Early neonatal discharge guidelines: Have we dropped the ball?

Abstract

OBJECTIVES:

To determine patterns of follow-up and prenatal education by family physicians and to assess whether practice patterns comply with the 1996 Canadian Paediatric Society/Society of Obstetricians and Gynecologists of Canada (CPS/SOGC) guidelines for early neonatal discharge.

DESIGN:

Mail survey.

SETTING:

A community of 300,000 people who were served exclusively for obstetrical care by a tertiary care hospital that performs 5000 deliveries per year and provides an early discharge program (EDP).

PARTICIPANTS:

Family physicians who provide prenatal and/or newborn care.

MAIN OUTCOME MEASURES:

The timing of neonatal follow-up and parental teaching by family physicians.

RESULTS:

Thirty-two per cent of the respondents scheduled their first postnatal visits two or more weeks after early discharge. There was no significant difference (P=0.7) in scheduling of follow-up for babies who were part of an EDP compared with those who were not. Fewer than 20% of physician respondents provided antenatal education in preparation for early discharge.

CONCLUSIONS:

The 1996 CPS/SOGC guidelines for physician follow-up after early neonatal discharge and for anticipatory parental education are not being followed consistently; however, these guidelines were disseminated without reinforcement. Until further study supports a change in practice guidelines, appropriate implementation strategies must be employed to ensure compliance.

The length of hospital stays following normal term delivery has decreased dramatically over the past few decades in North America. The Canadian Paediatric Society (CPS) defines early postpartum discharge as occurring less than 48 h after uncomplicated, term, vaginal delivery (1). Numerous studies in the past five decades have evaluated various outcomes following early postnatal discharge, including neonatal readmission rates (2,3), neonatal mortality rates (4) and emergency room visits (5,6). Review papers have concluded that it remains unknown whether early neonatal discharge is a safe and efficacious practice (7,8).

In 1996, the Society of Obstetricians and Gynecologists (SOGC) and the CPS released a joint statement that outlined recommendations designed to ensure that early neonatal discharge is implemented as safely and effectively as possible (1). These guidelines recommend that in-home follow-up by a health care professional occur within 48 h of hospital discharge, followed by physician assessment within one week (1). They further recommend that preparation for discharge, including information on infant feeding and detection of neonatal problems be provided as part of the normal antenatal education of all expectant parents (1). To date, no studies have investigated whether the guidelines achieve their purpose or whether they are actually followed by primary care physicians. The aim of the present study was to determine patterns of prenatal education and follow-up by family physicians, and to assess whether these practices comply with the CPS/SOGC guidelines for early neonatal discharge.

METHODS

The present study received approval from the ethics review board of, and was funded by a grant provided by, the IWK Grace Health Centre. The survey was conducted between January and June, 1997, in a community where primary obstetrical and newborn care is provided by family physicians, with some shared prenatal care by obstetricians. All obstetrical and neonatal care in this community is provided by one hospital – a tertiary care centre with approximately 5000 deliveries per year. The hospital provides an early discharge program (EDP) that involves in-home nursing follow-up for mothers and babies who are discharged within 48 h of a normal vaginal delivery and within 72 h of an uncomplicated caesarian delivery. Participation in the in-home follow-up program is voluntary, and the time of discharge is decided by the family members and their physician. The average postpartum length of stay for families who are enrolled in the EDP is 42 h, whereas the average for families who are not enrolled in the EDP is 65 h (9). The initial home visit occurs within two days of discharge, and additional visits may be arranged as needed. Nurses contact the infant’s family physician if any concerns are identified at the home visit.

A list of family physicians in this community who hold a general license, are registered with the Medical Society of Nova Scotia as of January 1997, and are served by the early discharge program was obtained. All physicians received a covering letter and a questionnaire with a self-addressed stamped envelope for return after completion. Physicians who did not return the questionnaire after the first mailing received up to three additional mailings at intervals of four to six weeks, and these mailings included another copy of the covering letter and the questionnaire. Physicians who do not provide prenatal or obstetrical care were excluded from the survey.

The questionnaire was designed in consultation with a departmental epidemiologist (Figure 1). Family physicians were asked when they scheduled the first postnatal visit following hospital discharge for babies who were enrolled in an early discharge program, as well as for those who were not enrolled. They were also asked when they addressed the educational issues that are necessary for preparation for early discharge. Questions regarding educational issues that were not specific to the CPS/SOGC guidelines (eg, cord care) were included for completion. As an indicator of their familiarity with the EDP, family physicians were asked what proportion of newborn infants in their practices were enrolled in the EDP.

Figure 1).

Items from questionnaire to family physicians

Data were entered using Microsoft Excel (Microsoft Corporation, United States). Statistics were calculated using EpiInfo Version 6.04c (Centers for Disease Control Prevention, United States) (9). P was calculated using McNemar’s χ².

RESULTS

Of the 357 physicians who were registered with a general license, 139 were excluded because they did not practice prenatal and/or newborn care at the time of the survey, which left 218 eligible respondents. One hundred seventy-six questionnaires were completed (a return rate of 81%). There was no significant difference in the timing of the first postnatal visit for babies in the early discharge program and for those in the non-early discharge program (P=0.7), as reported by family physicians (Figure 2). One-third of babies, regardless of their enrolment status in the EDP, were not seen by their physicians until two or more weeks after discharge. Greater than 96% of respondents indicated that at least 25% of the newborns in their practices were enrolled in the EDP upon hospital discharge.

Figure 2).

Timing of first newborn follow-up examination, as reported by family physicians. Y axis represents percentage of respondents

Although 80% of family doctors addressed feeding issues during prenatal visits, other baby care issues, such as signs of infection, when to see the family doctor, or elimination patterns, were not routinely addressed before delivery (Figure 3).

Figure 3).

Timing of prenatal education. Y axis represents the percentage of respondents. Respondents could choose as many answers as were applicable. FP Family physician

DISCUSSION

There is no consensus regarding the optimal timing of follow-up after early newborn discharge (10), although studies have shown that inadequate follow-up after early discharge increases neonatal morbidity such as severity of jaundice and dehydration (11). The 1996 CPS/SOGC guidelines for facilitating early neonatal discharge state that in-home follow-up by a health care professional should occur within 48 h of hospital discharge, followed by physician assessment within one week (1). Results of the present study indicated that one-third of primary care physicians did not arrange newborn follow-up until two or more weeks after early discharge, which was similar to the findings of the American study conducted by Maisels and Kring (12). Furthermore, there was no statistically significant difference in the timing of follow-up for babies who were enrolled in an EDP and those who were not enrolled, which implied that the length of the postpartum hospital stay does not affect the scheduling of the first postnatal office visit.

The present study found that, while 80% of physicians discussed infant feeding issues during prenatal visits, fewer than 17% provided prenatal counselling on such topics as normal patterns of elimination, signs of infection or indications to contact the family physician. Because the time spent in hospital (which had traditionally been used for parental teaching) is drastically reduced with shorter postpartum admissions, these topics must be addressed before delivery so that new parents will be capable of dealing with issues that may arise after discharge but before their first scheduled follow-up visit. A lack of education before delivery may result in an increase in visits to walk-in clinics and emergency room facilities within the first two weeks after discharge by anxious, new parents (5,6). A number of studies have examined the effects of perinatal parental education. Parental behaviours such as initiation of breastfeeding (13) and use of the emergency room (14) have been significantly changed through prenatal educational initiatives. There are no studies, however, to indicate the optimal timing or route of delivery of this information to parents, or to show that improved parental education decreases neonatal morbidity (15).

Our study has shown that family physicians in the community we surveyed are not consistently following the 1996 CPS/SOGC guidelines for facilitating early discharge. This was not unexpected, because the current literature indicates that physician compliance with clinical practice guidelines is generally poor, and there is little evidence that these guidelines improve patient outcomes (16). Failure to adopt the CPS/SOGC guidelines is related to both dissemination and reinforcement strategies (17). Passive dissemination of the clinical practice guidelines by publication in medical journals, as in the case of the CPS guidelines, has been shown to be a weakly effective dissemination strategy (13,17). Many of the family physicians who were surveyed in the present study may have been unaware of the guidelines that were published in the paediatric and obstetrical literature.

A lack of awareness of the clinical practice guidelines is likely to be not the only explanation for the lack of compliance (18). Even physicians who are aware of the practice guidelines have shown low levels of compliance without reinforcement strategies such as chart audits or educational interventions (17). Publication of the CPS/SOGC guidelines was done without reinforcement interventions and, thus, the guidelines were less likely to produce a change in practice. Since the time of our survey, early discharge practices have received attention in the popular and medical press (19). A repeat survey may demonstrate improved compliance with the guidelines.

In the present study, the 81% survey return rate ensures that any selection bias was minimized and, therefore, reflects an accurate representation of the practices of family physicians in the community that was studied. To minimize reporting bias, family physicians were purposely not asked about their awareness of the CPS guidelines and, therefore, the reasons for noncompliance could not be determined. Although some degree of reporting bias in our results was expected, this strengthens the position that the CPS/SOGC guidelines were not followed consistently, because respondents might over-report their compliance with known guidelines. Further studies should examine the reasons for noncompliance with the CPS/SOGC guidelines and should examine whether these guidelines are reasonable standards for improving neonatal care. This study represented the practices of family physicians in one local area, and generalizability may be limited to areas with similar programs for supporting families of newborns.

CONCLUSIONS

The 1996 CPS/SOGC guidelines for early neonatal discharge are not being followed consistently by family physicians. These guidelines, however, were disseminated without a strategy for reinforcement and, therefore, suboptimal compliance by primary care physicians may be expected. Until an evidence-based consensus regarding optimal preparation and follow-up practices for early neonatal discharge exists, the CPS/SOGC guidelines for facilitating early neonatal discharge provide reasonable safety measures. Thus, appropriate implementation strategies to increase compliance with these guidelines should be employed.