Timely+Discharge+Program

Goal: Simplify/Clarify the criteria to determine who is a candidate for early discharge and expedite these discharges with appropriate outpatient follow-up. Recognize that many “normal” newborns have too many risk factors to safely discharge them from the hospital in less than 48 hours.
 * 1) Low risk newborns and their mothers born before 6:00pm on any given day may be eligible for a next day discharge as of 24 hours of age. (See criteria below) These infants need outpatient follow-up within 48 hours.
 * 2) Normal newborns and their mothers with risk factors will be discharged when these factors can be addressed appropriately and it is medically safe to do so. These families should anticipate a 48 hour stay. Outpatient follow-up appointments will be made based on medical need.
 * 3) Mother-Baby pairs that do not meet timely discharge criteria but the family insists on an early discharge must have the risk explained to them and a note documenting the discharge plan in the chart. These infants should all have early follow-up appointments made

Antepartum/Intrapartum Course (should include but is not limited too)
 * Uncomplicated vaginal birth
 * Gestational Diabetes is okay if all the infant’s chemstrips are okay
 * Insulin dependent pre-gestational diabetes is not a candidate for TD
 * No pre-eclampsia requiring medical management
 * No meconium below the cords
 * No 5 minute apgar <7
 * No cord gases <7.1
 * Assisted vaginal birth okay if above met

Social - Recommend Social Work Eval Prior to D/C
 * Current (within last 2years) untreated parental substance abuse
 * All positive toxicology screens
 * History of domestic violence in current relationship/pregnancy
 * Lack of social support
 * Lack of housing
 * Maternal mental illness
 * Family with history of child abuse, CFS involvement
 * Limited prenatal care (<4visits) with other risks
 * Concern of mother’s ability to care for infant
 * Considering relinquishment
 * Special consideration for 1st time moms and teen moms

Newborn Course
 * Must be term infant between 38 – 42 weeks gestation
 * Must be appropriate for gestational age (weight 2750 – 4100 gms)
 * If breastfeeding, need latch > 7 times two
 * If bottlefeeding, need two feeds of 30cc minimum
 * Must have voided and stooled
 * Stable vital signs for the 12hours prior to d/c (HR 100 – 160, RR<60, T = 97.7 – 99.3)
 * Amount of weight loss assessed
 * No concerns of significant hyperbilirubinemia
 * No pending labs
 * Education complete
 * Mother’s post-partum course uncomplicated
 * No outstanding infectious issues.

Highlights of Updates to this Program


 * 1) Narrower normal temp range CCRMC currently 97.6 – 99.6, AAP 97.7 – 99.3
 * 2) If baby is born from noon on and is being considered for early discharge the next day, he/she will need to be weighed again at noon of day of discharge
 * 3) All babies < 38 weeks will get a ballard to determine actual gestational age. 37 weeks is not term.
 * 4) All babies < 2750 grams and greater than 4100 grams will get a ballard to determine actual gestational age. The terms borderline SGA and LGA will no longer be acceptable

Other Key Points Regarding Discharges


 * 1) For patients with significant weight loss (>8%) that affects disposition, recalculate the weight loss percentage to make sure what’s documented is correct. Document reweigh in H&P and discharge summary before discharge. Any patient with >8% weight loss should have a brief daily note written.
 * 2) For patients with murmurs at the time of discharge, a simultaneous pre- and post-ductal O2 Sat and 4-limb BPs should be obtained. This should be documented in the H&P. Decision regarding referral to Cardiology should be discussed with the attending.

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