Length of postnatal stay in healthy newborns and re-hospitalization following their early discharge
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《美国医学杂志》
Department of Pediatrics, University College of Medical Sciences and GTB Hospital, Delhi, India
Abstract
Objective. The present study was conducted prospectively to determine i) the length of postnatal hospital stay of healthy newborns and determine the factors facilitating their early discharge (< 48 h) and ii) the frequency and causes of re-hospitalization following early discharge, in a tertiary care hospital. Methods. Length of hospital stay was recorded for healthy newborns. Factors facilitating Early discharge were determined by both univariate and multivariate (multiple logistic regression) analyses. Of all newborns discharged within 48 h, every third case was called for a follow-up visit 72 hrs later and examined for any medical problem and need of re-hospitalization. Results. A total of 1134 babies were enrolled, of which 861 (76.2%) were discharged at or before 48 hours. The overall mean (SD) length of hospital stay was 46.4 (45.8) h. Factors contributing to early discharge included vaginal delivery (RR: 30.2; 95% CI: 19.0, 47.9; P<0.001), absence of pre-existing maternal disease or obstetric complication (RR: 4.32; 95% CI: 2.27, 8.22; P < 0.001), and birth weight of > 2.5 kg (RR: 1.91; 95% CI: 1.27, 2.89; P = 0.002). Of the 280 neonates called for follow-up, 193 reported. Of these, 61 (31.6%) were normal. Neonatal jaundice was the most frequent problem seen in 105 (54.4%) children on follow-up. Only 16 (8.3%) newborns needed re-hospitalization; the most common indication being neonatal jaundice (n=9). Conclusion. Most of the children in our set-up are being discharged within 48 hrs. Early discharge is governed primarily by maternal indications. A follow-up visit after 72 hr is important to assess the need of re-hospitalization in healthy newborns discharged within 48 hrs of birth.
Keywords: Discharge, Newborn, Policy, India
Early discharge is referred to as a postpartum hospital stay of ￡ 48 hours, as per the guidelines of American Academy of Pediatrics (AAP).[1] The issue of early newborn discharge has received widespread attention in the press as well as medical literature.[2],[3] Proponents of early discharge claim that it is safe and promotes family bonding and attachment, reduces the hospitalization care and patient costs and improves patient satisfaction.[4],[5] Concerns of early discharge include increased re-hospitalization rate, premature cessation of breast-feeding and increased parental anxiety.[3],[6],[7],[8] Of the available published literature from West, there is little scientific evidence to guide discharge planning for apparently healthy neonates.[7],[8] No studies or formal guidelines are available in developing countries to guide the appropriate timing of discharge of healthy neonates. Guidelines given by AAP cannot be adopted in totality in our perspective because of scarcity of hospital beds, limited resources, illiteracy and lack of follow-up facilities. Data needs to be generated from this part of the world.
This study was conducted to assess the length of postnatal hospital stay of healthy newborns and determine the factors facilitating their early discharge (￡ 48 hr) in a tertiary care hospital from India. Another objective was to ascertain the frequency and causes of re-hospitalization following early discharge.
Material And Methods
This study was conducted prospectively over a period of 2 months in the postnatal ward of a tertiary care government hospital in Delhi, India. The hospital, on an average, conducts 8,000-10,000 deliveries per annum.
All healthy neonates born during this period and transferred with their mothers following birth were included. Newborn infants weighing < 1800 g, < 34 wk gestation, or babies with asphyxia, major congenital anomalies, pathological hyperbilirubinemia and those requiring admission to neonatal intensive care unit (NICU) were excluded from the study population.
Data recorded for each subject included the maternal (parity, presence of medical disease, adequacy of ante-natal check-ups, obstetric complication, mode of delivery) and the neonatal (birth weight, gestational age) factors. Newborns were seen daily for their well being, as a part of routine care; and problems, if any were recorded. Neonates with major problems such as lethargy, refusal to feed, hypothermia, hypoglycemia, significant jaundice, convulsions, bleeding, sepsis etc. were admitted to NICU and excluded from the study. Newborn infants with physiological jaundice, cold stress, and other minor problems continued to stay in the postnatal ward. The hospital follows a Baby Friendly Policy and all mothers and relatives were counselled accordingly.
A newborn was considered fit for discharge, if she/he was feeding on the breast, has urinated and passed at least one stool, has no physical abnormality requiring hospitalization, has normal vitals (respiration < 60/min, heart rate 100-160 per min, axillary temperature 36-37°C), has received BCG, OPV and hepatitis B vaccinations and the mother and relatives are counselled regarding breast feeding. As per our policy, the mother-infant pair is discharged together. Thus, a neonate's discharge was deferred till the mother was discharged.
Length of stay was defined as the interval between birth and discharge (in completed hours) and noted for all study subjects. Early discharge was defined as the postpartum length of stay ￡ 48 hrs.
Of all newborns discharged within 48 hrs, every third case was called for a follow-up visit 72 hrs later and examined by the same person (DKS). The purpose of follow-up visit was to assess the infant's general health, hydration, jaundice, and to identify problems relating to feeding pattern. Any other medical problem, if present was recorded. The newborn was re-hospitalized if there was jaundice requiring intervention or any other major morbidity including sepsis. The admitting diagnoses of such newborns were recorded.
Statistical analysis: Chi square and Fisher's exact test were applied to determine the factors facilitating early discharge. A multiple logistic regression model was constructed for multivariate analysis, with length of stay (￡48 hr vs >48 hr) as the dependant variable. Factors contributing significantly to the early discharge on univariate analysis were included as independent variables. P <0.05 was considered significant.
Results
During the study period, a total of 1320 deliveries took place. Of these, 186 needed observation/admission in the NICU and were excluded Figure1. The mean (SD) length of stay of 1134 study subjects was 46.4 (45.8) hrs (median 30 hrs, range: 3 - 348 hrs). The median (range) weight and gestation of these babies was 2750 (1850-4600) g and 40 (34-42) weeks respectively.
Of the 1134 study subjects, 861 (76.2%) newborns were discharged within 48 hrs. table1 depicts the correlation between early discharge and mode of delivery, low birth weight, gestational age less than 37 weeks, presence of maternal medical disease or obstetric problem and neonatal jaundice. Multivariate logistic regression analysis revealed that the most important factors contributing to early discharge were vaginal delivery (RR: 30.2; 95% CI: 19.0, 47.9; P < 0.001), absence of pre-existing maternal disease or obstetric complication (RR: 4.32; 95% CI: 2.27, 8.22; P < 0.001), and birth weight of >2.5 kg (RR: 1.91; 95% CI: 1.27, 2.89; P = 0.002).
Of 287 infants called for follow-up, 193 (67.2%) turned up after discharge. The clinical characteristics of the babies lost to follow-up were similar to the ones assessed for medical problems. The mean (SD) age of discharge and follow-up of these newborn infants was 26.4 (8.7) and 78.1 (16.3) hrs respectively. Follow-up detail of these babies is depicted in Figure1.
All babies admitted for hyperbilirubinemia received phototherapy; none of the cases needed exchange transfusion. Other 7 cases underwent a septic screen and received antibiotics ranging from 3-10 days. All re-hospitalized infants improved and were discharged within 5-14 days.
Discussion
The mean term of stay for healthy newborn infants was 46.4 hrs in our study. The average length of stay reported in United States in 1992 was 2.6 days.[2] that declined in 1995 to 1.5 days for vaginal deliveries.[9] This trend towards early newborn discharge has also been reported from 22 other countries.[10] The reasons for decline included financial concerns due to limited hospital reimbursement as well as social factors such as changes in maternal expectations. No data on the term of stay of healthy well newborn infants is available from a developing nation. From this study, it appears that this is similar to that reported from developed countries.
On multivariate analysis, operative delivery, low birth weight and presence of maternal illness were found to associated with prolonged postnatal stay. These are comparable with reports from other countries.[11],[12] where the commonest reasons for prolonged newborn hospitalization were maternal morbidity, cesarean delivery and neonatal jaundice. The major pediatric concern of the early discharge policy is regarding inadequate observation of the newborn infants. In the present study, approximately two-third of neonates reporting for follow-up 3 days following discharge had some medical problem; the most common being neonatal hyperbilirubinemia. Conditions most likely to result in readmission after early discharge are neonatal jaundice, dehydration and feeding difficulties.[13] In our study also, more than 50% of children were readmitted because of hyperbilirubinemia.
A surrogate marker of efficacy of early discharge program used by various authors has been the readmission rates.[8],[14] Some studies have demonstrated that shortened neonatal hospital stay was associated with increased readmission rates up to 10%.[5],[7] Many studies, including three randomized controlled trials, have demonstrated no association between shorter neonatal hospital stay and readmission rates.[11],[12],[15] These studies, however, had one of the many limitations including selection bias, co-interventions, inappropriate control or insufficient power. In our study, 8.3% of the followed-up newborns eligible for early discharge needed readmission. However, we did not employ a control group to demonstrate any difference in readmission of those with early or standard discharge.
We could not follow-up all the neonates discharged within 48 hrs for logistics reasons. Moreover, not all the babies called for follow-up reported back. This resulted in a overall follow-up rate of only 23%. The results may thus be showing just the tip of the iceberg and may lead to an underestimation of the medical problems and the need for re-hospitalization.
Conclusion
Most of the healthy newborns in this tertiary care setting are being discharged within 48 hrs of delivery. Early discharge (￡ 48 h) is governed primarily by maternal indications, including vaginal delivery, absence of pre-existing maternal disease or obstetric complications. Neonatal jaundice is the most common indication of re-hospitalization following early discharge. A follow-up visit after 72 hrs is important to assess the need of re-hospitalization in healthy newborns discharged within 48 hrs of birth.
References
1. Committee on Fetus and Newborn. American Academy of Pediatrics. Hospital stay for healthy term newborns. Pediatrics 1995; 96: 788-790.
2. Centers for Disease Control and Prevention. Trends in length of stay for hospital deliveries-United States, 1970-1992. MMWR 1995; 44: 335-337.
3. Arnold S, Bernstein HH. Newborn discharge: A time to be especially thoughtful. Contemp Pediatrics 2000; 10: 45 (from http://cp.pdr.net/cp/).
4. Patterson PK. A comparison of postpartum early and traditional discharge groups. Quat Rev Bull 1987; 13: 365-371.
5. Waldenstrom U, Sundelin C, Lindmark G. Early and late discharge after hospital birth: Health of mother and infant in the postpartum period. Ups J Med Sci 1987; 92: 301-314.
6. Britton JR, Britton HL, Gronwaldt V. Early perinatal hospital discharge and parenting during infancy. Pediatrics 1999;104: 1070-1076.
7. Maisels MJ, Kring E. Length of stay, jaundice and hospital readmission. Pediatrics 1998; 101 : 995-998.
8. Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Early discharge of newborns and mothers: A critical review of the literature. Pediatrics 1995; 96: 716-726.
9. Hyman DA. What lessons should we learn from drive through deliveries. Pediatrics 2001; 107: 406-407.
10. Thilo EH, Townsend SF, Merenstein GB. The history of policy and practice related to the perinatal hospital stay. Clin Perinatol 1998; 25: 257-270.
11. Pittard WB, Geddes KM. Newborn hospitalization: A closer look. J Pediatr 1988; 112 : 257-261.
12. Welt SI, Cole JS, Myers MS, Shles DM, Jelosek FR. Feasibility of postpartum rapid hospital discharge. A study from a community hospital population. Am J Perinatol 1993; 10 : 384-387.
13. Gale R, Seidman DS, Slevenson DK. Hyperbilirubinemia and early discharge. J Perinatol 2001; 21 : 40 -43.
14. Lee K, Perlman M, Ballantyne M, Elliott I, To T. Association between duration of neonatal hospital stay and readmission rate. J Pediatr 1995; 127 : 758-766.
15. Carty EM, Bradley CF. A randomized controlled evaluation of early postpartum hospital discharge. Birth 1990; 17: 199-204.(Gupta Piyush, Malhotra Sa)
Abstract
Objective. The present study was conducted prospectively to determine i) the length of postnatal hospital stay of healthy newborns and determine the factors facilitating their early discharge (< 48 h) and ii) the frequency and causes of re-hospitalization following early discharge, in a tertiary care hospital. Methods. Length of hospital stay was recorded for healthy newborns. Factors facilitating Early discharge were determined by both univariate and multivariate (multiple logistic regression) analyses. Of all newborns discharged within 48 h, every third case was called for a follow-up visit 72 hrs later and examined for any medical problem and need of re-hospitalization. Results. A total of 1134 babies were enrolled, of which 861 (76.2%) were discharged at or before 48 hours. The overall mean (SD) length of hospital stay was 46.4 (45.8) h. Factors contributing to early discharge included vaginal delivery (RR: 30.2; 95% CI: 19.0, 47.9; P<0.001), absence of pre-existing maternal disease or obstetric complication (RR: 4.32; 95% CI: 2.27, 8.22; P < 0.001), and birth weight of > 2.5 kg (RR: 1.91; 95% CI: 1.27, 2.89; P = 0.002). Of the 280 neonates called for follow-up, 193 reported. Of these, 61 (31.6%) were normal. Neonatal jaundice was the most frequent problem seen in 105 (54.4%) children on follow-up. Only 16 (8.3%) newborns needed re-hospitalization; the most common indication being neonatal jaundice (n=9). Conclusion. Most of the children in our set-up are being discharged within 48 hrs. Early discharge is governed primarily by maternal indications. A follow-up visit after 72 hr is important to assess the need of re-hospitalization in healthy newborns discharged within 48 hrs of birth.
Keywords: Discharge, Newborn, Policy, India
Early discharge is referred to as a postpartum hospital stay of ￡ 48 hours, as per the guidelines of American Academy of Pediatrics (AAP).[1] The issue of early newborn discharge has received widespread attention in the press as well as medical literature.[2],[3] Proponents of early discharge claim that it is safe and promotes family bonding and attachment, reduces the hospitalization care and patient costs and improves patient satisfaction.[4],[5] Concerns of early discharge include increased re-hospitalization rate, premature cessation of breast-feeding and increased parental anxiety.[3],[6],[7],[8] Of the available published literature from West, there is little scientific evidence to guide discharge planning for apparently healthy neonates.[7],[8] No studies or formal guidelines are available in developing countries to guide the appropriate timing of discharge of healthy neonates. Guidelines given by AAP cannot be adopted in totality in our perspective because of scarcity of hospital beds, limited resources, illiteracy and lack of follow-up facilities. Data needs to be generated from this part of the world.
This study was conducted to assess the length of postnatal hospital stay of healthy newborns and determine the factors facilitating their early discharge (￡ 48 hr) in a tertiary care hospital from India. Another objective was to ascertain the frequency and causes of re-hospitalization following early discharge.
Material And Methods
This study was conducted prospectively over a period of 2 months in the postnatal ward of a tertiary care government hospital in Delhi, India. The hospital, on an average, conducts 8,000-10,000 deliveries per annum.
All healthy neonates born during this period and transferred with their mothers following birth were included. Newborn infants weighing < 1800 g, < 34 wk gestation, or babies with asphyxia, major congenital anomalies, pathological hyperbilirubinemia and those requiring admission to neonatal intensive care unit (NICU) were excluded from the study population.
Data recorded for each subject included the maternal (parity, presence of medical disease, adequacy of ante-natal check-ups, obstetric complication, mode of delivery) and the neonatal (birth weight, gestational age) factors. Newborns were seen daily for their well being, as a part of routine care; and problems, if any were recorded. Neonates with major problems such as lethargy, refusal to feed, hypothermia, hypoglycemia, significant jaundice, convulsions, bleeding, sepsis etc. were admitted to NICU and excluded from the study. Newborn infants with physiological jaundice, cold stress, and other minor problems continued to stay in the postnatal ward. The hospital follows a Baby Friendly Policy and all mothers and relatives were counselled accordingly.
A newborn was considered fit for discharge, if she/he was feeding on the breast, has urinated and passed at least one stool, has no physical abnormality requiring hospitalization, has normal vitals (respiration < 60/min, heart rate 100-160 per min, axillary temperature 36-37°C), has received BCG, OPV and hepatitis B vaccinations and the mother and relatives are counselled regarding breast feeding. As per our policy, the mother-infant pair is discharged together. Thus, a neonate's discharge was deferred till the mother was discharged.
Length of stay was defined as the interval between birth and discharge (in completed hours) and noted for all study subjects. Early discharge was defined as the postpartum length of stay ￡ 48 hrs.
Of all newborns discharged within 48 hrs, every third case was called for a follow-up visit 72 hrs later and examined by the same person (DKS). The purpose of follow-up visit was to assess the infant's general health, hydration, jaundice, and to identify problems relating to feeding pattern. Any other medical problem, if present was recorded. The newborn was re-hospitalized if there was jaundice requiring intervention or any other major morbidity including sepsis. The admitting diagnoses of such newborns were recorded.
Statistical analysis: Chi square and Fisher's exact test were applied to determine the factors facilitating early discharge. A multiple logistic regression model was constructed for multivariate analysis, with length of stay (￡48 hr vs >48 hr) as the dependant variable. Factors contributing significantly to the early discharge on univariate analysis were included as independent variables. P <0.05 was considered significant.
Results
During the study period, a total of 1320 deliveries took place. Of these, 186 needed observation/admission in the NICU and were excluded Figure1. The mean (SD) length of stay of 1134 study subjects was 46.4 (45.8) hrs (median 30 hrs, range: 3 - 348 hrs). The median (range) weight and gestation of these babies was 2750 (1850-4600) g and 40 (34-42) weeks respectively.
Of the 1134 study subjects, 861 (76.2%) newborns were discharged within 48 hrs. table1 depicts the correlation between early discharge and mode of delivery, low birth weight, gestational age less than 37 weeks, presence of maternal medical disease or obstetric problem and neonatal jaundice. Multivariate logistic regression analysis revealed that the most important factors contributing to early discharge were vaginal delivery (RR: 30.2; 95% CI: 19.0, 47.9; P < 0.001), absence of pre-existing maternal disease or obstetric complication (RR: 4.32; 95% CI: 2.27, 8.22; P < 0.001), and birth weight of >2.5 kg (RR: 1.91; 95% CI: 1.27, 2.89; P = 0.002).
Of 287 infants called for follow-up, 193 (67.2%) turned up after discharge. The clinical characteristics of the babies lost to follow-up were similar to the ones assessed for medical problems. The mean (SD) age of discharge and follow-up of these newborn infants was 26.4 (8.7) and 78.1 (16.3) hrs respectively. Follow-up detail of these babies is depicted in Figure1.
All babies admitted for hyperbilirubinemia received phototherapy; none of the cases needed exchange transfusion. Other 7 cases underwent a septic screen and received antibiotics ranging from 3-10 days. All re-hospitalized infants improved and were discharged within 5-14 days.
Discussion
The mean term of stay for healthy newborn infants was 46.4 hrs in our study. The average length of stay reported in United States in 1992 was 2.6 days.[2] that declined in 1995 to 1.5 days for vaginal deliveries.[9] This trend towards early newborn discharge has also been reported from 22 other countries.[10] The reasons for decline included financial concerns due to limited hospital reimbursement as well as social factors such as changes in maternal expectations. No data on the term of stay of healthy well newborn infants is available from a developing nation. From this study, it appears that this is similar to that reported from developed countries.
On multivariate analysis, operative delivery, low birth weight and presence of maternal illness were found to associated with prolonged postnatal stay. These are comparable with reports from other countries.[11],[12] where the commonest reasons for prolonged newborn hospitalization were maternal morbidity, cesarean delivery and neonatal jaundice. The major pediatric concern of the early discharge policy is regarding inadequate observation of the newborn infants. In the present study, approximately two-third of neonates reporting for follow-up 3 days following discharge had some medical problem; the most common being neonatal hyperbilirubinemia. Conditions most likely to result in readmission after early discharge are neonatal jaundice, dehydration and feeding difficulties.[13] In our study also, more than 50% of children were readmitted because of hyperbilirubinemia.
A surrogate marker of efficacy of early discharge program used by various authors has been the readmission rates.[8],[14] Some studies have demonstrated that shortened neonatal hospital stay was associated with increased readmission rates up to 10%.[5],[7] Many studies, including three randomized controlled trials, have demonstrated no association between shorter neonatal hospital stay and readmission rates.[11],[12],[15] These studies, however, had one of the many limitations including selection bias, co-interventions, inappropriate control or insufficient power. In our study, 8.3% of the followed-up newborns eligible for early discharge needed readmission. However, we did not employ a control group to demonstrate any difference in readmission of those with early or standard discharge.
We could not follow-up all the neonates discharged within 48 hrs for logistics reasons. Moreover, not all the babies called for follow-up reported back. This resulted in a overall follow-up rate of only 23%. The results may thus be showing just the tip of the iceberg and may lead to an underestimation of the medical problems and the need for re-hospitalization.
Conclusion
Most of the healthy newborns in this tertiary care setting are being discharged within 48 hrs of delivery. Early discharge (￡ 48 h) is governed primarily by maternal indications, including vaginal delivery, absence of pre-existing maternal disease or obstetric complications. Neonatal jaundice is the most common indication of re-hospitalization following early discharge. A follow-up visit after 72 hrs is important to assess the need of re-hospitalization in healthy newborns discharged within 48 hrs of birth.
References
1. Committee on Fetus and Newborn. American Academy of Pediatrics. Hospital stay for healthy term newborns. Pediatrics 1995; 96: 788-790.
2. Centers for Disease Control and Prevention. Trends in length of stay for hospital deliveries-United States, 1970-1992. MMWR 1995; 44: 335-337.
3. Arnold S, Bernstein HH. Newborn discharge: A time to be especially thoughtful. Contemp Pediatrics 2000; 10: 45 (from http://cp.pdr.net/cp/).
4. Patterson PK. A comparison of postpartum early and traditional discharge groups. Quat Rev Bull 1987; 13: 365-371.
5. Waldenstrom U, Sundelin C, Lindmark G. Early and late discharge after hospital birth: Health of mother and infant in the postpartum period. Ups J Med Sci 1987; 92: 301-314.
6. Britton JR, Britton HL, Gronwaldt V. Early perinatal hospital discharge and parenting during infancy. Pediatrics 1999;104: 1070-1076.
7. Maisels MJ, Kring E. Length of stay, jaundice and hospital readmission. Pediatrics 1998; 101 : 995-998.
8. Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Early discharge of newborns and mothers: A critical review of the literature. Pediatrics 1995; 96: 716-726.
9. Hyman DA. What lessons should we learn from drive through deliveries. Pediatrics 2001; 107: 406-407.
10. Thilo EH, Townsend SF, Merenstein GB. The history of policy and practice related to the perinatal hospital stay. Clin Perinatol 1998; 25: 257-270.
11. Pittard WB, Geddes KM. Newborn hospitalization: A closer look. J Pediatr 1988; 112 : 257-261.
12. Welt SI, Cole JS, Myers MS, Shles DM, Jelosek FR. Feasibility of postpartum rapid hospital discharge. A study from a community hospital population. Am J Perinatol 1993; 10 : 384-387.
13. Gale R, Seidman DS, Slevenson DK. Hyperbilirubinemia and early discharge. J Perinatol 2001; 21 : 40 -43.
14. Lee K, Perlman M, Ballantyne M, Elliott I, To T. Association between duration of neonatal hospital stay and readmission rate. J Pediatr 1995; 127 : 758-766.
15. Carty EM, Bradley CF. A randomized controlled evaluation of early postpartum hospital discharge. Birth 1990; 17: 199-204.(Gupta Piyush, Malhotra Sa)