The importance of enhanced NICU transition and discharge guidelines
Approximately 10% of newborns in the United States require care in a neonatal intensive care unit (NICU) . There has been increasing evidence of the importance of comprehensive NICU care that incorporates enhanced transition and discharge guidelines as a key component of family-centered NICU care [2,3,4]. The need is based on the fact that many NICU graduates have special healthcare needs, utilize increased post-discharge medical and social service resources, and are at increased risk of post-discharge emergency room visits and hospitalizations [2, 5, 6]. In addition, a significant percentage of parents of NICU graduates have increased social, environmental, economic, and mental health challenges and experience the effects of disparities that impact discharge readiness and affect parenting [7,8,9,10,11]. Therefore, a model of multidisciplinary, family-centered care, which meets the discharge needs of the parent-infant dyad, is needed to optimize outcomes . This model of discharge planning and care should begin pre-discharge (i.e., early in the NICU course), continue during the transition process, and extend to the post-discharge period. The goal is to provide a continuum of individualized, family-centered, and culturally competent support and education services that links the family to needed community resources. With the publication of this supplement, the National Perinatal Association provides a state-of-the-art framework for achieving interdisciplinary guidelines and recommendations for NICU Discharge Preparation and Transition Planning.
The following points are made: to accomplish this model of care, the NICU team needs to include not only the physicians, nurse practitioners, and nurses but parents [13,14,15], social workers, mental health providers, medical interpreters, and parent resource specialists . An important first step is developing a trusting relationship with the family. This starts with including parents as active participants in daily rounds. Social workers also play a key role by meeting with the family soon after admission and identifying the family’s strengths and challenges, including addressing any healthcare disparities and psychosocial challenges that may impact the parent’s ability to meet the needs of their infant and their capacity to provide for those needs. For example, the development of protocols to address healthcare disparities (e.g., having public insurance or no insurance, experiencing housing instability or food insecurity) and psychosocial risks (e.g., intimate partner violence, diagnosed or undiagnosed mental health disorders, acute stress, anxiety, depression, incarceration, involvement with child protective services, limited English proficiency, and low health literacy level) are needed.
The development of a teaching manual and resource guide that provides guidance on creating a safe sleep environment, instruction for preparing feeds, tools for preventing and treating infections, information on applying for the Supplemental Nutrition Assistance Program and the Women, Infants and Children special program, clear guidance on the timing, safety, and necessity of immunizations; and instruction for safely administering prescribed and over-the-counter medications is essential to facilitating the discharge education and transition planning process.
It is important that this family resource be reviewed and revised with caregivers during their NICU stay. Assisting caregivers as they prepare for discharge is an important component of the discharge planning process and has been shown to be beneficial. Caregivers should be given referrals for support services, medical benefits assistance, utility assistance, housing resources, and community resources for mental health support while in the NICU, as this will help facilitate a smoother transition home. Findings on components of the family needs assessment can be utilized for supportive anticipatory guidance.
Discharge planning includes confirmation that the family has appointments with their primary care provider, medical specialists, home healthcare (i.e., block nursing and/or standard visiting nurse), home equipment services or durable medical equipment providers. They should be transitioned to a NICU developmental follow-up program and receive a referral for early intervention programs offered under the Individuals with Disabilities Education Act Part C. These arrangements should be documented and shared in hard copy (on paper) and/or electronically with the family. A phone call to the family within 48 h of discharge is important to confirm that all is well and, when needed, to problem solve. Continued contact with the family post-discharge in a NICU follow-up program contributes to improved family satisfaction and improved developmental and mental health outcomes. Finally, the overarching goal of enhanced transition services is to improve the care and outcomes of the parent-infant dyad and to optimize healthcare utilization. The guidelines and recommendations published in this issue by the National Perinatal Association provide specific strategies that can be implemented by NICUs to move forward in this important initiative. It is anticipated that enhanced NICU service provision will continue to grow and spread as evidence of the proposed guidelines benefits to both the family and the healthcare system are appreciated and incorporated into NICU protocols.
Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2018. Natl Vital Stat Rep. 2019;68:1–47.
Vohr B, McGowan E, Keszler L, Alksninis B, O’Donnell M, Hawes K, et al. Impact of a transition home program on rehospitalization rates of preterm infants. J Pediatr. 2017;181:86–92.
Smith VC, Hwang SS, Dukhovny D, Young S, Pursley DM. Neonatal intensive care unit discharge preparation, family readiness and infant outcomes: connecting the dots. J Perinatol. 2013;33:415–21.
Pineda R, Bender J, Hall B, Shabosky L, Annecca A, Smith J. Parent participation in the neonatal intensive care unit: predictors and relationships to neurobehavior and developmental outcomes. Early Hum Dev. 2018;117:32–8.
Willis LD, Lowe G, Pearce P, Spray BJ, Willis R, Scott A, et al. Transition from an ICU ventilator to a portable home ventilator in children. Respiratory Care. 2020;65:1791–9.
Vohr B, McGowan E, Keszler L, O’Donnell M, Hawes K, Tucker R. Effects of a transition home program on preterm infant emergency room visits within 90 days of discharge. J Perinatol. 2018;38:185–90.
McGowan EC, Abdulla LS, Hawes KK, Tucker R, Vohr BR. Maternal immigrant status and readiness to transition to home from the NICU. Pediatrics. 2019;143:e20182657.
McGowan EC, Du N, Hawes K, Tucker R, O’Donnell M, Vohr B. Maternal mental health and neonatal intensive care unit discharge readiness in mothers of preterm infants. J Pediatr. 2017;184:68–74.
Hawes K, McGowan E, O’Donnell M, Tucker R, Vohr B. Social emotional factors increase risk of postpartum depression in mothers of preterm infants. J Pediatr. 2016;179:61–7.
Abdulla L, McGowan EC, Tucker RJ, Vohr BR. Disparities in preterm infant emergency room utilization and rehospitalization by maternal immigrant status. J Pediatr. 2020;220:27–33.
Manickam S, Vivier PM, Rogers ML, McGowan EC, Smego R, Tucker R, et al. Neighborhood inequality and emergency department use in neonatal intensive care unit graduates. J Pediatr. 2020;226:294–8.
Liu Y, McGowan E, Tucker R, Glasgow L, Kluckman M, Vohr B. Transition home plus program reduces Medicaid spending and health care use for high-risk infants admitted to the neonatal intensive care unit for 5 or more days. J Pediatr. 2018;200:91–7.
Murray CH, Joseph RA. Transition from NICU to home: are the parents ready to manage any emergency? An evidence-based project. Neonatal Netw. 2016;35:151–5.
Lakshmanan A, Kubicek K, Williams R, Robles M, Vanderbilt DL, Mirzaian CB, et al. Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study. BMC Pediatr. 2019;19:1–4.
Toly VB, Blanchette JE, Alhamed A, Musil CM. Mothers’ voices related to caregiving: the transition of a technology-dependent infant from the NICU to home. Neonatal Netw. 2019;38:69–79.
The NPA would like to thank the workgroup that convened to develop guidelines; the June 2019 and January 2021 national summit content experts who helped focus, revise, and review the guidelines; the five members of the workgroup affectionately referred to as the “small group” who verified the references; and specifically, Patti Bridges, Brigitte C. Desport, and Julia Yeary for their careful review and thoughtful editorial support.
Organizer: National Perinatal Association.Chairperson: Vincent C. Smith, MD, MPH.Steering Committee: Erin Armknecht, BA; Patti Bridges, MSW, LCSW; Joy Browne, PhD, PCNS, IMH-E (IV); Jenene Craig PhD, MBA, OTR/L; Brigitte C. Desport, DPS, OTR/L, BCP, ATP; Erika Goyer, BA; Cristal Grogan; Andrea Werner Insoft, LICSW, ACSW; Kristy Love; Cheryl Milford, EdS; Steve Richardson; Tiffany Willis, PsyD; Julia Yeary, LCSW, IMH-E®.Interdisciplinary Guidelines and Recommendations Development Work Group: Erin Armknecht, BA; Patti Bridges, MSW, LCSW; Joy Browne, PhD, PCNS, IMH-E (IV); Jenene Craig PhD, MBA, OTR/L; Brigitte C. Desport, DPS, OTR/L, BCP, ATP; Heidi Gates, RN; Erika Goyer, BA; Cristal Grogan; Andrea Werner Insoft, LICSW, ACSW; Carol Jaeger, DNP, RN; Judi Kleekamp, PT; Kristy Love; Cheryl Milford, EdS; Trudi N. Murch, PhD, CCC-SLP; Heather Cohen Padratzik, MHA, JD; Steve Richardson; Cuyler Romeo, MOT, OTR, SCFES, CLC; Betty Vohr, MD; Tiffany Willis, PsyD; Julia Yeary, LCSW, IMH-E®.Additional Content Expert Contributors: Michael T. Hynan, PhD; Carole Kenner, PhD, RN, FAAN; Jonathan S. Litt, MD, MPH, ScD; Nicole Lomerson, MPH; Molly Fraust Wylie.NPA Staff: Erika Goyer, BA; Kristy Love.
Publication of this supplement is sponsored by National Perinatal Association (NPA). The funding for this project was provided to NPA by private donations and supported by an educational grant provided by Sobi.
BRV served on the Interdisciplinary Guidelines and Recommendations workgroup.
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Vohr, B.R. NICU discharge preparation and transition planning: editorial. J Perinatol 42 (Suppl 1), 1–2 (2022). https://doi.org/10.1038/s41372-022-01310-y