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To determine whether early discharge of newborn infants from hospital is associated with increased risk of readmission during the first 28 days of life.
Population based, case control study, with linkage of records from the Washington State Birth Events Record Database and the Comprehensive Hospital Abstract Reporting System.
State of Washington, USA.
5595 case patients (infants readmitted to hospital during the first month of life) and 23 439 control infants (no readmission during the first month of life and matched for year of birth) were identified from a cohort of 310 578 births in Washington state between 1991 and 1994. Exclusion criteria were gestational age <36 weeks, multiple births, caesarean delivery, transfer to another hospital, or serious medical conditions including respiratory distress syndrome, pneumonia, sepsis, meconium aspiration, and some rare conditions such as extrophy of the bladder or double outlet right ventricle.
Assessment of risk factors
Length of hospital stay at birth was defined as early discharge (discharged within 30 h of birth) and later discharge (discharged 30–78 h after birth).
Main outcome measure
Hospital readmission at 7, 14, and 28 days after birth.
4971 newborn infants (17%) were discharged early. Newborn infants who were discharged early were more likely than those who were discharged later to be readmitted to hospital at 7 days (odds ratio [OR] 1.28, 95% CI 1.11 to 1.47), 14 days (OR 1.16, CI 1.03 to 1.32), and 28 days (OR 1.12, CI 1.00 to 1.25) (adjusted for birth year, gestational age, maternal race/ethnicity, insurance payer, maternal diabetes, premature rupture of membranes, pregnancy complications, sex, and parity). Analysis of a subgroup of healthy, liveborn singleton infants showed similar results for 7 days (OR 1.63, CI 1.35 to 1.96), 14 days (OR 1.34, CI 1.14 to 1.58), and 28 days (OR 1.22, CI 1.06 to 1.41) (adjusted for birth year, gestational age, maternal race/ethnicity, insurance payer, pregnancy complications, sex, and parity).
Early discharge of newborn infants <30 hours after birth was associated with an increased risk of readmission to hospital at 7, 14, and 28 days after birth.
Postpartum hospital stays have decreased dramatically over the past few decades to the present 12–48 hours for vaginal births and 4 days for caesarean births. Although initiated in response to consumer demands to “demedicalise” childbirth, this trend has continued and has intensified in response to pressures of cost containment.
Numerous studies have explored the safety of early postpartum discharge. Critical reviews of the literature have failed to reveal the optimum length of postpartum stay because of serious methodological flaws in the primary research including variable definitions of early discharge; small sample sizes with limited power; inadequate study designs lacking randomisation or appropriate control or comparison groups; limited generalisability because of selection bias, different inclusion criteria, and a variety of interventions before and after discharge; and diverse outcomes.1, 2
The studies by Liu et al and Edmonson et al explore the question of safety, while addressing the limitations of previous studies. Both studies are well designed and use similar methods, data sources, and time periods. They are population based, with case control designs and large sample sizes, enabling broad generalisability and increased power to draw meaningful conclusions. There initially appears to be a discrepancy in their results, but on further review this is because Liu et al looked at readmissions in general, whereas Edmonson et al looked only at feeding related readmissions, thus having a smaller sample size and lacking the statistical power to detect differences of the same magnitude. The 1 limitation associated with both studies is that no information is provided on predischarge or postdischarge practices, both of which can contribute to the safety of early discharge.
The results of these studies are important for postpartum nurses working in hospital and in the community. There are implications for clinical practice, education, research advocacy, and policy development.
Although most newborn babies remained healthy, there was an increased risk of readmission with early discharge in certain subgroups. This finding reinforces the need for nurses to carefully assess mothers and newborn babies before discharge. Screening criteria should be used to identify populations at increased risk and to assess readiness for discharge by considering biological, developmental, and psychosocial factors. Discharge decisions should not focus solely on timing but on readiness, which is individually determined.
Neither of the 2 studies gave information on services provided after discharge. Because early discharge was associated with increased risk of readmission for certain conditions, nurses need to provide close individual follow up within the first days of life. This would enable early identification of problems and subsequent intervention as well as promotion of child and family health and wellbeing. A range of comprehensive, flexible, and responsive postpartum discharge services which focus on neonatal and maternal assessment, breast feeding promotion, and teaching of infant care are needed. Given the current underfunding of community based postpartum discharge services, nurses must advocate for policy development and provision of funding for this range of options that ensures assessment and intervention at reasonable time intervals. Research will show whether the type, timing, intensity, and location of postpartum discharge follow up services are more crucial than the timing of hospital discharge.
Early postpartum discharge requires collaboration across sectors (hospitals, primary care, public health, and other community based programmes) and among providers (nurses, physicians, midwives, and other healthcare providers). Nurses can take a leadership role in collaborative planning and partnership building to create a “seamless” system of care and support for new mothers and their babies.
Nurses also have an important part to play in data collection and continuing research in this area. They can advocate for, and participate in, rigorous studies of sufficient size which examine the effect of different hospital stays and postdischarge practices on a range of outcomes for mothers and babies in diverse populations and settings. Only then can we inform practice, policy, and funding decisions.
Sources of funding: National Research Service Award; University of Washington, Seattle; and the Children's Research Endowment Fund, Children's Hospital and Medical Center, Seattle.
For article reprint: Dr L L Liu, Childhood Asthma Study Team, 146 N Canal, Suite 300, Seattle, WA 98103–8652, USA. Fax +1 206 543 5771.
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