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Hospital discharge of the high-risk neonate
HOSPITAL DISCHARGE OF THE HIGH-RISK NEONATE Sarah F. Zarbock,
The American
Academy
released a policy discharge
statement
of the high-risk
has been developed, basis of published, Four categories l l l l
The The The The early
of high-risk
newborns
preterm infant infant who requires technological support infant primarily at risk because of family issues infant whose irreversible condition will result in death
Adequate time to prepare the family to provide health care in their home and mobilize community resources to provide support services must be allowed before discharge. AAP’s proposed guidelines acknowledge that, similar to “the advances in neonatal care and changes in the
HOME
CARE PROVIDER
neonate.’
scientifically
are identified:
(AAP) recently
on the issue of hospital
to the extent
Determining when to discharge an infant after neonatal intensive care is a complex process. The decision is made even more difficult by cost-containment issues, notably lengths of hospital stay and increased emphasis on earlier discharge. Shortening the length of stay may benefit both infant and family because decreasing their separation may lessen the subsequent adverse effect on parenting. The risks of hospital-acquired morbidity, especially nosocomial infections, also may be reduced. However, the overriding concern related to discharge is that infants may be placed at risk for increased mortality and morbidity before they are physiologically stable.
302
of Pediatrics
PA-C
The statement possible,
derived
on the
information.
economic and societal forces, the complexity pita1 care issues has increased.”
DISCHARGE
of posthos-
PLANNING
The care of each high-risk neonate after discharge must be carefully coordinated to provide ongoing multidisciplinary support of the family. The discharge planning team should include the parents, primary care physician, neonatologist, neonatal nurses, and social worker. Other health professionals may be included as needed. Discharge planning should be initiated when neonate recovery is certain, even though a specific discharge date may not be predicted. The goal of the discharge plan is to ensure a successful transition to home care; these elements are essential: a physiologically stable infant, a family who can provide the necessary care without undue strain and with appropriate community support services, and a primary care physician prepared to assume medical responsibility with appropriate back up from specialists as needed. Six other components are critical to discharge planning. Parental education. Parental contact and involvement in their infant’s care should have been encouraged from the time of admission. The development of an individualized teaching plan helps parents acquire the skills and judgment
DECEMBER
19%. VOL. 3 NO. 6
SHARING
IN ALL DIMENSIONS
necessary for appropriate infant care at home. Caregivers and parents must understand that if an infant is discharged from the hospital before complete physiological maturation and resolution of all complications of high-risk birth, his or her care requirements will continue at home. Parents also must understand that the level of care being asked of them is beyond that of the usual parental role. Thus ample time is essential to teach the parents and caregivers the techniques and the rationale for each item in the care plan. Insofar as possible, at least two caregivers, one of whom must be a responsible adult, should be identified and educated for each infant because the demands of home care can be physically and emotionally draining. Primary care implementation. Preparing the infant for transition to primary care begins early in hospitalization: administering immunizations at the recommended ages, completing metabolic screening, and assessing hearing by an acceptable electronic measurement. Hematologic status assessment is recommended for all infants because of the high prevalence of anemia after neonatal intensive care. Unresolved medical problem evaluation. Comprehensive review of the hospital course and the active problem list of each infant, as well as careful physical assessment, will reveal unresolved medical issues and areas of function that have not reached full maturation. The predischarge evaluation should ensure appropriate home care and follow-up. Home care plan development. Although the content of the home care plan may vary among the four categories of infants, the common elements include:
family should be reviewed, noting any risk factors that may contribute to an adverse infant outcome. The availability of social support is essential to the success of every parent’s adaptation to the home care of a high-risk infant. After the family’s social support needs have been identified, an appropriate, individualized intervention plan using available community programs, surveillance, or alternative care placement can be implemented. Follow-up care determination and designation. In general, the attending neonatologist is responsible for coordinating follow-up care. A primary care physician should be identified as early as possible to facilitate care planning between the primary care setting and the subspecialty center-based discharge planning staff. In an ideal situation, the primary care physician will meet the parents before the baby’s discharge and, if possible, examine the infant in the hospital. The determination of readiness for home care of an infant after neonatal intensive care is complex. Carefully balancing infant safety and well-being with family needs and capabilities is required, as well as considering the availability and adequacy of community resources and support services. Although the AAP guidelines have been developed predominantly from the physician’s standpoint, they provide a valuable framework for all health care professionals involved in the transition of neonates from the hospital to the home.
REFERENCES American born.
Academy Hospital
lines (S98 12).
Identifying and preparing in-home caregivers Developing a comprehensive listing of required equipment and supplies and accessible sources Identifying and mobilizing necessary and qualified home care personnel and community support services Assessing the adequacy of the home’s physical facilities Developing emergency care and a transport plan as indicated Assessing available financial resources to ensure the parents’ ability to finance home care costs
of Pediatrics
of the high-risk
Pediatrics
1998;
American
Academy
of Pediatrics
abilities.
Guidelines
for home
cents with Wagner tal versus Center;
chronic
1988.
Armstrong-Dailey ed.
New
disease.
JL, Power home
York:
Committee
discharge
on Fetus and neonate:
102:page
on Children
of infants,
Pediatrics
children,
199.5;96:
EJ, Fox H. Technology-dependent care.
Philadelphia:
guide-
numbers?
Committee care
New-
proposed
Science
with
Dis-
and adoles-
161-4. children:
Information
hospi-
Resource
p. 99-105. A, Zarbock Oxford
SF. Hospice
University
care
for children.
2nd
Press, In press.
Specific details of planning home care for the technologydependent infant are included in the AAP policy statement,2 a consensus report,l and, for hospice care, in Armstrong-Dailey and Zarbock.4 Finally, the primary care physician’s input in formulating the home care plan of the technology-dependent infant is essential. Surveillance mobilization.
DECEMBER
and support services identification The psychosocial characteristics
1998.
VOL. 3 NO.
6
and of each
HOME
CARE PROVIDER
303
The American
Academy
released a policy discharge
statement
of the high-risk
has been developed, basis of published, Four categories l l l l
The The The The early
of high-risk
newborns
preterm infant infant who requires technological support infant primarily at risk because of family issues infant whose irreversible condition will result in death
Adequate time to prepare the family to provide health care in their home and mobilize community resources to provide support services must be allowed before discharge. AAP’s proposed guidelines acknowledge that, similar to “the advances in neonatal care and changes in the
HOME
CARE PROVIDER
neonate.’
scientifically
are identified:
(AAP) recently
on the issue of hospital
to the extent
Determining when to discharge an infant after neonatal intensive care is a complex process. The decision is made even more difficult by cost-containment issues, notably lengths of hospital stay and increased emphasis on earlier discharge. Shortening the length of stay may benefit both infant and family because decreasing their separation may lessen the subsequent adverse effect on parenting. The risks of hospital-acquired morbidity, especially nosocomial infections, also may be reduced. However, the overriding concern related to discharge is that infants may be placed at risk for increased mortality and morbidity before they are physiologically stable.
302
of Pediatrics
PA-C
The statement possible,
derived
on the
information.
economic and societal forces, the complexity pita1 care issues has increased.”
DISCHARGE
of posthos-
PLANNING
The care of each high-risk neonate after discharge must be carefully coordinated to provide ongoing multidisciplinary support of the family. The discharge planning team should include the parents, primary care physician, neonatologist, neonatal nurses, and social worker. Other health professionals may be included as needed. Discharge planning should be initiated when neonate recovery is certain, even though a specific discharge date may not be predicted. The goal of the discharge plan is to ensure a successful transition to home care; these elements are essential: a physiologically stable infant, a family who can provide the necessary care without undue strain and with appropriate community support services, and a primary care physician prepared to assume medical responsibility with appropriate back up from specialists as needed. Six other components are critical to discharge planning. Parental education. Parental contact and involvement in their infant’s care should have been encouraged from the time of admission. The development of an individualized teaching plan helps parents acquire the skills and judgment
DECEMBER
19%. VOL. 3 NO. 6
SHARING
IN ALL DIMENSIONS
necessary for appropriate infant care at home. Caregivers and parents must understand that if an infant is discharged from the hospital before complete physiological maturation and resolution of all complications of high-risk birth, his or her care requirements will continue at home. Parents also must understand that the level of care being asked of them is beyond that of the usual parental role. Thus ample time is essential to teach the parents and caregivers the techniques and the rationale for each item in the care plan. Insofar as possible, at least two caregivers, one of whom must be a responsible adult, should be identified and educated for each infant because the demands of home care can be physically and emotionally draining. Primary care implementation. Preparing the infant for transition to primary care begins early in hospitalization: administering immunizations at the recommended ages, completing metabolic screening, and assessing hearing by an acceptable electronic measurement. Hematologic status assessment is recommended for all infants because of the high prevalence of anemia after neonatal intensive care. Unresolved medical problem evaluation. Comprehensive review of the hospital course and the active problem list of each infant, as well as careful physical assessment, will reveal unresolved medical issues and areas of function that have not reached full maturation. The predischarge evaluation should ensure appropriate home care and follow-up. Home care plan development. Although the content of the home care plan may vary among the four categories of infants, the common elements include:
family should be reviewed, noting any risk factors that may contribute to an adverse infant outcome. The availability of social support is essential to the success of every parent’s adaptation to the home care of a high-risk infant. After the family’s social support needs have been identified, an appropriate, individualized intervention plan using available community programs, surveillance, or alternative care placement can be implemented. Follow-up care determination and designation. In general, the attending neonatologist is responsible for coordinating follow-up care. A primary care physician should be identified as early as possible to facilitate care planning between the primary care setting and the subspecialty center-based discharge planning staff. In an ideal situation, the primary care physician will meet the parents before the baby’s discharge and, if possible, examine the infant in the hospital. The determination of readiness for home care of an infant after neonatal intensive care is complex. Carefully balancing infant safety and well-being with family needs and capabilities is required, as well as considering the availability and adequacy of community resources and support services. Although the AAP guidelines have been developed predominantly from the physician’s standpoint, they provide a valuable framework for all health care professionals involved in the transition of neonates from the hospital to the home.
REFERENCES American born.
Academy Hospital
lines (S98 12).
Identifying and preparing in-home caregivers Developing a comprehensive listing of required equipment and supplies and accessible sources Identifying and mobilizing necessary and qualified home care personnel and community support services Assessing the adequacy of the home’s physical facilities Developing emergency care and a transport plan as indicated Assessing available financial resources to ensure the parents’ ability to finance home care costs
of Pediatrics
of the high-risk
Pediatrics
1998;
American
Academy
of Pediatrics
abilities.
Guidelines
for home
cents with Wagner tal versus Center;
chronic
1988.
Armstrong-Dailey ed.
New
disease.
JL, Power home
York:
Committee
discharge
on Fetus and neonate:
102:page
on Children
of infants,
Pediatrics
children,
199.5;96:
EJ, Fox H. Technology-dependent care.
Philadelphia:
guide-
numbers?
Committee care
New-
proposed
Science
with
Dis-
and adoles-
161-4. children:
Information
hospi-
Resource
p. 99-105. A, Zarbock Oxford
SF. Hospice
University
care
for children.
2nd
Press, In press.
Specific details of planning home care for the technologydependent infant are included in the AAP policy statement,2 a consensus report,l and, for hospice care, in Armstrong-Dailey and Zarbock.4 Finally, the primary care physician’s input in formulating the home care plan of the technology-dependent infant is essential. Surveillance mobilization.
DECEMBER
and support services identification The psychosocial characteristics
1998.
VOL. 3 NO.
6
and of each
HOME
CARE PROVIDER
303