DISCHARGE PLANNINGDISCHARGE PLANNING

The decision of when to discharge an The decision of when to discharge an infant from the hospital after a stay in infant from the hospital after a stay in the NICU is complex.the NICU is complex.made primarily on the basis of

the infant’s medical status but is complicated by several factors:◦readiness of families for discharge◦differing opinions about what forms

of care can be provided at home◦pressures to contain hospital

costs by shortening the length of stay.

Shortening the length of hospital stay may benefit the infant and family ◦Decreasing period of separation ◦May lessen subsequent adverse

effect on parenting ◦Risks of hospital-acquired morbidity

reduced

Categories of High-Risk Categories of High-Risk InfantsInfantsTHE PRETERM INFANTTHE INFANT WITH SPECIAL

HEALTH CARE NEEDS OR DEPENDENCE ON TECHNOLOGY

THE INFANT AT RISK BECAUSE OF FAMILY ISSUES

THE INFANT WITH ANTICIPATED EARLY DEATH

Categories of High-Risk Categories of High-Risk InfantsInfantsThe Preterm InfantPhysiologic stability

◦oral feeding sufficient to support appropriate growth

◦ability to maintain normal body temperature in a home environment

◦sufficiently mature respiratory control

Active program of parental involvement and preparation for care of the infant at home

Categories of High-Risk Categories of High-Risk InfantsInfantsThe Preterm Infantarrangements for health care after

discharge by a physician or other health care professional who is experienced in the care of high-risk infants

an organized program of tracking and surveillance to monitor growth and development

Categories of High-Risk Categories of High-Risk InfantsInfantsThe Infant with Special Health Care

NeedsThose requiring special or

assistive feeding techniquesThose requiring respiratory

assistanceThose with complex congenital

anomalies requiring supportive and assistive devices

Categories of High-Risk Categories of High-Risk InfantsInfantsThe Infant at Risk Because of

Family IssuesMaternal factors

◦lower educational level◦lack of social support◦marital instability◦fewer prenatal care visits

Categories of High-Risk Categories of High-Risk InfantsInfantsThe Infant at Risk Because of Family

IssuesParental substance abuse

◦adverse effects on the developing fetus in utero

◦possible postnatal exposure to drugs through breastfeeding or by inhalation

◦drug-seeking behaviors of parents may compromise the safety of the child’s environment

Categories of High-Risk Categories of High-Risk InfantsInfantsThe Infant With Anticipated Early DeathFor many infants with incurable,

terminal disorders, the best place to spend the last days or weeks of life is at home

Arrangements for medical follow-up and home-nursing visits

Management of pain and other distressing symptoms

Arrangements for home oxygen or other equipment and supplies

Categories of High-Risk Categories of High-Risk InfantsInfantsThe Infant With Anticipated Early

DeathProviding the family with

information on bereavement support for the parents, siblings, and others

Discussion of possible resources for respite of caregivers

Assistance in addressing financial issues

Timing of DischargeTiming of Dischargewhen the infant demonstrates

the necessary physiologic maturity discharge planning and

arrangements for follow-up and any home care have been completed

parents have received the necessary teaching and have demonstrated their mastery of the essential knowledge and skills

Timing of DischargeTiming of DischargeAn infant may be discharged

before one of the infant’s physiologic competencies has been met, provided the health care team and the parents agree that this is appropriate and suitable plans have been made to provide additional support needed to ensure safe care at home, such as tube feeding, cardiorespiratory monitoring, or home oxygen.

Timing of DischargeTiming of DischargeDischarge Screening

◦Hearing Screening◦Eye examinations◦Cranial ultrasonography◦Immunizations

Head UltrasonographyHead UltrasonographyAll infants with gestational age <32wk Initial: Day 7-10 Follow-upIf no hemorrhage or germinal matrix

hemorrhage◦If < 28 wk: wk 4 and at 36 wk PCA (or

discharge if < 36 wk)◦ If > 28 0/7 – 31 6/7 wk: wk 4 or at 36 wk

PCA (or discharge if < 36 wk)If IVH gr 2+ or intraparenchymal

hemorrhage: ff up at least weekly until stable

Ophthalmologic Ophthalmologic ExaminationExaminationAll infants BW <1500g or GA <32 wkInitial: If <27 wk: wk 6 If 27-28 wk: wk 5If 29-30 wk: wk 4 If 31-31 6/7 wk: wk 3Follow-upImmature retina zone 1 or 2 or low-grade

ROP: ff up every 2 wkImmature retina zone 3: ff up in 4-10 wkPrethreshold ROP: ff up weeklyRegressing ROP: ff up every 1–10 wk

depending on zone

Audiology screeningAudiology screeningAll infants to be discharged home

from NICUExamine at 34 wk gestation or

greater

Discharge PlanningDischarge Planningshould begin early in the hospital

course.Goal: to ensure successful transition to

home careEssential discharge criteria

◦physiologically stable infant◦ family who can provide the necessary care

with appropriate support services in the community

◦primary care physician who is prepared to assume the responsibility with appropriate backup from specialist physicians and other professionals as needed.

Discharge PlanningDischarge PlanningParental EducationCompletion of Appropriate

Elements of Primary Care in the Hospital

Development of Management Plan for Unresolved Medical Problems

Discharge PlanningDischarge PlanningDevelopment of the

Comprehensive Home-Care PlanIdentification and Involvement of

Support ServicesDetermination and Designation

of Follow-Up Care

Comprehensive Home-Care Comprehensive Home-Care PlanPlanidentification and preparation

of the in-home caregiversformulation of a plan for

nutritional care & administration of any required medications

development of a list of required equipment and supplies and accessible sources

Identification and mobilization of the primary care physician, the necessary and qualified home-care personnel and community support services

Comprehensive Home-Care Comprehensive Home-Care PlanPlanassessment of the adequacy of

the physical facilities within the home

Development of an emergency care and transport plan

Assessment of available financial resources to ensure the capability to finance home-care costs

Family and Home Family and Home Environmental ReadinessEnvironmental Readinessidentification of at least 2 family

caregivers and assessment of their ability, availability, and commitment;

psychosocial assessment for parenting strengths and risks;

a home environmental assessment that may include on-site evaluation

review of available financial resources and identification of adequate financial support.

Community and Health Care Community and Health Care System ReadinessSystem ReadinessA primary care physician has been

identified and has accepted responsibility for care of the infant.

Surgical specialty and pediatric medical subspecialty follow-up care requirements have been identified and appropriate arrangements have been made.

Neurodevelopmental follow-up requirements have been identified and appropriate referrals have been made.

Community and Health Care Community and Health Care System ReadinessSystem ReadinessHome-nursing visits for assessment

and parent support have been arranged, as indicated by the complexity of the infant’s clinical status and family capability, and the home-care plan has been transmitted to the home health agency.

For breastfeeding mothers, information on breastfeeding support and availability of lactation counselors has been provided.

ReferencesReferencesHospital Discharge of the High-

Risk Neonate, a Policy Statement, AAP, Committee on Fetus and Newborn, Pediatrics 2008;122;1119-1126

Manual of Neonatal Care 6th edition by Cloherty et.al.

THANK YOUTHANK YOU