Evaluation of an early discharge program for infants after childbirth in a military population

Military Medicine, Aug 2000 by Gries, Delores M

The objective of this study was to evaluate the outcome of an early discharge program for infants with regard to length of stay, patient safety, maternal satisfaction, and hospital expense in a military population. The study consisted of a retrospective analysis of data from two 6-month periods-March to August 1994 (before early discharge) and March to August 1996 (after early discharge)-in a military, tertiary care, teaching hospital. The criteria for early discharge included healthy term singleton newborns delivered by uncomplicated vaginal delivery with maternal support systems, transportation, and phone access. The interventions included maternal education regarding maternal and infant care and telephone follow-up at 48 hours and 5 days after discharge. The main outcome measures included length of hospital stay, inpatient cost, infant health services utilization, and maternal satisfaction (measured by survey). During the 6-month study periods in 1994 and 1996, a total of 1,911 deliveries were examined. The mean number (SD) of hospital days per infant was 2.54 0.83 in 1994 compared with 1.88 1.03 in 1996. There was not a statistically significant difference in the number of readmissions between 1994 (9 of 1042, 0.860 and 1996 (12 of 869, 1.380 (odds ratio = 1.61, 9596 confidence interval = 0.67, 3.83). A review of the infant health services utilization revealed a statistically significant increase in the total number of clinic visits (scheduled and unscheduled) before the 2-week wellchild visit for the 1996 group. However, that group did not experience a change in the number of emergency room visits. Seventy-five percent of mothers were satisfied with the program as assessed by questionnaire. In addition, the program was able to save 599 inpatient hospital days, for a total cost savings of $442,903.23 in 1996. This reduction in inpatient hospital days netted an average cost savings of $509.67 per infant. By following strict discharge criteria, increasing parent education before discharge, implementing a phone follow-up system, and ensuring easy access to care, an early discharge program in our military population was not associated with increased adverse newborn outcomes and reduced costs.

Introduction

Recently, hospitals and physicians have been under tremendous financial pressure to discharge mothers and their in

fants as early as possible.uz The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists stress that many neonatal problems manifest themselves during the first 72 hours after birth and that it is preferable for healthy neonates to remain in the hospital for more than 24 hours.334 The AAP has also set forth criteria that are to be met by the infant before leaving the hospital early.4.s These criteria include the following: uncomplicated vaginal delivery of a term singleton, vital signs stable for 12 hours, infant urination and stooling established, two successful feedings, normal physical examination, no bleeding 2 hours after a circumcision, no evidence of jaundice in first 24 hours of life, mother knowledgeable regarding infant care, support person available, laboratory data reviewed, and family, environmental, and social risk factors assessed.4.s

Limited data exist on the safety of early newborn discharges-s The Guidelines for Perinatal Care 3 suggest that readmission may be more common under early or very early discharge programs. Britton and Britton retrospectively studied 1,735 term newborns in a private metropolitan hospital and showed that early discharge with a normal 6-hour transitional period, combined with careful follow-up, did not increase the risk for readmission; however, newborns with an abnormal transitional period had a significantly increased incidence of rehospitalization.' They also demonstrated a significant cost-benefit ratio, with a substantial savings to both the family and the medical system, as a result of the early discharge. Several studies in military populations comparable to our patient population have also shown that early discharge was safe and cost-effective.6,112 These studies illustrate the potential for safety and cost savings of early discharge for the appropriate patient.611,13-16 A limitation of these studies is that hospital readmission by itself may not be a suitable outcome measure. Other outcome measures, including outpatient clinic visits, emergency room visits, and parental satisfaction, are important factors that need to be considered when evaluating overall safety and cost savings.

Madigan Army Medical Center (MAMC), a tertiary care military medical center, developed an early discharge program in 1994 that started in 1995. The MAMC early discharge program was developed using strict discharge criteria, phone follow-up, and easy access to care. Because of concern with very early discharge (

Methods

Patients

The patient population consisted of military dependents at Fort Lewis, Washington, and the surrounding catchment area, including enlisted, officer, and dependent daughters. Medical care is provided at nominal cost to military members and their families, and the majority of obstetrical patients receive routine prenatal care. There are 2,200 to 2,400 births annually, and newborn medical care is delivered by pediatricians, neonatologists, family practitioners, and pediatric residents. We evaluated two 6-month periods, March to August 1994 (before early discharge) and March to August 1996 (after early discharge). Only the records of infants on the newborn service were evaluated; the records of infants admitted to the level II and level III nurseries were excluded.