Preventing readmissions has always been a high priority for the clinicians in hospital newborn nurseries. Increasingly, hospital administrators are also focusing on reducing readmission rates, which are used as a key metric to assess the quality of patient care during a hospital admission and after discharge.
The newborn nursery at Henrico Doctors’ Hospital in Richmond, Virginia, has been following evidence-based protocols since before I joined in 2014. Our protocols for assessing the discharge readiness of term newborns are grounded in, and built upon, the guidelines in the 2010 American Academy of Pediatrics (AAP) “Policy statement—Hospital stay for healthy term newborns.”1
Last September, we implemented an early discharge checklist (see “Term newborn discharge checklist from Henrico Doctors’ Hospital”) for term newborns based on those protocols to provide a simple, efficient tool for double-checking that nothing has been missed before we sign off on discharging a patient early, but after 24 hours. Our 2016 30-day readmission rate for normal newborns born at Henrico dropped to 0.08% (3/3832 infants), compared with 0.25% (9/3638 infants) in 2015. To my knowledge, there have been no 30-day readmissions of well newborns to our hospital since the checklist was implemented, although it is possible that one or more patients under the care of a private pediatrician might have been readmitted to a different hospital.
How the checklist came about
Two things occurred in 2016 that led to the development and implementation of Henrico’s early discharge readiness assessment checklist for term newborns last September. One was a significant jump in midwifery deliveries and increasing numbers of mothers who were interested in going home early. The second was an incident in which a nurse, rushing to sign off on an early discharge at the request of the mother, inadvertently forgot to note a completed test in the patient’s chart.
Everyone on our newborn nursery staff is extremely knowledgeable about our protocols and diligent in following them. They are also human. Last July, I was reviewing the record of a recently discharged newborn and noticed that the critical congenital heart defect (CCHD) screen had not been charted. The poor nurse who had signed off had to be tracked down on her day off to confirm that the child had, indeed, been tested and had passed.
Given the importance of consistency in following our protocols and recording everything that happens to patients in our care, Henrico’s Women’s and Children’s leadership team met to discuss opportunities for process improvements. The team consisted of Amber Price, DNP, CNM, vice president of Women’s and Children’s Services; Alan Picarillo, MD, national medical director of Clinical Quality at Sheridan Healthcare (now Envision Physician Services); Cheryl Poelma, director of the Neonatal Intensive Care Unit and Progressive Care Nursery; and me.
We acknowledged that the process of checking that nothing was missed prior to sign-off was cumbersome and time consuming, and that the pressure to complete it by a certain time for an early discharge made it even more challenging, and more likely that a nurse might forget to chart a completed test at some point. We came up with the idea of a checklist that would let the nurses quickly and easily double-check that all the necessary steps have been completed before a patient is discharged early. Instead of discharging Mrs Smith, who was anxious to go home, and then finding out too late that the hearing screening hadn’t been done, the nurse could explain to her that the screening needed to be done before she could be sent home.
The concept was like that of a surgical time-out: a formal pause for a final double check to make sure that everything is as it should be before proceeding (in this case, signing off on the early discharge). The checklist could also serve as backup documentation, and because everyone was extremely familiar with the protocols, the checklist didn’t need to be detailed and we could keep it short.