classified into the hyperbilirubinemic (114 neonates) and non-hyperbilirubinemic groups (209 neonates). The gender, gestational age, Apgar score, age at nursery discharge, birth weight, and body weight at nursery discharge and at OPD were comparable between the two groups. TcB values at nursery discharge were positively correlated with TcB values in the OPD. Infants with hyperbilirubinemia exhibited significantly greater body weight loss from birth to the OPD follow-up and significantly less body weight gain from nursery discharge to OPD follow-up. Conclusion High TcB values at nursery discharge and a smaller body weight gain are associated with hyperbilirubinemia in term neonates who are exclusively breastfed.     

How well do diagnosis‐related groups perform in the case of extremely low birthweight neonates?

OBJECTIVE: To determine how well diagnosis related groups (DRG) perform for extremely low birthweight neonates, by examining length of stay (LOS) data for babies with birthweight of 750-999 g and managed in the seven New South Wales maternity hospital neonatal intensive care units (NICU). METHODOLOGY: Neonates with an admission weight of 750-999 g and admitted to one of the seven NICU were studied. Those who died or were transferred in the first 5 days were excluded, leaving the group of neonates defined by DRG P62Z. In order to allow comparisons between the different NICU, neonates whose care was split between two or more NICU were also excluded, leaving those who either died, were transferred to a nursery closer to their home or were discharged directly to their home. The relationship between LOS and a number of perinatal factors was studied for the total group, and LOS data were compared for individual hospitals. RESULTS: Length of stay was most strongly associated with mode of separation. It was also significantly associated with gestational age, time ventilated, oxygen need at 36 weeks postconceptual age, and retinopathy of prematurity. Neonatal intensive care units with the highest proportion of neonates being transferred had the lowest average LOS, and vice versa. CONCLUSIONS: The LOS of neonates in DRG P62Z is more strongly related to mode of separation (died, transferred or discharged home) than to factors that reflect best practice. A funding model that rewards NICU for a short LOS may unfairly disadvantage some units while favouring others.     

Do apnea monitors decrease emotional distress in parents of infants at high risk for cardiopulmonary arrest?

INTRODUCTION: The immediate post-partum period is stressful for most parents. The need to use a home apnea monitor may tax parental coping skills even further. Therefore, we conducted a study to assess the psychosocial consequences of apnea monitoring on parental emotional distress and family functioning. METHOD: We studied 104 parents of infants at high risk for cardiopulmonary arrest. Fifty-two parents had infants who used home apnea monitors, and 52 parents were age-matched and gender-matched control subjects. Data were collected during the infant's hospitalization, and then at 2 weeks, 3 months, and 6 months after discharge. At 1 year, parents were interviewed about their attitudes toward using the apnea monitor. RESULTS: Both groups experienced elevated levels of emotional distress, but the group with infants who used the monitors had significant increases in depression and hostility immediately following discharge from the hospital compared with baseline, whereas the non-monitored group had a significant increase in hostility at 6 months. At 1-year follow-up, the majority of the parents reported that they used the monitor every night, felt more secure in using it, and judged it helpful. DISCUSSION: The immediate period following hospital discharge of infants who need to use a home apnea monitor is characterized by significant emotional distress for the parents, which resolves over time. Anticipatory education and counseling of parents is recommended.     

Apnea of prematurity: risk factors and ambulatory treatment with caffeine citrate]

INTRODUCTION: Apnea of prematurity develop during the first days of life and usually resolve by the time the infant reaches 36-37 weeks postmenstrual age. In a few cases, they persist beyond term, especially in infants delivered at the youngest gestational ages (24-28 GA), and require specific care. In our unit, those preterm babies are discharged home with caffeine citrate treatment. Discontinuing the treatment is performed in hospital when they achieve a postmenstrual age of at least 42 weeks. OBJECTIVE: To identify predictive factors of persistent apnea in preterm babies. MATERIAL AND METHODS: Retrospective study comparing a population of 41 preterm infants discharged with treatment to 123 preterm babies discharged without treatment to identify predictors of persistent apnea. RESULTS: Factors significantly associated were: birth weight<1500 g, initial hypotension, gastroesophageal reflux, need for continuous positive airway pressure and multiparity. At home, no infant died and no adverse effect was reported by parents. CONCLUSION: Persistent apnea can be responsible for prolonged hospitalization. Risk factors can be identified in some children. Discharging with treatment can be an alternative to their hospitalization.     

Home oxygen management of neonatal chronic lung disease in Western Australia

Objective: To describe the course and management of infants with neonatal chronic lung disease who were discharged home on low-flow supplemental oxygen.
Methodology Retrospective case series in Western Australia.
Results Fifty-six neonates born in the 6 year period 1987-92 inclusive were discharged home on supplemental oxygen. The median gestational age was 27 weeks (range 22-40), median birthweight 865 g (range 450-3350), median oxygen flow rates 125 mL/min (range 30-850). The median corrected age at discharge was 1 month (range term-9.5) and this had decreased throughout the study period. Acute hospital readmissions were common (36 of 56, 64%). The majority of these admissions were for wheezing illnesses. Three infants died. The median corrected age at weaning from day oxygen was 4 months (range term-33) and from night oxygen was 6 months (range 2-38). Monitoring of oxygen saturation in air, in low-flow oxygen and in the overnight sleep study were important non-invasive guides in deciding when patients were ready for discharge, reducing the oxygen flow rate and when oxygen could be ceased, respectively.
Conclusions The home oxygen programme enables infants with neonatal chronic lung disease to be discharged home earlier, is safe, and well accepted by parents and community health care workers.     

Home oxygen status and rehospitalisation and primary care requirements of infants with chronic lung disease.

OBJECTIVES: To determine whether the rehospitalisation and primary care requirements of infants with chronic lung disease (CLD) during the first two years after birth were influenced by a requirement for supplementary oxygen after discharge from the neonatal intensive care unit. METHODS: Review of records from both the hospital and general practitioner. Patients: 235 infants, median gestational age 27 (range 22-31) weeks, 88 of whom were receiving supplementary oxygen when discharged home. RESULTS: Overall, the infants required a median of 2 (range 0-20) admissions per patient, 8 (0-41) outpatient attendances, 13 (0-76) contacts with the general practitioner, and 17 (0-169) consultations with other primary healthcare professionals. The home oxygen patients required significantly more and longer admissions (p < 0.01) and more outpatient attendances (p < 0.05). The total cost of care per infant of the home oxygen group was greater (p < 0.001); this reflected higher costs for hospital stay (p < 0.01), total inpatient care (p < 0.01), and primary care drugs (p < 0.01). CONCLUSION: Despite routine use of antenatal steroids and postnatal surfactant, certain patients with CLD, particularly those who receive home oxygen treatment, show high rates of utilisation of health service resources after discharge from the neonatal care unit.     

High versus restricted use of home oxygen therapy, health care utilisation and the cost of care in chronic lung disease infants

Use of home oxygen therapy for prematurely born infants with chronic lung disease (CLD) can facilitate early discharge, but affected infants might require more readmissions. Our aim was to determine if health care utilisation and associated costs in the first 2 years were greater in centres with a high compared to centres with restricted use of home oxygen therapy. A retrospective review of the hospital and general practitioner (GP) medical records of 235 infants with CLD (median gestational age 27 weeks; range 22–33 weeks) was performed to note their readmissions, outpatient attendances, community service referrals and cost of care in the first 2 years after birth. A total of 76 infants (64%) in the high use centres and 12 (10%) in the restricted use centres were discharged home on oxygen. Infants in the high use centres were discharged home from neonatal care at a younger age (median 37.7 versus 39.9 weeks; P <0.001), but subsequently had similar numbers of inpatient events, and less GP ( P =0.012) and community care ( P <0.001) contacts, although their duration of home oxygen use was longer ( P <0.001). The post-discharge costs were similar in the two types of centre, but the neonatal costs ( P <0.0001) and total cost of care per infant over the first 2 years ( P <0.0001) were lower in the high use centres. Conclusion:early discharge and high use of home oxygen therapy was not associated with an increased cost of care or increased morbidity.Abbreviations CLD chronic lung disease - GP general practitioner - ICU intensive care unit     

Home oxygen status and rehospitalisation and primary care requirements of infants with chronic lung disease

Objectives: To determine whether the rehospitalisation and primary care requirements of infants with chronic lung disease (CLD) during the first two years after birth were influenced by a requirement for supplementary oxygen after discharge from the neonatal intensive care unit. Methods: Review of records from both the hospital and general practitioner. Patients: 235 infants, median gestational age 27 (range 22–31) weeks, 88 of whom were receiving supplementary oxygen when discharged home. Results: Overall, the infants required a median of 2 (range 0–20) admissions per patient, 8 (0–41) outpatient attendances, 13 (0–76) contacts with the general practitioner, and 17 (0–169) consultations with other primary healthcare professionals. The home oxygen patients required significantly more and longer admissions (p < 0.01) and more outpatient attendances (p < 0.05). The total cost of care per infant of the home oxygen group was greater (p < 0.001); this reflected higher costs for hospital stay (p < 0.01), total inpatient care (p < 0.01), and primary care drugs (p < 0.01). Conclusion: Despite routine use of antenatal steroids and postnatal surfactant, certain patients with CLD, particularly those who receive home oxygen treatment, show high rates of utilisation of health service resources after discharge from the neonatal care unit.     

Quality of life of mothers and families caring for preterm infants requiring home oxygen therapy: a brief report

OBJECTIVE: To investigate the impact on mothers and families of caring for a premature infant receiving home oxygen therapy (HOT). METHODS: Standard questionnaires were used to compare the functioning of mothers and families of 10 premature infants receiving HOT, 10 premature infants who were discharged from hospital on HOT but who no longer required it and 20 premature infants who had never required treatment with HOT. RESULTS: After adjustment for gestational age, chronological age, birthweight and place of residence (urban/rural), the care required by premature infants receiving HOT had a significantly greater impact on their families than the care of infants not receiving HOT. Mothers of premature infants receiving HOT reported significantly less vitality and more mental health problems than mothers of infants not receiving HOT. CONCLUSIONS: The use of HOT for premature infants may have a significant adverse impact on their mothers and families.     

Early neonatal presentations to the pediatric emergency department

As a result of shorter postpartum hospital stays, many medical concerns, which traditionally have been managed in newborn nurseries, are presenting to the pediatric emergency department (PED). We undertook a study to determine the profile of early neonatal visits to the PED. In addition, we examined the influence of maternal factors and length of postpartum hospital stay on PED visits. METHODS: We conducted a retrospective chart review of all neonates < or = 8 days of age who presented to the PED between June 1990 and May 1995. Data gathered from neonatal and corresponding maternal charts included neonatal and maternal demographics, prenatal instruction, length of postpartum stay, source of referral, age at presentation, presenting complaint, diagnosis, disposition, and course in hospital, if admitted. RESULTS: A total of 559 neonatal visits were identified. Neonatal use of the PED increased 245% compared to an overall increase in PED use of 8.7% during the study period. Jaundice, difficulty breathing, feeding problems, and irritability were the most common presenting complaints while the most frequent diagnoses were normal physiology, jaundice, feeding problems, and query sepsis. Our overall admission rate was 33%. Self-referred patients were at a significantly lower risk of serious illness (16% admitted vs 49 % of consult patients). The self-referral rate increased with maternal age less than 21, single marital status, no prenatal classes, and primiparity. The length of postpartum hospital stay was identified in 389 neonates (55 early discharge (ED) and 334 non-early discharge (NED). The ED group had a significant increase in annual PED utilization compared to the NED group changing from 2% of the total population in study year 1 to over 31% in the final year. The ED and NED groups did not differ significantly with respect to the majority of chief complaints, frequency of PED diagnoses, admission rates, or maternal characteristics. CONCLUSIONS: Use of the PED by neonates < or = 8 days of age increased significantly over the study period. The majority of neonates presented by self-referral and were discharged with advice only. Mothers who were young, single, primiparous, or who had not attended prenatal classes presented with neonates who were less seriously ill. Although ED neonates represent an enlarging subset of PED visitors, they do not appear to differ significantly from NED neonates with respect to PED complaints, diagnoses, and disposition.     

Use of sleep studies in the neonatal intensive care unit

Although early hospital discharge of infants can be both cost-effective and better for developmental care and parent-infant bonding, neonatal caregivers need to ensure infant safety. One of the concerns of early discharge is the risk that premature babies may continue to have apnea, bradycardia, and oxygen desaturation after discharge and that these events can be serious enough to increase morbidity and mortality. The discharging provider bears the responsibility of assessing each infant's risk for persistent apnea and providing the care and monitoring appropriate for his presumed risk level. Presently there is no universally accepted testing method that can accurately predict which infants will experience significant apnea. Neonatal sleep studies are one of the objective methods being evaluated to identify infants at risk for persistent apnea. This article addresses arguments for and against the use of sleep studies to determine the risk of apnea in neonates about to be discharged, types of sleep studies and what they test, and how sleep studies can be useful in determining infant care.     

不同起始时间应用咖啡因对早产儿安全性及有效性的评估：一项江苏省多中心研究

目的 评估早产儿（胎龄≤31周）早期和晚期使用咖啡因的有效性和安全性。方法 从江苏省8家医院的新生儿重症监护室中回顾性选取640例胎龄≤31周的早产儿作为研究对象,其中早期应用咖啡因510例（生后≤72 h开始应用;早期应用组）,晚期应用咖啡因130例（生后>72 h开始应用;晚期应用组）。比较两组早产儿的临床资料。结果 早期应用组和晚期应用组在出生体重、Apgar评分、性别、胎龄、入院年龄等方面的比较差异无统计学意义（P > 0.05）。早期应用组咖啡因应用起始日龄和撤除日龄小于晚期应用组（P < 0.05）;早期应用组咖啡因应用时间短于晚期应用组（P < 0.05）。两组之间入院时呼吸支持情况的比较差异无统计学意义（P > 0.05）。早期应用组呼吸暂停发生率低于晚期应用组（P < 0.05）;早期应用组用氧时间和住院时间短于晚期应用组（P < 0.05）。早期应用组支气管肺发育不良发生率和家庭氧疗率显著低于晚期应用组（P < 0.05）。两组出院时新生儿颅内出血、脑室周围白质软化、坏死性小肠结肠炎、早产儿视网膜病变、动脉导管未闭的发生率和纠正胎龄40周时新生儿神经行为评分的比较差异均无统计学意义（P > 0.05）。两组的病死率比较差异亦无统计学意义（P > 0.05）。结论 早产儿（胎龄≤31周）早期应用咖啡因可显著缩短咖啡因应用时间、用氧时间和住院时间,且无明显不良反应。     

Long-term outcome of preterm infants discharged home on kangaroo care in a developing country

Several hospital-based studies have shown the beneficial effect of kangaroo care on preterm infants. Long-term outcome was studied in 297 preterm infants born at Harare Hospital weighing 500-1800 g, discharged home on kangaroo care and followed up for 12 months. Of these, 79 (26.6%) died, 141 (47.5%) survived to complete follow-up and 77 (25.9%) were lost to follow-up. Of those who died, median birthweight was 1460 g, median age at hospital discharge 7 days, median weight at discharge 1400 g and median age at death 66 days. Of those who completed follow-up, median birthweight was 1575 g, median age at hospital discharge was 6 days and median weight at hospital discharge was 1500 g. Of those who were lost to follow-up, median age at loss to follow-up was 70 days, median birthweight was 1540 g, median age at hospital discharge was 5 days and median weight at hospital discharge was 1500 g. The hospital re-admission rate was 22.9% with 8.8% mortality. Maternal mortality and chronic morbidity rates were 4.7% and 7.4%, respectively. On comparing those who died with those who completed follow-up, mother's age <20 years, birthweight <1500 g and maternal mortality and chronic morbidity were significant risk factors for infant mortality. Age at discharge and weight at birth and on discharge were not significantly associated with infant mortality.     

Early hospital discharge of the healthy term neonate: the Italian perspective.

AIM: An appropriate timing of hospital discharge of the healthy, term neonate represents a balance between birth medicalization and surveillance of immediate health hazards. In the absence of European recommendations, the authors have conducted a broad national survey on the current policies of neonatal discharge. METHODS: A 13-item questionnaire was sent to 136 Italian birth centers. Quantitative variables were expressed as mean+/-range. Qualitative variables were expressed as frequencies. chi squared test was used for variables comparison. RESULTS: Mean age at discharge for a vaginally delivered neonate was 72 hours. Twelve percent of centres would not schedule a follow-up appointment. Neonates born after a cesarean section were discharged at a mean age of 97 hours. Almost all centres (95/98) would discharge an healthy infant without risk factors for hyperbilirubinemia with a total serum bilirubin (TSB) of 13 mg/dL at 72 hours but 14.7% of these centers would not recheck TSB. The same healthy neonate would be discharged at the age of 45 hours with a TSB=10 mg/dL in 67/98 centers and in 11.9% of cases would not be rechecked. CONCLUSION: Most Italian hospitals discharge healthy, term neonates born after spontaneous vaginal delivery (SVD) at over 72 hours of age. This policy should protect from missed diagnoses of clinical importance (e.g. hyperbilirubinemia). On the other hand, a prolonged hospitalization tends to increase maternal discomfort and medical costs. Implementing a protocol of home visits/clinic follow-up appointments after an earlier discharge may minimize health hazards and medical costs and optimizing the patient's feedback.     

Margin of safety for discharge after apnea in preterm infants

OBJECTIVE: Most neonatologists include an apnea-free period in the criteria for the discharge of preterm infants. However, the length of time one should wait after the cessation of apnea before sending an infant home without a monitor is debated. We undertook this study in an attempt to define a minimal and safe observation period between the time of the last apnea episode and discharge. METHODS: We reasoned that in infants with idiopathic apnea of prematurity, the intervals between days on which apnea occurs gradually increase until some point at which clinically significant apnea ceases. Therefore, knowledge about the intervals between days on which apnea occurred just before the last apnea would provide a reasonable estimate of the minimal safe observation interval between the last apnea and discharge. We reviewed the charts of 266 infants born in 1993 and 1994 at 相似文献   

Early and long‐term outcome after tracheostomy in children

Background: Tracheostomy has become an increasingly important issue for children discharged with primary or secondary respiratory problems. Despite the known advantages, considerable controversy remains regarding the appropriate indications, timing, and results of tracheostomy, in the context of home care. The aims of this study were to retrospectively evaluate our experience with tracheostomy and to consider problems related to this procedure, both in the hospital and after discharge. Methods: We performed a retrospective chart review of all patients receiving new tracheostomies in our department, over a 5‐year period. Results: Thirty tracheostomies were performed in 30 patients over a 5‐year period. The overall tracheostomy rate among ventilated patients was 3.4%. Most (90%) of the tracheostomies were placed after mechanical ventilation. Patients who were successfully decannulated spent significantly less time in intensive care, both before (P= 0.01) and after surgical tracheostomy procedure (P= 0.034) when compared to the patients discharged with tracheostomy, either with or without home ventilation. These patients also had shorter total intensive care admissions (P= 0.002) and shorter hospitalizations overall (P= 0.013). Successful decannulation was achieved in five patients (17%). The cumulative mortality rate was 17% in the pediatric intensive care unit, 20% within 30 days, and 41% within 1 year. Conclusions: Patients admitted with anatomic or functional airway problems had higher decannulation rates. Patients who were successfully decannulated also had significantly shorter PICU stays prior to tracheostomy. In patients with neurologic and muscular disease, or with chronic heart/lung disease, decannulation rates are very low, and these patients have a higher mortality risk after discharge.     

Early newborn hospital discharge and readmission for mild and severe jaundice

OBJECTIVES: To further explore the relationship of early newborn hospital discharge and readmission for jaundice, and to determine if early hospital discharge was associated with increased severity of jaundice among those readmitted. METHODS: We performed a population-based case-control study using Washington State vital statistics, birth certificates, and hospital discharge abstracts from 1991 to 1995. Cases included 750 infants readmitted to the hospital for jaundice in the first 2 weeks of life; controls included 3192 infants not readmitted. Infants with severe medical conditions and those delivered by cesarean section were excluded. Early hospital discharge was defined as fewer than 30 hours in the hospital, late hospital discharge, 30 to 78 hours. We assessed the risk for hospital readmission for jaundice, for hospital readmissions classified as brief (< or =2 days) or prolonged (>2 days), and for hospital readmissions classified as uncomplicated or complicated. RESULTS: Infants discharged from the hospital early were at increased risk for jaundice (odds ratio, 1.34 [95% confidence interval, 1.10-1.64] adjusted for birth year, gestational age, maternal race and age, parity, payer, and infant sex). The risk associated with early hospital discharge was similar regardless of whether the hospital readmission was brief or prolonged and complicated or uncomplicated. One hundred twenty-two infants would have to stay for longer than 30 hours to avoid 1 jaundice readmission. CONCLUSIONS: While newborns discharged from the hospital early are at increased risk for hospital readmission for jaundice, the clinical significance is limited. Mandating longer neonatal stays may not be the most effective strategy to prevent hospital readmission for jaundice and its complications.     

Shorter hospital stay for moderately preterm infants

AIM: To determine length of hospital stay (LOS) for moderately preterm infants during the last 20 years, and to identify factors affecting the number of bed-days. METHODS: Review of LOS for all infants delivered between 30 to 34 gestational weeks during 1983, 1988, 1993, 1998 and 2002. Exclusion criteria: life-threatening abnormalities, chromosomal anomalies and death during hospitalization. RESULTS: 564 included infants accounted for 20% of admissions and 48% of bed-days in the neonatal unit. Between 1983 and 2002, maternal age and use of nasal continuous positive airway pressure increased, use of antibiotics and mechanical ventilation decreased, whereas distributions for gestational age, birthweight, gender, smallness for gestational age, low Apgar score or incidence of respiratory distress syndrome did not change. For healthy inborn singletons discharged home, LOS decreased from 1983 (28+/-11 d, mean+/-SD values) to 2002 (14+/-7 d, p<0.05). Infants born more immature had longer LOS, but postconceptional age at discharge did not differ between age groups. CONCLUSION: LOS for moderately preterm infants has decreased as a result of individualized neonatal care and organization of homecare support. Shorter LOS is of benefit to the family, prevents overcrowding in the NICU and has important economic implications.