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Careful discharge planning, follow-up vital for high-risk neonates facing hospital discharge, updated AAP guidelines state

Tuesday, November 11 2008 | Comments
Evidence Grade 6 What's This?
New guidelines designed to guide the hospital discharge of high-risk infants call for individualized care planning and detailed discharge planning.

The guidelines from the American Academy of Pediatrics (AAP) update an AAP policy statement released in 1998. Drawing on evidence from recent studies, the guidelines address the timing of discharge and planning for care after discharge, including the necessity of identifying a primary care physician, or "medical home," well before discharge.

In addition to giving general recommendations, the guidelines offer guidance specific to 4 categories of high-risk infants: the preterm infant, the infant with special health care needs or dependence on technology, the infant at risk because of family issues, and the infant with anticipated early death.

When considering the hospital discharge of preterm infants, clinicians should consider more than the attainment of a certain weight (typically, 2,000 g). Randomized, clinical trials have shown that earlier discharge is possible without adverse health effects when preterm infants are discharged on the basis of physiologic criteria rather than body weight, the guidelines advise. Specifically, clinicians should consider the following essential physiologic competencies: oral feeding sufficient to support appropriate growth, the ability to maintain normal body temperature in a home environment, and sufficiently mature respiratory control.

The use of a home monitor does not preclude the need for demonstrated respiratory competency before discharge, the guidelines caution, and should not be used to justify the discharge of infants who are still at risk of apnea.

Concerning the discharge of the infant with special health care needs or dependence on technology, the guidelines stress that gavage, or gastrostomy tube, feeding has a limited role and should be cautiously considered only when feeding is the last issue that requires continued hospitalization.

Careful discharge planning is essential for all high-risk infants but is of special importance to those infants at risk because of family issues, such as parental substance abuse.

For all high-risk neonates, clinicians should consider 6 critical components of discharge planning: parental education, completion of appropriate elements of primary care in the hospital, development of a management plan for unresolved medical problems, development of a comprehensive home care plan, identification and involvement of support services, and determination and designation of follow-up care.

Identifying the infant's primary care physician "well before discharge" fosters communication and care coordination between hospital clinicians and the primary care provider, the guidelines note.

"Pertinent information about the nursery course, including a discharge summary, and the home care plan should be given to the primary care physician before the infant's discharge," the guidelines recommend.

"The goal should be to provide coordinated care and family support," the guidelines state. "Efficient team work by health care professionals is imperative." (Bell EF, et al. Pediatrics 2008;122:1119-1126.)

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