Discharge Planning
Ruth A. Hynes
Theresa M. Andrews
Changes in the health care system in the United States are encouraging earlier discharges and more out of hospital care. This comes at a time when some infants are requiring higher levels of complex care at home. The movement to make the discharge process increasingly family centered and efficient requires careful and organized discharge planning. The optimal safe and successful discharge requires mutual participation between the family and the medical and surgical teams and should begin at admission and follow the continuum of the infants hospital stay.
I. GOALS OF A COMPREHENSIVE DISCHARGE PLAN
Is individualized to meet infant and family needs and resources
Begins early; planning can begin with a prenatal diagnosis or upon admission to the neonatal intensive care unit (NICU)
Includes ongoing daily assessment and clearly identified goals
Anticipates potential delays in development and directs care toward prevention and early intervention
Promotes multidisciplinary communication as an essential component
Is community-based, with early identification of a primary pediatrician and other community resources
Promotes access to care and progression through the provider system with minimal fragmentation of care and duplication of services
Decreases the possibility of readmission
II. FAMILY ASSESSMENT
is a key component of a successful discharge process. Families are able to build on their strengths if given the opportunity to participate in the care early and be an active participant in the discharge process. Early partnership with the family promotes confidence and decreases stress by enhancing the parents’ feeling of control. The ability to provide adequate parent education is vital for the successful transition to home. With early planning, ongoing teaching, and attention to the family’s needs and resources, the transition to home can be smooth, even in the most complex cases. The family assessment should address the following questions:
Family
Who will be the primary caregiver(s) for the infant? How willingly is this responsibility assumed?
What is the family structure? Do they have a support system? Does one need to be developed or strengthened?
Are there language or learning barriers? Address this early.
How do they learn best? The nursing team should maximize the use of educational tools: written materials, visual props, and demonstrations.
How do previous or present experiences with the infant’s care affect the family’s ability to oversee care after discharge?
What are the actual as well as perceived complexities of the skills required to care for the infant?
What are their coping habits and styles?
Do the parents have any medical or psychological concerns that may have an impact on caretaking abilities?
What are the cultural beliefs and how might these affect the care of the infant?
What are the financial concerns? Will the family’s income change? If so, what resources are available to compensate?
Are there issues related to the family’s living conditions that will be challenging? Families can become overwhelmed by the volume of medical equipment that will be delivered to the home in the days before discharge. Evaluate the home nursery and other spaces for the infant/caregivers and supplies. Have the parent take pictures to evaluate layout options. Discuss supply storage recommendations such as plastic bins on wheels, baskets, and so forth.
Home environment. If an infant will require in-home respiratory support, make a referral to a durable medical equipment (DME) company. A respiratory therapist (RT) must assess the home to evaluate outlets in the infant’s area, measure door openings, inquire about electrical panel location and capacity, and ensure a safe environment.
Stress and coping. The separation of family and infant, inability to experience a traditional parenting role, and the inclusion of multiple caregivers in daily care can all be stressors to a family. The early establishment of parents as partners and participants in their infant’s care helps a family cope with the stress and separation associated with NICU care. The medical team, including the social worker, should assess the family’s psychological readiness for a transition to home. Social work can make recommendations for further community psychological supports as needed. It is helpful to keep in mind that while a family is preparing for a child with complex medical needs, they may also be grieving the loss of a traditional experience.
Financial resources. Social workers and/or resource specialists should assess a family’s financial situation early. A preterm delivery or need for complex home care can alter the family’s plans for work and child care. Loss of work, income changes, cost of co-payments, and inability to make career moves because of insurance coverage all affect the family’s financial stability. Social work can offer secondary insurance resources early if an infant’s medical course appears to require a longer than 30 days hospitalization, or if an infant is predicted to have long-term medical needs.
III. SYSTEM ASSESSMENT.
It is important to know how a facility functions, who assumes responsibility for various components of discharge planning, and how communication is carried out. Enough cannot be said about the need for consistency in care providers during the discharge process. Effective relationships with the family,
as well as a health care team that is familiar with an infant, will help immensely with concise communication and will enhance an organized discharge process. Identifying payer coverage early promotes timely assessment of contractual requirements.
as well as a health care team that is familiar with an infant, will help immensely with concise communication and will enhance an organized discharge process. Identifying payer coverage early promotes timely assessment of contractual requirements.
A physician or nurse practitioner is responsible for daily management of care. In teaching institutions where staff rotates, families may need to adjust to many different providers. For those infants with complex issues, identifying a primary attending physician or practitioner provides the family with more continuity. The team then can coordinate, implement, and evaluate the developed care plan.
The infant’s primary nurse and nursing team follows the family through the NICU stay coordinating, implementing, and evaluating the developed care plan on a daily basis.
Respiratory, physical, and occupational therapists teach families necessary specific skills and assist in transitioning care to community resources.
Social workers assess and support the family. Social work should be a part of family and team meetings to help facilitate communication with the family.
In the hospital, case manager/patient care coordinator gathers the necessary insurance coverage, sets up the homecare systems (i.e., Visiting Nurse Association [VNA], Medical Supply Company, Early Intervention Referral), and blocked hours if approved by the insurance company. The NICU case managers are the key contact in working with services and insurance companies to secure prior authorizations for exceptions to benefits, equipment, and ambulances.
The role of a discharge coordinator or planner varies by institution. The discharge planner can assist in identifying infants who may be approaching discharge, discuss alternatives to home if necessary, and can work with the medical and nursing teams to ensure that the family receives discharge planning in a timely and organized manner.
A Resource Specialist can be helpful in finding other financial resources available to families to cover medical costs once the patient is discharged.
Payer resources, such as health maintenance organizations (HMOs) and thirdparty payers, often have case managers to assist in the coordination of services. Use of preferred providers may be contractually required. Out-of-hospital case managers can be consulted by the family or by the NICU case manager to help clarify issues of coverage and resource availability.
Interpreters assist in communication with families when indicated. Any complex discharge updates and teaching should be done with an interpreter when a family is not fluent in English.
IV. INFANT’S READINESS FOR DISCHARGE
Healthy growing preterm infants are considered ready for discharge when they meet the following criteria:
Able to maintain temperature in an open environment
Able to take all feedings by bottle or breast without respiratory compromise
Demonstrates steady weight gain evidenced by a preterm infant weight gain of 10 to 15 g/kg/day and a term infant weight gain of 20 to 30 g/kg/day
Free of apnea or bradycardia for 5 days (see Chap. 31)
Able to sleep with head of bed flat without compromising the infant’s health and safety. (If reflux is present and compromising infant’s health or safety, provide patient with Tucker Wedge & Sling equipment available through Children’s Medical Ventures: www.tuckersling.respironics.com)
Infants with specialized needs require a complex, flexible, ongoing discharge and teaching plan. Medications and special formulas or dietary supplements should be obtained as early as possible to optimize teaching. Some discharge specifics may not be identified until just before discharge. It is important to consider the infant’s relative fragility and the complexity of interventions. Include assessment of behavioral and developmental issues, and evaluate parental recognition and response.
Discharge screening. Complete routine screening tests and immunizations according to individual institutional guidelines (see Table 18.1).
Cranial ultrasonography (see Chap. 54 and Table 18.1) screening for intraventricular hemorrhage and periventricular leukomalacia for all infants who satisfy the following criteria:
Weight < 1,500 g or gestational age <32 weeks.
Perform head ultrasonography at day of life 1 to 3, if results alter clinical management, day of life 7 to 10, and then at 1 month of age.
Immunizations. Administer according to American Academy of Pediatrics’ guidelines based on chronologic, not postconceptional, age (http://www.cdc.gov/vaccines and see Chap. 7).
Car seat trial (see Table 18.1). Infants who fail a car seat test need to be retrialed in a car bed. Car seat testing can be repeated in the community setting 1 month later.
V. PREPARING THE FAMILY FOR DISCHARGE.
A well-thought-out plan prepares the family to recognize trouble early and seek medical attention before the health of their infant is compromised. Poor discharge planning has been linked to increased unscheduled health care use and readmissions.
Begin teaching early to allow the caregivers adequate time to process information, practice skills, and formulate questions. Make teaching protocols detailed and thorough. Include written information for the family to take home to use as references (see Fig. 18.1 and Table 18.2). Standardize information to ensure that every family member receives the same essential information. Create a discharge binder to help organize infant’s care and routines. Address necessary medical information, well-baby care, “back to sleep,” developmental issues, secondhand smoke, and shaken baby syndrome. Provide cardiopulmonary resuscitation (CPR) education early and possibly repeat closer to discharge date. Include several family members in the learning process so that the parents can get needed support.
Simplify and organize care by thoroughly reviewing the infant’s daily regimen.
Table 18.1 Guidelines for Routine Screening, Testing, Treatment, and Follow-up of Infants Admitted to Neonatal Intensive Care Unit (NICU)
Newborn state screening for metabolic disease (see Chap. 60)
Criteria
▪
All infants admitted to the NICU
Initial
▪
Day 3 or discharge (D/C) date (whichever comes first)
Follow-up
▪
Day 14 or D/C date (whichever comes first)
▪
Week 6 (if BW <1,500 g)
▪
Week 10 (if BW <1,500 g)
Head ultrasonography (see Chap. 54)
Criteria
▪
All infants with GA <32 wk (or any GA at any time if clinically indicated)
Initial
▪
Day 7-10 (in the case of critically ill infants, when results of an earlier ultrasonography may alter clinical management, an ultrasonography should be performed at the discretion of the clinician)
Follow-up (minimum if no abnormalities noted)
▪
If no hemorrhage or germinal matrix hemorrhage
□
If <32 wk: week 4 and at 36 wk post menstrual age (or discharge if <36 wk)
▪
If intraventricular (grade 2+) or intraparenchymal hemorrhage: follow-up at least weekly until stable (more frequently if unstable posthemorrhagic hydrocephalus or clinically indicated)
Ophthalmologic examination (see Chap. 64)
Criteria
▪
All infants with BW <1,500 g or GA <32 wk
Initial
▪
If <27 wk: week 6
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