Dr Michelle McEvoy, Fiona Hanrahan and Prof Tom Clarke outline the early discharge guideline policies in the Rotunda Hospital, to ensure the health and the safety of new mothers and their babies
The length of hospital stay after birth has been steadily decreasing over the last 50 years. In the 1950s, the recommended postpartum stay was six days. In Ireland, even as recently as 2004, mothers and newborn babies stayed an average of four days after birth.
Although there is no standard definition for early hospital discharge, the American Academy of Pediatrics (AAP) defines ‘early’ and ‘very early’ discharge as 48 and 24 hours, respectively, after an uncomplicated vaginal delivery.
In Ireland, there has been a growing trend towards earlier hospital discharge, and it is now becoming common practice for mother and baby to be discharged at 24 to 48 hours postnatally.
There are numerous factors that have driven the trend towards so-called ‘drive-through deliveries’. Undoubtedly, as in other countries, economic factors have played an important role. However, one of the key issues for Ireland has been the remarkable growth in the population.
The latest report from Eurostat shows that Ireland has the highest birth rate in the European Union – 18.1 births per 1,000 population, which is well ahead of the next-highest birth rates in the UK at 13 per cent and France at 12.9 per cent.
Over the past 10 years, the birth rate has risen by 22 per cent. This is a staggering figure that has left our maternity services struggling to keep pace.
Increasing maternal choice, bed shortages and nursing manpower shortages are factors in the increasing number of infants being discharged home early after birth. Therefore, it is crucial that we understand the effect of such practices on the health of these newborns.
There are several potential advantages of early hospital discharge for both mother and baby, in addition to the obvious economic benefits. Shorter hospital stays may help decrease the risk of iatrogenic infection.
Some authors have suggested that early discharges help prevent the overly aggressive assessment of normal variations in newborn physiological changes, which may occur when infants stay in the hospital for several days after birth, such as mild hyperbilirubinemia.
Finally, there are numerous psychosocial benefits of early discharges, such as improved infant-mother bonding and family adaptation.
However, despite these advantages, there remain concerns about the safety of early discharges for both mother and baby. A recent Cochrane review, which assessed the safety, impact and effectiveness in published trials of early discharge policies for healthy mothers and term infants, concluded that adverse outcomes could not be ruled out due to limitations in methods of published studies.
One of the largest studies on early postpartum discharges was carried out in Washington between the years 1989 to 1990 by Malkin et al., who reviewed over 47,000 deliveries. Over the one-year period of study, just over 9,000 infants were discharged before 30 hours of age.
More likely to die
The study found that those infants discharged early from hospital were more likely to die within the first 28 days of life than those infants sent home later. However, the study did not address the timing or type of follow-up that early discharge infants received. Although much of the published evidence remains inconclusive, contradictory and methodologically flawed, there is a growing body of evidence to suggest that this trend towards earlier discharge may potentially affect newborn morbidity and therefore raises concern about the desirability of this practice.
In 1995, the AAP developed guidelines emphasising the importance of individualised assessment for early discharge of healthy term newborns and the use of stringent discharge criteria. Early discharge without appropriate support and services is potentially dangerous.
The AAP stresses the need for appropriate follow-up of these infants. Many countries have well-developed community services for mothers and newborns; however, in Ireland the only assistance available from most maternity units to mothers after hospital discharge is the public health nurse, who is required to call once to the mother during the 10 days after birth.
An early discharge guideline policy was therefore developed for the Rotunda Hospital, based on the AAP guidelines and adapted to the local support systems available within our institution and local community.
Within the Rotunda Hospital, a midwifery-led service, called DOMINO (DOMiciliary IN and Out), is already established. The DOMINO team consists of eight midwives who provide antenatal, intrapartum in hospital and postnatal care to women with low-risk pregnancies. This ensures community follow-up of infants discharged home at six to 12 hours of age. On average, seven to 10 babies are discharged weekly under the care of the DOMINO service.
An Early Transfer Home (ETH) team of five midwives, which provides similar community postnatal follow-up, was established in 2007. The establishment of these services has helped ensure that newborn infants are followed up at home for five to seven days, and intensive support is provided to breastfeeding mothers.
All babies are also reviewed by their GP at seven to 14 days of age. Neonatal problems can be identified early and managed appropriately by skilled, specialised midwives. During 2007-2008, 2,000 babies (and their mothers) were discharged to the care of the ETH service.
In 2008, the Rotunda Hospital introduced new Early Discharge Guidelines, based on the AAP’s recommendations. Mothers and newborns considered for early discharge must be either under the care of the DOMINO or ETH services, or the infant must be over 24 hours of age and fulfil all the early discharge criteria. Included in the checklist are, that the infant must be:
-Term infant (37-42 weeks);
-Birth weight must be appropriate (2.5-4.5kg);
-Multiparous (second child or greater, if not DOMINO/ETH);
-Infant must have passed meconium and urine;
-Infant must have a normal neonatal physical examination and observations – including normal pre-feed blood glucose, pulse oximetry and transcutaneous bilirubin measurement;
-There should be no maternal condition that can adversely affect the newborn, including maternal drug abuse and maternal illness such as diabetes mellitus;
-The infant must have successfully breastfed or formula fed;
-Appropriate follow-up and screening must be arranged;
-The family must have a GP;
-There should be no other cause of concern, i.e. social concerns.
Congenital cardiac conditions may not become apparent until several days after birth. Clinical examination remains the most frequently used means of diagnosing congenital heart disease; however, routine examination of apparently healthy newborn babies detects less than half of those with congenital cardiac malformations because, in the first few days, they are asymptomatic and without signs. Therefore a normal discharge clinical examination does not exclude serious congenital cardiac malformation.
Pulse oximetry (oxygen saturation) screening offers an effective, accurate and reliable means for maximising detection of cyanotic CHD in asymptomatic infants. All infants in the Rotunda have their pulse oximetry checked prior to discharge.
In recent years, the occurrence of kernicterus and hyperbilirubinaemia has become a cause of concern that must be addressed by improved neonatal discharge practices. Kernicterus is preventable, provided excessive hyperbilirubinaemia is promptly identified and appropriately treated. Potential lapses in care have been identified by the AAP, and these are addressed in our early discharge policy.
As clinical assessment of jaundice is unreliable, particularly in non-Caucasian infants, all infants considered for early hospital discharge in the Rotunda Hospital must have a documented transcutaneous bilirubin (TcB) measurement and risk-factor assessment to determine the need for further investigation and the timing of follow-up.
The time of follow-up after discharge is vitally important. Although the literature remains contradictory, many studies conclude that early hospital discharge is associated with an increase in hospital readmission rates for neonatal conditions that may not become apparent until the infant is discharged from hospital.
Therefore, even with careful screening and early post-discharge follow-up, there remains a potentially significant increase in clinical adverse outcomes following early discharge. Based on the American Academy of Pediatrics guidelines, all newborns discharged early from the Rotunda Hospital are therefore followed up at home within 24 hours by the midwifery-led DOMNO/ETH services or are seen in our paediatric outpatient department. This is a key component of ensuring newborn safety, as not all early neonatal problems can be identified during the first 24-48 hours after birth.
Although the introduction of an early discharge policy will help guide practitioners in deciding whether or not early discharge is appropriate, individualised assessment of newborns to determine the optimal time of discharge is essential. We recommend that other hospitals discharging infants early use a similar type of checklist.
Dr Michelle McEvoy, SPR Neonatal Paediatrics; Fiona Hanrahan, Assistant Director of Midwifery/Nursing; and Prof Tom Clarke, Consultant Neonatologist, Rotunda Hospital.