1. DISCHARGE PLANNING

2. The decision of when to discharge an infant from the hospital after a stay in the NICU is complex. made primarily on the basis of the infant’s medical status but is complicated by several factors: ◦ readiness of families for discharge ◦ differing opinions about what forms of care can be provided at home ◦ pressures to contain hospital costs by shortening the length of stay.

3. Shortening the length of hospital stay may benefit the infant and family ◦ Decreasing period of separation ◦ May lessen subsequent adverse effect on parenting ◦ Risks of hospital-acquired morbidity reduced

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 T HE INFANT WITH ANTICIPATED EARLY DEATH

5. Categories of High-Risk Infants The Preterm Infant Physiologic stability ◦ oral feeding sufficient to support appropriate growth ◦ ability to maintain normal body temperature in a home environment ◦ sufficiently mature respiratory control Active program of parental involvement and preparation for care of the infant at home

6. Categories of High-Risk Infants The Preterm Infant arrangements for health care after discharge by a physician or other health care professional who is experienced in the care of high- risk infants an organized program of tracking and surveillance to monitor growth and development

7. Categories of High-Risk Infants The Infant with Special Health Care Needs Those requiring special or assistive feeding techniques Those requiring respiratory assistance Those with complex congenital anomalies requiring supportive and assistive devices

8. Categories of High-Risk Infants The Infant at Risk Because of Family Issues Maternal factors ◦ lower educational level ◦ lack of social support ◦ marital instability ◦ fewer prenatal care visits

9. Categories of High-Risk Infants The Infant at Risk Because of Family Issues Parental substance abuse ◦ adverse effects on the developing fetus in utero ◦ possible postnatal exposure to drugs through breastfeeding or by inhalation ◦ drug-seeking behaviors of parents may compromise the safety of the child’s environment

10. Categories of High-Risk Infants The Infant With Anticipated Early Death For many infants with incurable, terminal disorders, the best place to spend the last days or weeks of life is at home Arrangements for medical follow-up and home-nursing visits Management of pain and other distressing symptoms Arrangements for home oxygen or other equipment and supplies

11. Categories of High-Risk Infants The Infant With Anticipated Early Death Providing the family with information on bereavement support for the parents, siblings, and others Discussion of possible resources for respite of caregivers Assistance in addressing financial issues

12. Timing of Discharge when the infant demonstrates the necessary physiologic maturity discharge planning and arrangements for follow-up and any home care have been completed parents have received the necessary teaching and have demonstrated their mastery of the essential knowledge and skills

13. Timing of Discharge An infant may be discharged before one of the infant’s physiologic competencies has been met, provided the health care team and the parents agree that this is appropriate and suitable plans have been made to provide additional support needed to ensure safe care at home, such as tube feeding, cardiorespiratory monitoring, or home oxygen.

14. Timing of Discharge Discharge Screening ◦ Hearing Screening ◦ Eye examinations ◦ Cranial ultrasonography ◦ Immunizations

15. Head Ultrasonography All infants with gestational age <32wk Initial: Day 7-10 Follow-up If no hemorrhage or germinal matrix hemorrhage ◦ If < 28 wk: wk 4 and at 36 wk PCA (or discharge if < 36 wk) ◦ If > 28 0/7 – 31 6/7 wk: wk 4 or at 36 wk PCA (or discharge if < 36 wk) If IVH gr 2+ or intraparenchymal hemorrhage: ff up at least weekly until stable

16. Ophthalmologic Examination All infants BW <1500g or GA <32 wk Initial: If <27 wk: wk 6If 27-28 wk: wk 5 If 29-30 wk: wk 4If 31-31 6/7 wk: wk 3 Follow-up Immature retina zone 1 or 2 or low-grade ROP: ff up every 2 wk Immature retina zone 3: ff up in 4-10 wk Prethreshold ROP: ff up weekly Regressing ROP: ff up every 1–10 wk depending on zone

17. Audiology screening All infants to be discharged home from NICU Examine at 34 wk gestation or greater

18. Discharge Planning should begin early in the hospital course. Goal: to ensure successful transition to home care Essential discharge criteria ◦ physiologically stable infant ◦ family who can provide the necessary care with appropriate support services in the community ◦ primary care physician who is prepared to assume the responsibility with appropriate backup from specialist physicians and other professionals as needed.

19. Discharge Planning Parental Education Completion of Appropriate Elements of Primary Care in the Hospital Development of Management Plan for Unresolved Medical Problems

20. Discharge Planning Development of the Comprehensive Home-Care Plan Identification and Involvement of Support Services Determination and Designation of Follow-Up Care

21. Comprehensive Home-Care Plan identification and preparation of the in-home caregivers formulation of a plan for nutritional care & administration of any required medications development of a list of required equipment and supplies and accessible sources Identification and mobilization of the primary care physician, the necessary and qualified home-care personnel and community support services

22. Comprehensive Home-Care Plan assessment of the adequacy of the physical facilities within the home Development of an emergency care and transport plan Assessment of available financial resources to ensure the capability to finance home-care costs

23. Family and Home Environmental Readiness identification of at least 2 family caregivers and assessment of their ability, availability, and commitment; psychosocial assessment for parenting strengths and risks; a home environmental assessment that may include on-site evaluation review of available financial resources and identification of adequate financial support.

24. Community and Health Care System Readiness A primary care physician has been identified and has accepted responsibility for care of the infant. Surgical specialty and pediatric medical subspecialty follow-up care requirements have been identified and appropriate arrangements have been made. Neurodevelopmental follow-up requirements have been identified and appropriate referrals have been made.

25. Community and Health Care System Readiness Home-nursing visits for assessment and parent support have been arranged, as indicated by the complexity of the infant’s clinical status and family capability, and the home-care plan has been transmitted to the home health agency. For breastfeeding mothers, information on breastfeeding support and availability of lactation counselors has been provided.

26. References Hospital Discharge of the High-Risk Neonate, a Policy Statement, AAP, Committee on Fetus and Newborn, Pediatrics 2008;122;1119-1126 Manual of Neonatal Care 6 th edition by Cloherty et.al.

27. THANK YOU