Preventable conditions top list of reasons for readmission among preemies

 

Jonathan Davis

In response to suggestions that readmission of a newborn to the hospital is an indicator of an “inadequate” assessment of readiness for discharge, Young and colleagues analyzed the Enterprise Data Warehouse of Intermountain Healthcare to identify newborns readmitted to the hospital within 28 days of discharge and the underlying etiology for the readmission.

They specifically focused on newborns discharged from well baby nurseries with gestational ages from 34 to42 weeks at birth. Out of 296,114 infants who were discharged during the study, 5,308 were readmitted, mostly for feeding problems and jaundice, or respiratory distress and infection.

 

Jennifer Lee

As expected, gestational age was strongly associated with the need for readmission. Late preterm and early term newborns were significantly more likely to be readmitted compared with term infants, with most readmissions occurring within a week of the initial hospital discharge. There was also significant variation noted between participating centers.

It is unclear if this is the result of variations in hospital policy, follow-up routines, or number of deliveries per year. Infants who were admitted to the neonatal intensive care unit (NICU) for more than 24 hours were excluded because some centers routinely admit many late preterm infants to the NICU for more intensive monitoring. These infants are at higher risk for temperature instability, apnea and bradycardia, and feeding difficulties and often require longer hospital stays until they further mature. 

It would also be interesting to know how many infants were feeding poorly or losing weight prior to discharge and were not readmitted. What was different about these infants and the outpatient practices that might have prevented readmission? Were they mostly first time mothers or mothers who have previously had other children? Were there delivery complications that contributed to the preterm birth? Were the mother’s exclusively breast-feeding and not able to get sufficient feedings into the infant? These are very important factors that would likely influence readmission rates as well.

Discharge planning is an important step in caring for all newborns, but especially for those born too early. Even those born at “early term - 37-38 weeks gestation” had higher readmission rates than those born at 39 weeks or after. A number of approaches are recommended at discharge (especially in late preterm or early term newborns: 1) effectively communicate with parents prior to initial hospital discharge to make sure they feel comfortable and supported caring for their infant; 2) counsel parents regarding early signs that their infants are having difficulties and when to ask for help; 3) in higher risk situations, send a visiting nurse to the home to make sure the infant is thriving; 4) having plans for close follow-up with a pediatrician, family practice physician, or other health care provider shortly after discharge (even over weekends or holidays); 5) arranging for adequate lactation support (if nursing) and recognizing the need to temporarily supplement with pumped breast milk or formula if infants are having difficulty feeding and gaining weight; and 6) keeping borderline infants in the hospital an extra 24 to 48 hours to ensure they are ready for discharge.

All medical personnel caring for these infants need to aware of the unique needs of high risk infants and standardize our approaches in order to prevent costly readmissions and the parental distress that comes with them.