1. Discharge Planning in the NICU
In order to improve the discharge process a team got together and worked on redoing the discharge form so that is was easier to follow was utilized from day one and involved every area that was responsible for discharge of an infant.
A Multidisciplinary Three-Phase Approach

2. Discharge Begins on Admission
We all know that discharge planning starts at admission, but when we see a small preemie with a long road ahead it is hard to begin thinking about the discharge process. To help clarify what should be done, a multidisciplinary discharge process has been developed, using a three-step approach. It is designed to have an easy and logical flow.
By braking us the discharge into different phases we will be able to begin the discharge process earlier and not try to do it all in 1 or 2 days.

3. Multidisciplinary Form
The new discharge form will allow for all disciplines involved in the discharge process to document progress being made toward the goal of discharge.
It is a one stop check to see the progress being made by nursing, family services, nutrition, PT, OT, developmental services, medical staff, speech therapy, and even NB pictures.
Unlike the current form which is just for nursing to use everyone will be documenting on this form. And with it all on one form everyone will know what has been done and what needs to be done.

4. Family Centered Care
Because we are a family centered care facility it is important that we involve the parents in this process from the start.
In the corner of the baby’s name tag there will be an image depicting what phase of discharge their child is in.
As the baby progresses from one phase to the next the image on the name tag will be changed to reflect the progress being made towards discharge.

5. Family Centered Care
The image is designed to allow all disciplines involved to know the phase of discharge and to encourage parent involvement.
Parents will see the picture and ask its purpose, opening the communication of discharge.

6. Family Centered Care
If parents are too overwhelmed initially the image is a good opening for staff to introduce the topic of discharge with the family.
As the image changes parents will be prompted to ask what is expected in the new phase.
This will help to make parents feel a part of their child’s care. It will also be exciting for them to see that they have moved into the next phase, a step closer.

7. The 3 Phases of Discharge
Caterpillar
Cocoon
Butterfly

8. Moving Through the Phases
As you will see there is a lot of information being documented for discharge. Not all of it will be applicable for every baby. The white areas on the sheet will be required, the grayed out areas are only if applicable to the case, the X’d out boxes are not required.
As on the old sheets there is space for us to show repeat teaching and re-demonstration but in the case of for example orientation to the unit we only need to do this once so the other columns are x’d out.

9. Moving Through the Phases
The time spent on each phase will be determined by how critical the baby’s condition is.
Critically ill infants may spend awhile in the first phase before moving on.
An infant who recovers quickly could potentially move through two phases in a day.
During morning rounds the discharge phase will be discussed for the infant if the baby is to move into the next phase the nurse will be told by the team and the nurse will notify the secretary so that a new name take can be made for the infant with the new phase symbol on it. The discharge phase that the infant is in should also become part of shift to shift report.

10. Phase 1: The Caterpillar
This is started with the admission of the infant to the NICU.
Initially it is an information gathering phase. The family assessment and special considerations are filled out. Although this was completed by family services in the past, it can be done by any of the disciplines (nursing, medical, etc.) that has the opportunity to acquire the information.

11. Phase 1: The Caterpillar
Family services will do their assessment and plan and arrange any necessary community services or referrals.
Families will be oriented to the unit and given their education packet.
The initial newborn screen is documented here.

12. Phase 1: The Caterpillar
Initial referrals for lactation consultant, OT, PT, family and developmental services are made in this phase.
Families are started on their education of signs and symptom of pain and illness. Comfort measures are taught.

13. Phase 2: The Cocoon
This phase starts with the successful extubation of the infant.
Parent education will involve bathing, diapering, skin care/cord care, back-to- sleep, and immunizations.
Shaken baby video should be shown and documented in this phase.

14. Phase 2: The Cocoon
The patient care manager is introduced in this phase.
Scripts for meds and supplies are written by the MD.

15. Phase 2: The Cocoon
Feeding education and reflux precautions are taught.
Family services evaluates parent’s comfort level with discharge and check that baby supplies are in place.
Need for and information given on services in OT, speech, and developmental.

16. Phase 3: The Butterfly
This phase starts when the infant is on full feeds and is in a crib.
Hearing screening is completed.
Car seat challenge is done.
Final newborn screen is completed and documented.
Note the baby may receive several newborn screens during their stay but only the initial (phase 1) and final (phase 3) screens are documented in the discharge.

17. Phase 3: The Butterfly The MD/NP/PA will:
Notify parents of pending discharge.
Arrange for circumcision.
Write orders for follow up appointments, CPR/Monitor training, and pharmacy teaching.
Write discharge summary and review with attending.
Have discharge orders written and signed day before discharge.

18. Phase 3: The Butterfly Circumcision care is taught.
WIC referral is made.
Baby is “back- to-sleep”.
Special formula instructions are given.
Scripts are filled and printed education sheets are reviewed with parents by pharmacy.

19. Phase 3: The Butterfly
Family services will confirm discharge address and get CPS clearance if needed.
Discharge planner will arrange and confirm completion of CPR, monitor, and oxygen training. Home care referrals will be done and equipment delivery confirmed.

20. Phase 3: The Butterfly
Developmental services will provide information on recommended positioning and “tummy time”. Referrals to early intervention and information on developmental clinic will be given.
Infant should be signed up and have pictures taken.

21. Day of Discharge
Document discharge weight, length and head circumference.
Complete and sign nursing discharge orders and patient instruction form.
Confirm identity of parent and infant.
Give follow up appointment sheet to parents.

22. Consistency
With consistent attention to the phases of discharge and documentation by all disciplines involved, the process for discharging infants from the NICU will develop into a smooth and easy process.