Neonatal Intensive Care Unit Discharge Planning

Vincent C. Smith

Theresa M. Andrews

A successful transition from the neonatal intensive care unit (NICU) to home is critical in order to ensure a safe and confident transition home for newborns and their families. In keeping with the rest of newborn care, there is a progressive trend toward increased family centeredness and efficiency that requires careful and organized discharge planning. The optimal safe and successful discharge requires mutual participation between the family and the medical faculty and should begin at admission and follow the continuum of the infant’s hospital stay. This chapter discusses the infant’s discharge readiness as well as the discharge preparation for the family.

NICU discharge readiness is the attainment of technical skills and knowledge, emotional comfort, and confidence with infant care by the primary caregivers at the time of discharge. NICU discharge preparation is the process of facilitating discharge readiness to successfully make the transition from the NICU to home. Discharge readiness is the desired outcome, and discharge preparation is the process.

I. INFANT’S DISCHARGE READINESS. The American Academy of Pediatrics (AAP) recommends the transition to home occur when the infant achieves physiologic maturity and has completed all predischarge testing and treatment.

A. Healthy growing preterm infants are considered ready for discharge when they meet the following criteria:

1. Able to maintain temperature in an open environment

2. Able to take all feedings by bottle or breast without respiratory compromise

3. Demonstrates steady weight gain evidenced by a weight gain of 20 to 30 g/day

4. Free of apnea or bradycardia for 5 days (see Chapter 31)

5. Able to sleep with head of bed flat without compromising the infant’s health and safety

B. Complete routine screening tests and immunizations according to AAP, local, and regional guidelines (Table 18.1). For all infants

1. Newborn screening (see Chapter 8)

2. Hearing screening (see Chapter 68)

3. Immunizations administered according to AAP guidelines based on chronologic, not postmenstrual, age (http://www.cdc.gov/vaccines and see Chapter 7)

For preterm infants

4. Head ultrasound and ophthalmologic evaluation if indicated screening (see Chapter 67)

5. Car seat/bed use (see Table 18.1). Prior to discharge, each preterm infant requires a car seat or car bed evaluation as appropriate.

C. When planning discharge, it is important to consider the infant’s relative fragility and the complexity of care needs. Infants with specialized needs require a complex, flexible, ongoing discharge care plan. Because medications, special formulas, and/or dietary supplements may be challenging for the parents to obtain, the need for these items should be identified early so they can be obtained as soon as possible to optimize discharge teaching opportunities. 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.

Table 18.1. Guidelines for Routine Screening, Testing, Treatment, and Follow-up at Neonatal Intensive Care Unit (NICU)

Newborn Screening
*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)
Day 30 or D/C date (whichever comes first)
Continue monthly
On D/C date if more than 7 days since prior screen
Head Ultrasound (see Chapter 54)
*Criteria*
All infants with gestational age (GA) <32 weeks
*Initial*
Days 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 hemorrhage only Week 4 and at 40 weeks’ postmenstrual age (or discharge if <40 weeks)
If intraventricular (grade 2+) or intraparenchymal hemorrhage: Follow up at least weekly until stable (more frequently if unstable posthemorrhagic hydrocephalus). (Daily head circumference measurement should also be performed in the case of ventricular dilatation.)
Note: An ultrasound should be done at any GA at any time if thought to be clinically indicated.
Audiology Screening (see Chapter 68)
*Criteria*
All infants being discharged home from NICU or who are at 34 weeks PMA or greater at the time of transfer to a level 2 nursery
*Timing*
Examine at 34 weeks gestation or greater.
Car Seat and Car Bed Fit Assessment and Screening
*Criteria*
All infants to be discharged home from NICU and born at <37 weeks or BW <2,500 g or with other conditions that may compromise respiratory status (e.g., chronic lung disease, airway anomalies, and tracheostomy).
*Timing*
Fit assessment or screening prior to discharge home
Ophthalmologic Examination (see Chapter 67)
*Criteria*
All infants with birth weight ≤1,500 g or GA <31 0/7 weeks
Infants with a birth weight between 1,500 g and 2,000 g or GA 31 0/7-34 0/7 weeks with high-illness severity (e.g., those who have had severe respiratory distress syndrome, hypotension requiring pressor support, or surgery in the first several weeks of life) per the discretion of the attending neonatologist
*Timing of Initial Exam*
GA		Postmenstrual Age		Week after Birth
22^*		29		7
23^*		30		7
24		31		7
25		31		6
26		31		5
27		31		4
28		32		4
29		33		4
30		34		4
31+		—		4
^*Guidelines have been adjusted slightly from the AAP recommendations per BCH Ophthalmology’s discretion.
If the infant is transferred to another nursery prior to 4 weeks of age, recommend exam at the receiving hospital.
If the infant is discharged home prior to 4 weeks of age, examine prior to discharge.
*Follow-up (Based on Most Recent Exam Findings)*
Follow-up examinations should be recommended by the examining ophthalmologist on the basis of retinal findings classified according to the international classification. The following schedule is suggested:
Stage		Zone		Follow-up
Immature (no ROP)		I		≤1 week
Immature (no ROP)		posterior II		1-2 weeks
Immature (no ROP)		mid-anterior II		2 week
Immature (no ROP)		III		3 week
I		I		≤1 week
I		II		2 weeks
I		III		2-3 weeks
II		I		≤1 week
II		II		1-2 weeks
II		III		2-3 weeks
III		II		≤1 week
Regressing		I		1-2 weeks
Regressing		II		2 weeks
Regressing		III		2-3 weeks
Follow up after resolution of ROP depends on the severity of the active phase of ROP but should occur by age 1 year. The following findings warrant consideration of treatment:
Stage			Zone
I, II, or III with plus disease			I
III no plus disease			I
II or III with plus disease			II
*Guidelines have been adjusted slightly from the AAP recommendations per BCH Ophthalmology’s Discretion
Hepatitis B Vaccination (see Chapter 48)
*Criteria*
All infants being discharged home from NICU
*Initial*
If weight ≥2,000 g and stable: Vaccinate at birth or shortly thereafter.
If weight ≥2,000 g and unstable: Defer vaccination until the infant’s clinical condition has stabilized.
If weight <2,000 g: Vaccinate at 30 days or discharge (whichever comes first).
Synagis RSV Prophylaxis
*Criteria*
Synagis RSV prophylaxis should be considered from November through March for infants who meet any of the following criteria:
	□ GA at birth <29 0/7 weeks
	□ GA at birth 29 0/7-31 6/7 weeks with chronic lung disease defined as need for supplemental oxygen for at least 28 days after birth
	□ Certain types of hemodynamically significant congenital heart disease
	□ Pulmonary abnormality or neuromuscular disease that impairs ability to clear secretions from upper airways
	□ Profound immunocompromised condition
*Timing*
Give first dose 48-72 hours before discharge.
Infant Follow-up Program (IFUP)—Offered at Many Hospitals That Have a Level 3 NICU
*Criteria*
All infants with GA <32 weeks at birth
*Timing*
Referral completed before discharge
First appointment to be scheduled at 3 months post due date
Neonatal Neurology Program
*Criteria*
All infants meeting one of the following conditions:
	□ Neurologic disorders (e.g., intracranial hemorrhage, neonatal seizures, and stroke)
	□ Neuromuscular disorders
	□ Recipient of therapeutic hypothermia for HIE
*Timing*
Referral completed before discharge
Note: Infants with GA <32 weeks at birth should also be referred to IFUP
Early Intervention Program (EIP)
*Criteria*
Infant meeting four or more of the following criteria:
	□ BW <1,200 g
	□ GA <32 weeks
	□ NICU admission >5 days
	□ Apgar <5 at 5 minutes
	□ Intrauterine growth restriction (IUGR) or small for gestational age (SGA) (refer to growth curves)
	□ Chronic feeding difficulties
	□ Suspected central nervous system abnormality
	□ Maternal age <17 years or 3 or more births at maternal age <20 years
	□ High school education <10 years
	□ Parental chronic illness or disability affecting caregiving
	□ Lack of family supports
	□ Inadequate food, shelter, and clothing
	□ Open or confirmed protective service investigation (“51-A”)
	□ Substance abuse in the home
	□ Violence in the home
*Timing*
Referral completed before discharge
PMA, postmenstrual age; BW, birth weight; AAP, American Academy of Pediatrics; BCH, Boston Children’s Hospital; ROP, retinopathy of prematurity; RSV, respiratory syncytial virus.