Dr Flaster is a board-certified pediatrician, with an emphasis on pediatric hospitalist care and emergency medicine, at Envision Physician Services. He currently is the director of the Pediatric Hospitalist Program at Henrico Doctors’ Hospital in Richmond
Preventing readmissions has always been a high priority for the clinicians in hospital newborn nurseries. Here's how one program works on cutting down readmission rates.
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.
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.
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.
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.
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.
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.