Stick the Landing: Improving Support for Families to Ensure a Safe Transition Home

Infants who graduate from an intensive care unit and their families face unique challenges after discharge due to their relative medical complexity compared to infants who did not require intensive care after birth. In addition, these small patients are discharged into the community without the benefit of a pre-existing relationship with a primary care pediatrician.

Babies discharged from the CHOP Newborn/Infant Intensive Care Unit (N/IICU) are particularly complex.

CHOP data from the Children’s Hospitals Neonatal Database (CHND) reveals that:

• 21 percent of infants discharged to home were on tube feedings
• 6 percent were on oxygen or a respiratory device (other than an apnea monitor)
• 15 percent were on three or more medications
• 42 percent required follow-up with three or more specialists
• 8 percent of our discharges had an incredible seven or more specialist referrals at discharge

Parents and pediatricians who are struggling to care for a complex NICU graduate do not often let the inpatient providers know how the transition to home could have been improved.

To remedy this, Annie Giaccone, MD, associate medical director of CHOP’s Neonatal Outreach Program, and Lori Brittingham, RN, are leading an effort to improve the discharge process by soliciting feedback from families and pediatricians.

In the last few years, members of their Discharge Improvement Work Group have conducted focus groups and surveys to identify areas where parental education and preparation could be improved as well as how we can better communicate with primary care pediatricians around the time of discharge.

In addition, John Chuo, MD, neonatal quality officer and medical director of CHOP Telemedicine, is the recipient of a grant from Verizon to develop an innovative effort utilizing telemedicine technology to hold post-discharge follow-up visits between complex patients and a multidisciplinary team from Neonatology.

As a result of these efforts, the following opportunities for improvement have been identified:

• Parent education and preparation should begin earlier in the admission and not be compressed in the days leading up to discharge.
• There needs to be a more effective process for communicating with primary care physicians prior to discharge.
• The process for scheduling subspecialty appointments is overly complex and challenging for families to navigate.

Several initiatives have been launched to address these issues. They include:

• Plans to open a dedicated education space within our N/IICU that will be staffed by nurse educators and will provide appropriate education to family members throughout their baby’s hospitalization.
• A new multidisciplinary partnership with our outpatient pediatrician colleagues that will improve the methods, timing and content of patient handoffs.
• Resources allocated by CHOP’s Department of Clinical Nutrition to provide interim outpatient nutrition support for infants discharged on tube feedings.
• The reorganization of the Complex Scheduling Program to dedicate staff to helping N/IICU graduates manage multiple specialty appointments.

Our N/IICU continues to pursue feedback from PCPs and parents of discharged babies. After providing the highest level of care for patients during their hospitalization, there is new focus on the need to “stick the landing” and ensure families have the optimal support to transition home safely.

Join the conversation on this important topic by contacting Annie Giaccone.