Summary of Literature

Most published studies on early discharge describe outcomes of specific individual programs, each with its own particular and often unique characteristics.(3) Socioeconomic factors, geography, nationality, ethnicity, birth setting, and other population characteristics vary widely, as do criteria for determining an infant's candidacy for early discharge. Varied methods of risk screening and parental education have been utilized, maternal support systems at home differ widely, and mechanisms of follow-up vary fromphone calls to home and office visits. The definition of early discharge differs considerably among studies: infants discharged in the“late” group in one study may actually gohome atan earlier postnatal age than the “early” group of another. As a result, it is often difficult to compare data from different reportsor to generalize results from one program to other settings. Appendix II provides a summary of articles reviewed.

Psysiologic Stability

An important advantage to earlier hospital discharge is that nosocomial (hospital-acquired) infection is minimized for both infant and mother.⁷ However, this must be weighed against the risk that early discharge may not provide adequate time for routine medical and social assessment of the mother-infant dyad.⁸

The Committee on Fetus and Newborn of the American Academy of Pediatrics⁹ recommends that the hospital stay of the mother-infant dyad should be long enough to allow identification of problems and to ensure that the family is able and prepared to care for the baby at home. Many cardiopulmonary problems related to the transition from an intrauterine to an extrauterine environment become apparent during the first 12 hours after birth. However, other problems such as jaundice, ductal-dependent cardiac lesions, and gastrointestinal obstruction may require a longer period of observation by skilled personnel.

Norr and Nacion,¹⁰ in their comparative review, observed that although infants discharged early are rehospitalized more often than their mothers, their rehospitalization rate is still low. Infant readmission rates vary a great deal from one program to another, in contrast to the relative stability of maternal readmission rates. In the Norr study, almost all of this variability reflected differences in the definition and treatment of hyperbilirubinemia. Other reasons for readmission included: transient tachypnea, bradycardia, and hypothermia.

Other studies¹¹ reconfirm that treatment of jaundice with phototherapy is the most frequent cause for readmission in some hospitals. Additional reasons for readmission include; respiratory, feeding, bacterial and viral infection, and circumcision problems. In a study by Pittard and Geddes,¹² suspected infectious disease was overwhelmingly the major cause for readmission; while hyperbilirubinemia was rarely the reason for readmission. Maternal age, race, and parental financial status were not predictors of early infant readmission in this study. The high variability in readmission rates for jaundice, historically the most significant reason for readmission, suggests that hospitals can sharply affect their readmission rates for newborns by changing their management of hyperbilirubinemia.

The criteria delineated to measure physiologic stability for infant discharge from the University of Colorado Health Sciences are reported by Conrad.¹¹ The criteria for early discharge were:

• Apgar scores at 1 and 5 minutes are >7.
• The infant is term (38-42 weeks) and weights 2700 to 4000 grams.
• Minimum stay of 24 hours, transition to normal thermoregulation in an open crib, completion of two successful feedings, evidence of stool and void, completion of neonatal screening for metabolic disease and blood type and Coomb's test (Rh- and O mothers) prior to discharge.
• Vital signs are within normal ranges at discharge:
  - Axillary temperature: 36.1EC to 37.2EC
  - Heart rate: 110 to 150 beats per minute
  - Respirations: 25/min. to 60/min.
• The infant has a normal hospital course and resents no signs or sumptoms that require continuous observation.
  - Blood dextrose concentration maintained >2.5 mmol/L
  - Hematocrit 0.45 to 0.65
  - Infants with ABO-incompatible infants must be held for 48 hours and released only if they do not require therapy for hemolysis.
• Physical examination completed by house officer.

Although infant mortality has not been reported in relationship to early discharge, 1994 Minnesota health statistics indicate that infant mortality rates decrease after the first day of birth. Of 64,277 live births, 296 resulted in neonatal deaths, 189 in first-day deaths (largely associated with low birth weight and congenital anomalies), and 57 in 1-6 day deaths. See Appendix IV for distribution of causes of death.

Screening

Screening programs are designed to prevent morbidity and mortality through early diagnosis of medical problems and congenital disorders that can have serious sequelae. Adequate screening programs require universal participation, prompt diagnosis, and mechanisms for parental notification and education. Common screening tests include: phenylketonuria, galactosemia, maple syrup urine disease, congenital adrenal hyperplasia, and congenital hypothyroidism. Some states also mandate screening for sickle cell disease and various sexually transmissible infections.¹³

The screening samples are generally designed for samples taken on the second or third day of life. Screening performed less than two days after delivery may cause some screening test results to be invalid, and those tests will have to be repeated. If screening is done too soon, not only will it be necessary for infants to be retested, there is the danger that those administering the screening program will assume incorrectly that the results of these screening tests are reliable. If the infant leaves the hospital before all necessary screening tests have been administered, follow-up screening must be completed in a timely fashion, no later than two weeks after birth.¹⁴

Minnesota Statute 144.125 states that all Minnesota newborns shall be tested for the following diseases: phenylketonuria (PKU), galactosemia, hypothyroidism, hemoglobinopathy (sickle cell disease) and adrenal hyperplasia.¹⁵ Three of the five tests (PKU, hypothyroidism and adrenal hyperplasia) are not reliable if performed less than 48 hours post-delivery.

The statute further states that it is the duty of the 1) administrative officer or other person in charge of each institution caring for infants 28 days or less of age and 2) the person required to register the birth of the child to administer these tests in accordance with the rules prescribed by the state commissioner of health.¹⁶

The duties of the responsible party include: informing parents or guardians that their newborns will be screened and providing explanation for the screening and their rights to refuse; collecting a specimen for screening no later than the fifth day after the infant's birth; if samples have been taken prior to 24 hours after birth, notifying the parents or guardians verbally and in writing of the necessity of having the Phenylketonuria test repeated on their newborns no later than the 14th day of life; recording the date the specimen is collected in a permanent record; and sending the specimen card including all required information to the Minnesota Department of Health.¹⁶

Care of Newborn

The American College of Obstetrics and Gynecology¹⁷ (ACOG) recommends that early or very early discharge with regard to care of the newborn should ensure maternal readiness to assume independent responsibility for her newborn through demonstrated skill and ability in feeding techniques, skin and cord care, measurement of temperature with a thermometer, and ability to assess infant well-being and recognize common neonatal illnesses. Family members who will care for the child should attend prenatal childbirth education or infant care classes, in which problems of the first days after birth are discussed.

Breast-feeding

Some researchers suggest that early discharge may foster enhanced breast-feeding.³ In a Swedish study by Waldenstrom,²¹ infants discharged early were breast-fed significantly more often on the third and fourth days postnatally than those staying in the hospital, although no difference in incidence of breast-feeding was observed during the subsequent 10 days. Carty and Bradley¹⁸ reported that a significant difference in breast-feeding was observed between the early discharge group and the traditional stay group. At one month, 87% of the women in the early discharge group and 79% in the traditional group were giving their babies breast milk only.

According to a study by Waldenstrom,²¹ however, cited differences in breast-feeding rates may be more related to differences among women studied rather than to the day of discharge.

Education

Braveman¹ points out, “Early discharge has reduced the time available for in-hospital teaching and support on breast-feeding, infant care, women's health needs, and family planning, and for maternal and family psychological assessment.” For this, Beck²¹ suggests, “What early discharge programs need to routinely include are teaching sessions during the last trimester which focus on postpartum discharge instructions for mothers and babies such as episiotomy care and umbilical cord care.”

In contrast to this, Harrison²⁵ suggests that education may be more effective and appropriate in the home environment following the birth: “Compared with the hospital environment, the home may provide more opportunities to include other family members in the teaching program. In addition, parents are often more ready to learn in their home environment, after they have had a chance to assume responsibility for their infant's care.”

The American College of obstetricians and Gunecologists

The American College of Obstetricians and Gynecologists (ACOG) believes that changes in practice such as early discharge following obstetrical delivery should be based on sound scientific data that demonstrate good outcomes for mother and infant, as well as being cost effective. As yet, these data do not exist.¹⁷

ACOG acknowledges that selective, early discharge is safe and desirable for some mothers and babies. However, a decision for early discharge should be individualized and should be a mutual decision between the patient, her family, and the obstetrical provider - taking into account medical risk factors, support systems for the family, and the readiness of the mother to care for herself and her newborn.

ACOG supports legislation addressing insurance coverage for postpartum care that meets the following criteria:

• The appropriateness of individual discharges is left to the discretion of the physician and patient.
• The Guidelines for Perinatal Care provides the basis for required coverage.
• Patients are not provided incentives or disincentives by insurers to access care that is inconsistent with the Guidelines for Perinatal Care.

The American College of Nurse-Midwives

The American College of Nurse-Midwives (ACNM) position is that the timing of discharge after birth is a clinical decision determined by the patient's medical condition and circumstances, the content and quality of prenatal care, the conduct of labor and birth, the newborn's condition, and the availability of qualified personnel to provide early post-partum and newborn assessment. Many women and their newborns are appropriate candidates for early discharge, and payers should be flexible in the decision regarding timing of discharge.

The ACNM will welcome what it and others would embrace as a balanced and broad-reaching Newborns and Mothers Health legislation by which no clinician would be forced to fight for care that is safe, and no mother forced to return home before receiving adequate medical, physical and social support to care for herself and her baby.⁶

Minnesota Medical Association

The Minnesota Medical Association (MMA) passed a resolution at its most recent annual meeting stating that an appropriate postpartum length of stay and any required follow-up care, including nurse home visits, should be determined by the physician and patient and not by an arbitrary time integral. The resolution also indicated that the MMA opposes mandatory reduced hospital stays of one day for vaginal delivery, and three days for cesarean sections (the day of delivery being defined as day 0).²⁹

American Medical Association

The American Medical Association (AMA)is concerned that managed care's practice of requiring routine early discharge for newborns and their mothers may be dangerous to the health and well-being of the mother and child. The decision of when to leave the hospital should be left to the physician and patient and not be based solely on the financial considerations of the managed care company. S. 969 would provide reasonable protection for mothers and their babies so that they are not forced to leave the hospital before it is safe to do so.³⁰

Minnesota Nurses Association

The Minnesota Nurses Association (MNA) has also passed a resolution regarding postpartum hospital stays. Their position is that legislation mandating 48-hour hospitalization does not address the need for assessment of anticipated problems in the postpartum period and education of parents. The maternal and child health Registered Nurses in the hospital settings have the ability and responsibility to assess for complications and plan necessary education and post-hospital referrals. Discharge timing should be a mutual decision made by the family and their health care providers including registered nurses.

Therefore, the MNA supports state and federal policies which create incentives for the insurance industry to provide adequate coverage for maternal-child health care, based upon individual need including a length of stay, as determined by the client with the Registered Nurse, Certified Nurse Midwife, or Physician. In addition, the MNA supports state and federal policies which would require third party payers to cover a minimum of two home visits by a Public Health or Registered Nurse with expertise in community and maternal child health nursing.³¹

American Academy of Pediatrics

The American Academy of Pediatrics' Committee on Fetus and Newborn⁹ have developed minimum criteria for newborn discharge. These criteria are set forth on page 22.

American Academy of Family Physicians

The American Academy of Family Physicians (AAFP) adopted a resolution in September 1995 stating that the AAFP reaffirms physician authority for decision-making regarding length of stay of mothers and newborns after delivery. Furthermore, the AAFP endorses reimbursement of both professional and hospital costs for medically-indicated stays determined by the physician.³²

Council on Scientific Affairs

The Council on Scientific Affairs has stated that in the absence of definitive empirical data, perinatal discharge of mothers and infants should be determined by the clinical judgment of attending physicians and not by economic considerations. This decision should be made based on the criteria of medical stability, delivery of adequate pre-discharge education, need for neonatal screening, and determination that adequate feeding is occurring. A plan should be in place for psychosocial and medical follow-up, as outlined in the Guidelines for Perinatal Care developed by the AAP and ACOG.¹³

HealthPartners

HealthPartners position statement on discharge states that hospital discharge following normal vaginal delivery is dependent on the medical and physical stability of the mother and her newborn infant; it is not dependent upon a prescribed length of hospital stay. Appendix III of this report identifies HealthPartners' criteria to be met and procedures to be followed when considering discharge within 24 to 36 hours after normal vaginal delivery.

Additionally, HealthPartners states that early discharge is only an option and that the final decision for each patient's length of stay is based on medical necessity and mutual agreement between the patient and her provider.³³

Blue Cross Blue Shield of Minnesota

Blue Cross Blue Shield of Minnesota's (BCBSM) policy statement for postpartum stays states that the decision of the length of stay should be based on medical necessity and determined on a case-by-case basis. The decision for an appropriate discharge will be made collaboratively between the attending physician, facility, and the patient.

BCBSM will become involved in the decision if the length of stay exceeds 48 hours for a normal vaginal delivery and 96 hours for a cesarean section. The case will be reviewed for medical necessity using standard criteria.³⁴

Medica

Medica provides discharge guidelines which are to be met prior to discharge following vaginal delivery. Medica discharge criteria are presented in Appendix III of this report.³⁵

Guidelines for Infant Discharge

The guidelines put forth by the American Academy of Pediatrics(9) may serve as a basis for meeting the minimum discharge criteria. See below for specific discharge criteria recommendations:

• The antepartum, intrapartum, and postpartum courses for both mother and baby are uncomplicated.
• Delivery is vaginal.
• The baby is a single birth at 38-42 weeks' gestation and the birth weight is appropriate for gestational age according to appropriate intrauterine growth curves.
• The baby's vital signs are documented as being normal and stable for the 12 hours preceding discharge, including a respiratory rate below 60/min. a heart rate of 100 to 160 beats per minute, an axillary temperature of 36.10C to 37.0C in an open crib with appropriate clothing.
• The baby has urinated and passes at least one stool.
• The baby has completed at least two successful feedings, with documentation that the baby is able to coordinate sucking, swallowing, and breathing while feeding.
• Physical examiantion reveals no abnormalities that require continued hospitalization.
• There is no evidence of significant jaundice in the first 24 hours of life.
• The mother's knowledge, ability, and confidence to provide adequate care for her baby are documented by the fact that she has received training sessions regarding the following issues:

  • Breast-feeding or bottle-feeding. The breast-feeding mother-infant dyad should be assessed by trained staff regarding nursing position, latch-on, adequacy of swallowing, and mother's knowledge of urine and stool frequency.
  • Cord, skin, and infant genital care.
  • Ability to recognize signs of illness and common infant problems, particularly jaundice.
  • Proper infant safety (e.g., proper use of a car seat and positioning for sleeping).
• Family members or other support person(s), including health care providers, such as the family pediatrician or his/her designees, familiar with newborn care and knowledgeable about lactation and the recognition of jaundice and dehydration are available to the mother and the baby for the first few days after discharge.
• Laboratory data are available and reviewed, including maternal syphilis and hepatitis B surface antigen status, cord or infant blood type and direct Coombs' test result as clinically indicated.
• Screening tests are performed in accordance with state regulations. If the test is performed before 24 hours ofmilk feeding, a system for repeating the test must be assured during the follow-up visit.
• Initial hepatitis B vaccine is administered or a scheduled appointment for its administration has been made within the first week of life.
• A physician-directed source of continuing medical care for both the mother and the baby is identified. For newborns discharged in less than 48 hours after delivery, a definitive appointment has been made for the baby to be examined within 48 hours of discharge. The follow-up visit can take place in a home or clinic setting, as long as the personnel examining the infant are competent in newborn assessment and the results of the follow-up visit are reported to the infant's physician, or designees, on the day of the visit.
• Family, environmental, and social risk factors should be assessed. These risk factors may include but are not limited to: 1) untreated parental substance abuse/positive uring toxicology results in the mother or newborn; 2)history of child abuse or neglect; 3) mental illness in a parent who is in the home; 4) lack of social support, particularly for single, first-time mothers; 5) no fixed home; 6) history of untreated domestic violence, particularly during this pregnancy; or 7) teen mother, particularly if other conditions above apply. When these or other risk factors are present, the discharge should be delayed until they are resolved or a plan to safeguard the infant is in place.

It is essential that all infants having a short hospital stay be examined by experienced health care providers within 48 hours of discharge. If this cannot be assured, then discharge should be deferred until a mechanism for follow-up evaluation is identified.

The purpose of the follow-up visit is to:

• Assess the infant's general health, hydration, and degree of jaundice; identify any new problems; review feeding pattern and technique, including observation of breast-feeding for adequacy of position, latch-on, and swallowing; and assess historical evidence of adequate stool and urine patterns.
• Assess quality of maternal-infant interaction and details of infant behavior.
• Reinforce maternal or family education in infant care, particularly regarding infant feeding.
• Review the outstanding results of laboratory tests performed before discharge.
• Perform screening tests in accordance with state regulations and other tests that are clinically indicated.
• Identify a plan for health care maintenance, including a method for obtaining emergency services, preventive care and immunizations, periodic evaluations and physical examinations, and necessary screening.

In summary, the fact that a short hospital stay (<48 hours of age) for healthy term infants can be accomplished does not mean that it is appropriate for every mother and infant. Each mother/infant dyad should be evaluated individually to determine the optimal time of discharge.

Guidelines for Maternal Discharge

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have developed Guidelines for Perinatal Care;¹⁴ an excerpt related to care of the mother is shown below:

Upon discharge, the following points should be reviewed with the mother or, preferably, with both parents:

• Condition of the neonate
• Immediate needs of the neonate (e.g., feeding, methods and environmental supports)
• Roles of the obstetrician, pediatrician, and other members of the health care team concerned with the continuous medical care of the mother and neonate.
• Availability of support systems, including psychosocial support
• Instructions to follow in the event of a complication or emergency
• Feeding techniques, skin care, including cord care; temperature assessment and measurement with the thermometer; and assessment of neonatal well-being and recognition of illness
• Reasonable expectations for the future
• Importance of maintaining immunization begun with initial dose of hepatitis B vaccine

When the mother is discharged early, certain criteria should be met:

• The mother should have an uncomplicated vaginal delivery following a normal antepartum course and should have been observed after delivery for a sufficient time to ensure that her condition is stable. Pertinent laboratory data, including a postpartum determination of hemoglobin or menatocrit level and, if not previously obtained, ABO blood group and Rh typing, should have been obtained. If indicated, the appropriate amount of RhIg should have been administered.
• Family members and other support person(s) should be available to the mother for the first few days following discharge
• The mother should be aware of possible complications and should have been instructed to notify the appropriate practitioner, as necessary
• Procedures for readmission of obstetric patients should be consistent with hospital policy, as well as local and state regulations.

Carty, 1990

The study took place at a tertiary care maternity hospital in Vancouver. All women expecting a vaginal birth were eligible to participate. Women who agreed to be randomly assigned to one of three discharge times were visited at home by a project nurse at approximately 38 weeks' gestation who explained the study in greater detail, obtained written consent, and assigned time of discharge. The final sample consisted of 131 women. The discharge schedules were as follows:

• Early discharge:
• Group 1-12 to 24 hrs. (n=44) Group 2-25 to 48 hrs. (n=49)

• Traditional stay:
• Group 3-4 days (n=38).

Five project nurses made home visits to the women under their care according to the following schedules : group 1 on days 1, 2, 3, 5, and 10 after delivery; group 2 on days 3, 5, and 10; group 3 on day 10 only. At each visit the nurses provided similar nursing care to that received by women in hospital. They conducted a physical assessment of the mother and baby, dealt with the immediate concerns of the parents, assisted them with getting to know their baby, and dealt with the many facets of incorporating a new member into the family. Questionnaires were left with the participants to be completed at four time periods : 37 weeks' gestation, during hospital stay, 1 week postpartum, and 1 month postpartum.

Results: The demographic characteristics of the women in the three groups did not differ significantly after randomization. Over 95% of the women were Caucasian, 93% were married or living with their partner, 65% had completed junior college or university, and 58% had a combined family income over $40,000. Fifty-three percent were primiparas and 47% multiparas.

Maternal and infant health: Regardless of the time of discharge, the women experienced a generally healthy postpartum course. The frequency of maternal problems requiring physician referral in the first 10 days postpartum was 5.3% (n=5) in the early discharge groups and 7.9% (n=3) in the traditional stay group. One instance of each problem was reported, by group, as follows : group 1 - urinary tract infection and episiotomy infection; group 2 - mastitis, episiotomy infection, and subinvolution; and group 3 - endometritis, episiotomy infection, and subinvolution. Of women referred to a physician, two (1.5%0 were hospitalized within the first month postpartum : one from the earliest discharge group for a urinary tract infection, and the other, from the traditional stay group for endometritis.

During the first 10 days postpartum, the frequency of problems in infants requiring physician referral was 4.3% in groups 1 and 2, and 2.6% in group 3. Reasons were hyperbilirubunemia, cord infection, ABO incompatibility, diaper rash, and respiratory difficulties.

Breast-feeding: On discharge from hospital, 98% of all women in the study were breast-feeding. At one month, 87% of the women in the early discharge groups and 79% in the traditional group were giving their babies breast milk only. The one-month questionnaires were returned by mail with a rate of return of 75%.

Psychological functioning: The responses of the women in the three groups did not differ significantly with respect to levels of trait anxiety, or state anxiety assessed prenatally, in hospital at one week, or at one month postpartum.

Women in the three groups did not differ on their prenatal scores on the Beck Depression Index. Those who stayed in hospital for 4 days scored significantly higher on that index at the 1-month follow-up (P<0.05) than did women who were discharged 12 to 24 hours postpartum.

At one week, women who were discharged within 24 hours scored significantly higher than those in the two other groups on the subscale assessing confidence regarding the mothering role (P<0.03). There were no significant differences among the groups with respect to scores on this subscale completed at one month postpartum. This finding suggests that women who have complete responsibility for their baby earlier feel more confident initially than those who do not. It could also mean that the nursing visits enhanced women's feelings of confidence regarding their mothering role.

Patient satisfaction: All the women were satisfied with their care, as demonstrated by their responses on the patient satisfaction questionnaire. However, women who were discharged earliest reported being significantly more satisfied than those discharged later (P<0.0009) they were also significantly more satisfied with nursing care.

In summary, this study shows favorable results for early discharge. However, it is appropriate to point out that since participants were healthy, well-educated women and living in a stable relationship with their husbands or partners, the findings cannot be generalized to a high-risk population. Moreover, since participation was voluntary, it studied only a particular type of woman, who is willing to experience postpartum care that ranges from going home within 12 to 24 hours after birth to a hospital stay of 4 days. As for satisfaction, since the nurses providing home visits were specially chosen, one can only conjecture that some of the findings related to satisfaction, depression, and confidence in the mothering role might have been different if the study nurses had also provided in-hospital care for group 3.

Conrad, 1989

This is a retrospective review of newborn hospital and outpatient medical record of 2000 consecutively born infants admitted into the transitional nursery for level I care at University of Colorado Health Sciences Center, Denver. Infants who initially required a higher intensity of care (i.e., direct admissions in level II or III nursery units) were excluded from this study. The data collected included the following : sex, estational age, birth weight, length of hospital stay, neonatal complications, need to transfer into level II or III units, reason for the hospital stay to exceed 36 hours, documentation of outpatient follow-up within 48 hours of initial discharge, and readmission to the hospital within seven days of initial discharge.

Results: Review of the financial status of mothers demonstrated that 77% were in a lower income bracket (23% were eligible for Medicaid assistance, and the remaining 54% had an average income for a family of four <$17,000 per year). The maternal age in this group was 23.2+5.1 years.

The newborn medical records from the 2000 infants born during the study period were divided into three groups. Group 1 consisted of infants discharged within 24 to 36 hours of birth (n=1091), group 2 infants were discharged 36 to 48 hours after birth (n=343), and group 3 infants were discharged more than 48 hours after birth (n=563). Although no significant differences in birth weight and gestational age were found among any of the discharge groups, there was a trend in group 3 toward greater numbers of infants of 37 weeks' gestation or less and 42 weeks' gestation or longer, as well as greater numbers of infants small or large for gestational age.

The reasons hospital stay exceeded 36 hours for group 2 and 3 infants included:

• Maternal problems that included recovery from cesarean section, postpartum tubal ligation, and recovery from pregnancy-induced hypertension and genital injuries (lacerations and contusions of the maternal genitalia).
• Infant problems - low birth weight was the most frequent neonatal cause for the newborn hospitalization to exceed 36 hours (10.3%). The 51 infants who stayed for social reasons included all infants born to mothers with psychiatric disease and substance abuse.

All infants in group 1 had a mandatory outpatient follow-up visit within 48 hours of discharge. Successful visits were accomplished in 91.1% of the cases. Reasons for the 8.9% unsuccessful visits were : no documentation 3.8%, could not locate 4.1%, refused by parent 0.6%, child adopted 0.3%.

The overall readmission rate for the entire population studied was 1.8%. Significantly greater numbers of readmissions came from infants in group 1 (2.3%) than from group 3 (0.895, P<.05). Treatment of jaundice with phototherapy was the most frequent cause for readmission, 65% of these came from group 1. The second most common reason for readmission was physical signs suggesting bacteremia or viremia.

The authors comment that illiteracy, young maternal age, lack of transportation, and inability to defray the cost of prenatal care may serve to limit prenatal child care education and medical care for women in lower socioeconomic groups. Single-parent status may limit support at home. Provision of health care through several ambulatory systems as well as frequent household moves and a lack of telephone service compromise the establishment of optimal follow-up in the postpartum period. These problems could serve to limit the applicability of early newborn discharge, as outlined by the AAP and ACOG, to large segments of the population that otherwise meet the medical criteria.

Arborelius, 1989

This study was carried out from October 1984 to September 1985 in Motala Hospital, Motala, Sweden. Early discharge was a voluntary alternative for subjects of this study. All pregnant women living in the central parts of Motala were informed by their midwives at the end of the pregnancy. They were told that no decision had to be made before the delivery, and that they could return to the hospital if things did not work out.

Early discharge was defined as hospital stay of 0-2 days after birth, and late discharge as 5-6 days after birth. The families who chose early discharge got daily home visits by a midwife and/or a pediatric nurse. The patients were also free to call the hospital at any time. At the hospital a pediatric examination of the child was done 6-7 days after birth; if necessary an obstetrical examination of the mother was also done.

Altogether 44 women (7 primiparae and 37 multiparae) participated in this study, 22 in the early discharge group and 22 in the controls. There were no differences between the early discharge group and the control group regarding demographic variables such as age, living conditions, education, social class, marital status and nationality. The fathers were also interviewed. There were no differences between the groups regarding the number of days the fathers had been at home during the first month after birth.

Results: Both the early discharge group and the control group were very satisfied with their choice of length of stay.

Breast-feeding: A full month after birth 18/22 mothers in the early discharge group were breast-feeding and 21/22 in the control group. Half a year after birth the corresponding numbers were 12/19 and 14/19. The differences were not significant.

Pittard, 1988

This study is a review of the hospital charts for all infants admitted to the well-baby nursery is the Medical University of South Carolina between January 1 and December 31, 1985. Because of the need for obstetric beds, the practice at the MUSC was to discharge newborn infants after 24 hours but before 48 hours after delivery. To assess neonatal well-being after this moderately early discharge, the number of infants readmitted to the hospital within 6 weeks of birth was evaluated.

The early discharge group comprised 1714 infants who had no maternal or newborn clinical problem identified within the first 24 hours of life. These neonates remained in the hospital for 31 + 5 hours after delivery. The 622 infants in the control group were those who had no neonatal problems identified during the first 24 hours of life and were assigned to an extended hospitalization (92 + 44 hours) solely as a result of maternal concerns. All neonates with extended hospitalization because of neonatal problems were not included in the study.

Results: Of the 1714 babies discharged moderately early, 52 (3.0%) were readmitted within 6 weeks of birth. Of the 622 control cohort infants, 17 (2.7%) were readmitted by 6 weeks of age. Of the 69 total readmissions, 50 (72%) resulted from suspected infectious disease. Six infants had sepsis, with blood or spinal fluid cultures positive for bacterial growth. Five infants were readmitted for jaundice in the first week after discharge. None of these infants required an exchange transfusion, and the serum bilirubin concentration declined with phototherapy in each case.

Of the total study population, 3.3% of the indigent, 3.1% of the Medicaid babies, and 1.5% of the private service babies were readmitted within 6 weeks of birth. Of the babies delivered by cesarean section 2.7% were readmitted by age 6 weeks. This incidence did not differ significantly from the readmission incidence of either the remaining control infants or the experimental infant group.

Of the infants discharged moderately early, 2.6% of black infants and 4.0% of white infants were readmitted within 6 weeks of birth. These rates did not differ significantly from each other, nor from the readmission rates among the extended hospitalization group.

In conclusion, therefore, suspected infectious disease was overwhelmingly the major cause for readmission; hyperbilirubinemia was rare. Maternal age, race, and parental financial status were not predictors of early infant readmission.

Thurston, 1985

This is an evaluation of safety and satisfaction of patients discharged early after delivery. Participation in the early discharge program by both mothers and physicians was voluntary. Discharge was proposed within 48 hours postpartum.

Mothers electing early discharge were assessed by their physicians for suitability. Routine home visits were made on the third, fourth and fifth postpartum days by a select group of specially trained Community Health Nurses who had received additional recent theoretical content and clinical experience in obstetrics. This was followed by a further at about two or three weeks post delivery, a visit which was already being made to all new mothers. Nurses followed established protocol on each of these visits, providing routine patient care, postnatal teaching, and assessment of the physical and emotional status of the mother and physical condition of the baby. A total of 376 women participated in this program.

Results: A high percentage of mothers (78%) breast fed their babies at discharge from the hospital and 75% had continued breast-feeding at five days postpartum. Nursing records indicated maternal problems were most commonly related to perineal bruising, discomfort and hemorrhoids or to breast related symptoms. For babies, the most frequently noted problems were associated with a “jaundiced” coloring or to difficulties with skin care such as diaper rash.

Three mothers and three babies had developed a more serious complication during the first few weeks post delivery. Two infants were discharged with bilirubin readings on the second day exceeding that stated in the criteria, and, for one baby, it is unclear whether discharge occurred before the level was known. Both were readmitted to hospital with high bilirubin levels, and were treated with phototherapy. Another baby was seen and readmitted for respiratory illness at 32 days after discharge.

Two mothers had late postpartum hemorrhages owing to retained placenta and were readmitted for dilation and curettage.

The hospital stay was deemed appropriate in length by 86% of respondents, too short by 7%, and too long by the remaining 7%. Altogether, 97% of participants would suggest the program to friends, and 93% would participate again. Reasons cited were that the program was basically good, that they were more relaxed at home, that bonding improved, and that a home support system was available to them. Only 5% of patients would not participate again, stating that they required more rest, additional help at home, or did not want early discharge.

Yanover, 1976

A total of 88 low-risk patients were randomly assigned to either the early discharge group (n = 44) or control group (n = 44), at Kaiser-Permanente Medical Center, San Francisco. There were no statistically significant differences between the to groups in age, race, father's occupation, planned pregnancy, duration of marriage, length of time to conceive, mother's and father's education, presence of another child in the home, or mother's preference regarding enrollment in prenatal education classes, natural childbirth, or breast-feeding.

Patients in the control group were discharged not earlier than 48 hours with a pediatric visit at two weeks, and obstetric visit at six weeks. Patients in the study group stayed for 12-24 hours postpartum, and the perinatal nurse practitioner made daily home visits for health surveillance and teaching of parent craft through the fourth postpartum day, with additional visits as needed. The perinatal nurse practitioner who was assigned to a family was available to that family during the first two weeks postpartum.

Results: No significant differences or trends were observed in the numbers and types of morbidity occurring during hospitalization or during the first six weeks after delivery in mothers or infants of the study and control groups. The 13 cases of infant morbidity are:

The mothers' complications included precipitous or prolonged labor, midforceps delivery, obstetric laceration, postpartum infection, and postpartum hemorrhage.

The authors estimate that the cost of providing the program's services was approximated by the immediate saving derived from early discharge.

Discharge Procedures

1. Mother and, if possible, her support person are informed of abnormal signs or symptoms to watch for in the first several days following discharge and given written instructions on how to receive assistance if questions or emergencies arise.
2. A home or office visit to assess newborn status is scheduled within 2 to 5 days following discharge. If the patient declines, cancels, or fails the visit, a phone call is made within this time frame to ascertain the well-being of both mother and infant.
3. Routine pediatric (well child) care commences within 2 weeks and a postpartum visit is scheduled within 4 to 8 weeks.

Expectations

1. Expectations of hospitals:

   1. Policies, procedures and or protocols are in place to support appropriate postpartum monitoring and assessment.
   2. Review and reassurance are provided for safe transition of care to home.
2. Expectations of obstetric providers:

   1. Facilitate the inclusion of newborn care into prenatal education.
   2. Discharge planning is initiated prior to hospitalization
   3. Timing of discharge is coordinated with assessments of maternal medical and physical stability, newborn status, and patient concurrence.
3. Expectations of practitioners who provide newborn care:

   1. Provision of appropriate home nursing visits or office visit within 2 days of discharge.
   2. Office or phone availability for questions by either home nurse or parents.
4. Expectations of HealthPartners:

   1. Ongoing monitoring of patient outcomes and satisfaction.
5. Expectations of patients:

   1. Assume an active role in planning for the birth process and the transition of care from hospital to home.
   2. Identify the practitioner selected to provide newborn care prior to hospitalization.