Getting community peds to buy in
Pediatric hospitalists at Henrico take care of about 78% of our newborn patients, so I was able to contact them all quickly and easily to get their agreement. Because we wanted the follow-up protocols to be universal, I also visited all the private pediatricians’ offices in the community and met with each doctor to review the AAP recommendations and explain our proposed criteria for follow-up visits. These pediatricians also wanted to follow best practice and prevent readmissions, and so they readily agreed.
Standardization but individualization
Prior to discharge, every item on our checklist must be ticked off with a check mark, unless there is a very good, well-documented reason to make an exception. At the same time, the care must be tailored and individualized as appropriate. For example, babies who have a weight loss of 10% or less usually can be discharged and seen by their pediatrician the next day. However, if one of them has a private pediatrician who is on vacation, or if it’s a holiday or weekend and that doctor can’t be reached, we will keep the patient an extra day.
Timely maternal screenings
Although we’ve built in timing parameters for some of the key newborn testing and assessments in the checklist, our staff also knows the importance of timely maternal screenings. For example, if a mother is hepatitis B positive or her status is unknown, early screening allows us to administer the active vaccine within the first 12 hours, when it is most effective. If she is positive, we administer the hepatitis B immunoglobulin (HBIG) vaccine at the same time.
Similarly, group B streptococcus (GBS), a major cause of neonatal sepsis, affects many mothers. If the mother is identified as being GBS positive, we try to treat her with antibiotics a minimum of 4 hours prior to delivery.
Ensuring an effective, high-quality, hospital-to-home transition
Parent/family education and proper home environment and support systems assessments play a key role in helping to prevent newborn readmissions and are part of the AAP policy statement guidelines.
Safety education topics include feeding issues; sleep issues (eg, ensuring that the baby is in the supine position for sleeping; the dangers of co-sleeping); environmental issues (eg, tobacco smoke); and transportation issues (eg, how to choose and use a car seat correctly). If the parents have already purchased a car seat that is not appropriate, we help them select the correct car seat and we keep the infant until the parents can buy the right one.
We also help families with social services, if needed. For example, if the parents bought the wrong car seat and they’re not getting reimbursed, we’ll advocate for them to get reimbursed.
We use a multidisciplinary team approach to care to help us identify families with socioeconomic and medical barriers to discharge who may require enhanced discharge support. In addition, we tailor family education and discharge instructions as appropriate.
The continuum of care into the outpatient setting relies on effective communication among healthcare providers. We speak with the patient’s primary care provider and share the medical records to make certain the patient has proper postdischarge follow-up. For example, if a baby has jaundice and a borderline elevated bilirubin level, we might call the pediatrician prior to discharge to alert him or her that the infant’s bilirubin is trending a bit high, and that if he or she doesn’t breastfeed well and loses some weight, it might be a problem.
For patients who are discharged early, we try to ensure that there is a pediatric follow-up visit within 24 to 48 hours of discharge. Timely follow-up not only helps prevent readmissions, it also can help ensure that if a patient does need to be readmitted, that child is brought back and can be treated appropriately before a serious problem develops.
Our early discharge checklist protocol at Henrico Doctors’ Hospital has nearly eliminated term newborn readmissions after discharge. To help your facility initiate a similar program, see “Four strategies for reducing newborn readmissions.”
1. American Academy of Pediatrics (AAP), Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics. 2010;125(2):405-409.