Hospital Discharge of the High-Risk Neonate

Abstract

This policy statement updates the guidelines on discharge of the high-risk neonate first published by the American Academy of Pediatrics in 1998. As with the earlier document, this statement is based, insofar as possible, on published, scientifically derived information. This updated statement incorporates new knowledge about risks and medical care of the high-risk neonate, the timing of discharge, and planning for care after discharge. It also refers to other American Academy of Pediatrics publications that are relevant to these issues. This statement draws on the previous classification of high-risk infants into 4 categories: (1) the preterm infant; (2) the infant with special health care needs or dependence on technology; (3) the infant at risk because of family issues; and (4) the infant with anticipated early death. The issues of deciding when discharge is appropriate, defining the specific needs for follow-up care, and the process of detailed discharge planning are addressed as they apply in general to all 4 categories; in addition, special attention is directed to the particular issues presented by the 4 individual categories. Recommendations are given to aid in deciding when discharge is appropriate and to ensure that all necessary care will be available and well coordinated after discharge. The need for individualized planning and physician judgment is emphasized. Pediatrics 2008;122:1119-1126 INTRODUCTIONThe decision of when to discharge an infant from the hospital after a stay in the NICU is complex. 1 This decision is made primarily on the basis of the infant's medical status but is complicated by several factors. These factors include the readiness of families for discharge, differing opinions about what forms of care can be provided at home, and pressures to contain hospital costs by shortening the length of stay. Insofar as possible, determination of the readiness for discharge should be based on peer-reviewed scientific evidence. Shortening the length of a hospital stay may benefit the infant and family by decreasing the period of separation of infant and parents; moreover, the infant may benefit from shortening its exposure to the risks of hospital-acquired morbidity. However, the overriding concern is that infants may be placed at risk of increased mortality and morbidity by discharge before physiologic stability is established. Infants born preterm with low birth weight who require neonatal intensive care experience a much higher rate of hospital readmission and death during the first year after birth compared with healthy term infants. 2-5 Careful preparation for discharge and good follow-up after discharge may reduce these risks. It takes time for the family of a high-risk infant to prepare to care for their infant in a home setting and to obtain the necessary support services and mobilize community resources. With increased survival of very preterm and very ill infants, many infants are discharged with unresolved medical issues that complicate their subsequent care. Infants are ofte...

Feasibility of transferring intensive cared preterm infants from incubator to open crib at 1600 grams

“…The majority of preterm infants achieves these competencies between 34 and 36 weeks postmenstrual age [1]. A target weight of 1800–2000 grams is often chosen for incubator weaning, but this cut-off is largely based on the professional experience of clinicians and varies widely among neonatal units [2].…”

Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study

“…Guidance on hospital discharge for high-risk neonates from the American Academy of Pediatrics is informed by a robust evidence base describing the specific needs of vulnerable neonates at the time of hospital discharge and hence what should be put into place. 16 Although neonates with complex congenital anomalies are highlighted as a vulnerable population, specific guidance for the postdischarge care of neonates with CHD is not provided. In the UK, the management of children with CHD, including infants after being discharged home, falls within the responsibility of 'congenital heart networks of care', including designated 'outreach' services provided or supported by the specialist centres.…”

“…16,63,64 These guidelines address the needs of (1) the preterm infant; (2) the infant with special health-care needs or dependence on technology; (3) the infant at risk because of family issues; and (4) the infant in whom early death is expected; however, no specific studies were found detailing the implementation or effectiveness of these guidelines.…”

Very Preterm Infants with Technological Dependence at Home: Impact on Resource Use and Family

“…These infants are particularly fragile and need enhanced care coordination before and after neonatal discharge [7]. However, due to the lack of estimates of health care resource utilization by this population, advocating for funding of high-risk multidisciplinary comprehensive follow-up programs to facilitate care coordination may be difficult [8, 9].…”

“…Also, studies have shown that NICU clinicians often lacked knowledge concerning the burden of caring for infants with medical complexity at home [10]. Therefore, a better understanding of risk factors for medical complexity and pattern of health care resource utilization is important to plan for resource allocation, enhance parental teaching and empowerment, and coordinate follow-up care [7, 11]. …”