BCC Lam

Early Discharge Policy of Newborn Infants

"Early to bed and early to rise, makes a man healthy, wealthy and wise" "Early warning, early detection, early diagnosis and treatment, early discharge......". Indeed, early has always connoted an astuteness, a positive gain of some sort.

Under the present cost driven health care management system, as well as medical and social reasons to view childbirth as a natural event rather than illness, there is a great pressure on clinicians to follow the early discharge policy of newborns and mothers from the hospital. regardless whether this is evidence-based practice or not.

A Critical review of English language literature cited in the Index Medicus and the International Nursing Index¹ showed that published research has provided little knowledge of the consequences of short maternal or newborn hospital stays or varying post-discharge practices for the general population. Studies of self-selected early discharge should not be generalized to unsuitable settings where early discharge is mandatory. Many studies used rehospitalization rate as one of the end point to conclude that early discharge is safe and cost-effective. This approach was subjected to much criticism because of either a lack of control studies or the lack of supporting statistical data. Furthermore, several studies have observed potentially clinically significant increase in adverse outcomes associated with early discharges, even with careful screening and early post-discharge follow-up.^2,3

It is even more worrying that classic kernicterus has been reported to occur in apparently healthy full term breast fed newborns.⁴ Thus close post-discharge follow-up is essential to prevent such highly morbid yet preventable conditions. As a result, there are increasing concern in the United States to readdressed the issue of early discharge policy. More clinical attention are called for mothers and infants during this most vulnerable period. Potential problems like jaundice, failure of breast feeding, various neonatal cardiac and gastrointestinal problems with late manifestations can occur even in low risk infants. The National Institute of Child Health and Human Development and the Agency for Health Care Policy and Research convened a workshop in March 1995 and concluded that early discharge policies without appropriate supports and services are dangerous. The groups also made recommendations to conduct further researches on the various strategies of post-delivery care, on new diagnostic techniques for identification of infants at risk of increased bilirubin production. They also suggested to incorporate pre-natal and perinatal education as part of the discharge protocols.⁵

In Hong Kong, there is an increasing trend to follow the early discharge policy to circumvent the problems of bed and nursing manpower shortages. However, before we transplant the early discharge policy for newborns in Hong Kong, we should be aware that some health problems are more prevalent and some disease patterns are unique in our local Chinese infants. Neonatal jaundice is more common in Chinese infants.⁶ Glucose-6-Phosphatase deficiency is very common. It occurs in 4.42% of male infant and 8.4% of female are heterozygous.⁷ They are at the risk of provoked or even spontaneous haemolysis during the early neonatal period. The rapid onset of jaundice as a result of haemolysis exposed the infants to high risk of bilirubin encephalopathy. Besides, the physiological jaundice in Chinese infants tend to peak at day 5 instead of day 2 to day 3 of life.⁸ There were also a higher risk of development of kernicterus in Chinese jaundice baby.⁹ Furthermore, inspite of improvement of the education level of the general public during the last decade, the overall medical knowledge, in particular with reference to newborn care are still suboptimal. Besides, good community and social supports for breast feeding is still lacking. Direct transplantation of the early newborn discharge policy without provision of routine post-discharge medical service is dangerous.

We were under intense pressure to practise the early discharge policy (48 hours post delivery) for uncomplicated delivery since last year to achieve hospital savings. After lots of discussions and deliberations we were able to convince the hospital about the need to implement a number of strategies to safe-guard the safety of the early discharge policy. These strategies includes:

1. Individualized discharge plans for high risk neonates and mothers.

2. Physical examination by Paediatrician before discharge.

3. Routine cord blood screening for direct coomb's test, mothers' and babies' blood groups, G6PD status. These results should be known before discharge to identify babies at risk of severe jaundice whom should be excluded from the early discharge programme.

4. Physical check-up for all the babies again on day 5 to look for congenital problems that might be missed in the earlier examination and for detection of the peak jaundice at the Day Care Centre.

5. Walked-in Day Care services to deal with early neonatal problems arising within first 2 weeks post-discharge.

6. Regular education sessions for mothers on breast feeding and baby care at the Day Care Centre.

In the year 1995, we have a total of 4760 live birth deliveries. Sixty-five per cent of infants fits the early discharge criteria and were discharge at 48 hours. There were a total of 4275 neonatal attendance at the Day Care Centre and a total of 342 readmissions into our own hospital and 17 readmissions to other hospitals. The readmission rate was 7.56%. The majority of the readmissions were due to neonatal jaundice requiring treatment. Three babies required exchange transfusion for severe hyperbilirubinaemia and none of them suffered from bilirubin encephalopathy. Other problems detected on follow up screening of the low risk infants included infection, gastro-oesophageal reflux, laryngomalacia, otitis media, aspiration pneumonia, and coartation of aorta.

In conclusion, even with an individualised early discharge policy we are witnessing an increase of readmission rate. The readmission rate was relatively high when compared with those reported in the literature.^1,2 Before considering further shortening of the stay to 24 hours post delivery in some hospitals, careful planning of the post-discharge follow up or home visit is essential. A careful cost-benefit study should also be conducted.

As health care professionals, the ultimate goal for health care delivery is not simply the prevention of morbidity and mortality and the consideration of cost-effectiveness, but the promotion of health and well being for the child and family. Although early discharge for some selected mothers and babies may be beneficial. "Appropriate" discharge and "Follow up" strategies should be advocated instead of routine "Early" discharge and "Cut" cost.

Acknowledge

I like to thank Miss Irene Lee, Ward Manager of Day Centre in collecting the statistics at the Day Centre in Tsan Yuk Hospital.

References

1. P Braveman, S Egerter, M Pearl, et al. Early discharge of newborns and mothers: A critical review of the literature. Paediatrics 1995;96:716-26.

2. Lemmer CM. Early discharge with outcome of primiparous and their infants. J Obstet Gynecol Neonatal Nurs 1987;16:230-6.

3. Conrad PD, Wilkening RB, Rosenberg AA. Safety of newborn discharge in less than 36 hours in an indigent population. AM J Dis Child 1989;143:98-101.

4. MJ Maisels, TB Newan. Kernicterus in otherwise healthy, breast fed term newborns. Paediatrics 1995;96:730-3.

5. C Catz, JW Hanson, L Simpson, et al. Summary of the workshop: early discharge and neonatal hyperbilirubinemia. Paediatrics 1995;96:743-5.

6. Yeung CY. Neonatal Hyperbilinrubinaemia in Chinese. Trop Geog Med 1973;25:151-7.

7. Yeung CY, Lee FT. Erythrocyte G6PD assay in Chinese newborn infants with a automated method. HK J Paediatr 1985:2:46-51.

8. Yeung CY. Bilirubin metabolism in Chinese newborn infants. Proceedings of Centennial scientific conference. Faculty of Medicine, Hong Kong, Hong Kong University Press 1987:261-8.

9. Yeung CY. Kernicterus in term infants. Aust J Paediatr 1985;21:352-6.