When would the nurse begin preparing an infant and family for discharge?

Discharge From the Hospital

Numerous criteria need to be met before a high-risk infant is ready for discharge from the hospital (Table 117.8). Before discharge, infants should be taking most or all nutrition by nipple, either bottle or breast. Some medically fragile infants may be discharged home while receiving gavage feedings after the parents have received appropriate training and education. Growth should be occurring at steady increments, with a goal weight gain of approximately 30 g/day. Temperature should be stable and normal in an open crib. Infants should have had no recent episodes of apnea or bradycardia requiring intervention for at least 5-7 days prior to discharge. Stable infants recovering from BPD may be discharged on a regimen of home oxygen given by nasal cannula as long as careful follow-up is arranged with home pulse oximetry monitoring and outpatient visits. All infants with birthweight <1,500 g or gestational age <30 wk at birth should undergo an eye examination to screen for ROP. If born preterm, hemoglobin or hematocrit should be determined to evaluate for possible anemia of prematurity. Every infant should have a hearing test before discharge. Routine vaccinations should be given based on chronological age before discharge. In addition, palivizumab (Synagis) should be given to eligible infants duringrespiratory syncytial virus (RSV) season immediately before discharge for prophylaxis against RSV, with continued monthly doses arranged as an outpatient as appropriate.

If all major medical problems have resolved and the home setting is adequate, premature infants may then be discharged when their weight approaches 1,800-2,000 g, they are >34-35 wk PMA, and all the above criteria are met. Parental education, close follow-up, and healthcare provider accessibility are all essential for early discharge protocols. Ideally, the primary caregivers for the infant have a chance to provide infant care in the hospital with nursing supervision and help before discharge home. All high-risk infants should follow-up with their primary care provider within a few days of discharge.

Collaboration

Discharge planning, just as inpatient management itself, requires a team approach (Table 17-1). Optimally, the inpatient service has a multidisciplinary approach that includes at least nursing, social services, and a coordinator familiar with local payer structures and other outpatient and community resources, such as home care agencies and alternative care facilities.

Nursing input is vital because nurses interface with patients and families in a different way from physicians; this allows valuable insight into the relative strengths and weaknesses of each patient—information that is critical for appropriate discharge planning. Social workers bring another viewpoint that can shed light on the patient's and family's response to illness and their ability to manageposthospitalization care. This perspective should help guide the timing of discharge and what postdischarge services will be necessary. The discharge planner begins reviewing charts on admission, looking for medical documentation of discharge goals. This allows the planner to immediately start coordinating with payers on issues such as anticipated length of stay and available outpatient services. For adult patients, experience with nurse discharge planners and comprehensive discharge planning demonstrates reduced costs and lengths of stay.2,3 Other possible members of a discharge team include therapists, nutritionists, and child life specialists, all of whom may have unique information that impacts discharge planning. Additionally, a postdischarge coordinator can follow up on pending laboratory results and ensure that the family is able to keep or schedule appointments, obtain prescribed medicines, and follow through with other discharge plans. A weekly (or more frequent) meeting of all parties involved in discharge planning to review ongoing cases and the availability of additional consultation is an effective technique used by many hospitalist groups. This type of multidisciplinary approach can identify significant issues that may affect discharge planning and may serve as a source of quality improvement projects. The hospitalist should be involved in developing mechanisms to ensure the timely review of patient charts by related services to identify discharge issues and improve hospital resource utilization.

Most important, patients and families must be partners in the discharge process. Clear goals for admission, as well as discharge criteria and anticipated obstacles, make it easy for the patient and family to follow the course of the hospitalization and prepare for discharge. The hospitalist must be aware of the prevailing Patients' Bill of Rights regarding necessary notification of discharge, as well as the mechanisms for patients to dispute discharge decisions.

Communication with the PCP is essential for appropriate discharge planning,4 and the American Academy of Pediatrics has established the following guidelines for minimum communication with the PCP: communication on admission, for any significant events, and on discharge.5 Good relationships and ongoing communication with referring physicians can help define the best means of communication. It is also important to clarify the capacity of outpatient services to handle ongoing medical needs. Because many factors influence the PCP's ability to handle various levels of acuity and necessary follow-up after discharge, these issues must be considered during discharge planning. Likewise, it is important to establish open lines of communication with alternative care facilities so that transfer procedures can be initiated as soon as a potential transfer is anticipated. All communication of patient information must be mindful of Health Insurance Portability and Accountability Act (HIPAA) regulations.6

Following Discharge from the Hospital

If the initial postoperative course has been smooth, planning for discharge is possible by the end of the first or second week after LT. Recovery is often more protracted, particularly in debilitated recipients. Once discharged, patients are seen at frequent intervals during the first postoperative month. Liver biochemical test levels should normalize within a few weeks. Graft dysfunction is an indication for prompt liver biopsy to exclude acute cellular rejection. CMV becomes an important infectious consideration 3 or more weeks post-transplant.153 Histologic features suggestive of CMV hepatitis include “owl’s eye” inclusion bodies in the hepatocytes, as well as neutrophilic abscesses with focal necrosis of the parenchyma (seeChapter 83). Recipients who are CMV naïve are at increased risk of CMV infection, particularly if they receive a graft from a CMV-seropositive donor. These patients are candidates for more intensive antiviral prophylaxis. Oral valacyclovir or valganciclovir for 3 to 6 months following LT is recommended for CMV prophylaxis.154

A distinction is made between asymptomatic CMV viremia, which may not require additional antiviral therapy, and CMV disease with systemic complaints such as fever, graft hepatitis, and diarrhea. CMV viremia is detected by PCR-based quantitative nucleic acid testing and by identification of CMV pp65 antigenemia.154 Reactivation of CMV in a previously infected recipient tends to be less clinically severe than de novo infection. The diagnosis of tissue-invasive CMV disease requires confirmation by immunohistochemistry or insitu DNA hybridization techniques, because CMV viremia is not a reliable diagnostic finding in these cases.154 High-dose IV ganciclovir is effective for treating CMV infection; however, viral resistance has been described. Oral valganciclovir is also a therapeutic option for milder CMV disease. Intravenous ganciclovir is the preferred antiviral agent for patients with severe CMV infection or GI involvement (which may limit the bioavailability of oral antiviral agents). Treatment of CMV infection should be continued for at least 2 weeks and until complete resolution of symptoms with viral eradication is achieved.154 Not only is CMV infection an important cause of morbidity and mortality in liver transplant recipients, but it also has been implicated in other complications—notably chronic graft rejection and severe recurrent HCV infection. Following an episode of CMV infection, secondary prophylaxis with antiviral agents is not routinely recommended and is not associated with fewer relapses.154

Trimethoprim/sulfamethoxazole is prescribed to preventPneumocystis jiroveci infection. In patients intolerant of sulfa drugs, options include atovaquone, dapsone tablets, or inhaled pentamidine, although these agents are less effective than trimethoprim/sulfamethoxazole and have a narrower spectrum of protection against other opportunistic pathogens.155 Prophylaxis needs to be continued for at least one year following LT.

Discharge planning

Discharge planning identifies patients who will need nursing home placement or home care services. It helps to estimate the patient's hospital length of stay; offer opportunities to review with the patient and family the patient's diagnosis, prognosis, and choices for discharge location; and review medications, home safety, and the promotion of patient self-care. The site of discharge is largely based on the patient's functional status and the availability of family and paid caregivers. For patients with limited rehabilitation potential, a long-term care nursing home can provide personal care and patient safety. Patients with an educational disadvantage appear to be at greater risk of functional decline and might be more likely to be transferred to a nursing home.30 Patients with cognitive dysfunction at the time of hospital admission are also less likely to recover in the short term and will be more likely to need an alternate site at discharge.31 Transitions of care are often performed abruptly without concerted effort to coordinate the process of transfer from hospital to alternate sites such as subacute care or nursing home.32 Electronic hospital records and discharge systems might help to expedite the process of transitional care and to offer hope for improved coordination of care during this critical period of patient management. Systematic reviews suggest that computerized physician order entry can reduce the rate of medication errors during hospitalization, implying that this benefit could extend to postacute care.33 Websites for health care professionals prove a useful resource in the care of elderly patients (Table 8.2).

Discharge From the Hospital

Traditionally, infants remained in the hospital receiving antimicrobial therapy until bacterial cultures were negative for 48 hr or even longer. Multiple studies have suggested that shorter culture observation periods (i.e., 24 or 36 hr) may be reasonable since most pathogens in the blood grow within this time frame when automated blood culture monitoring systems are used. In one multicenter retrospective cross-sectional study, 91% of blood cultures were positive by 24 hr and 96% by 36 hr. Fewer studies have evaluated thetime to positivity of CSF and urine cultures, but in one large study of febrile infants 28-90 days old, all positive CSF cultures grew within 24 hr (median time to positivity, 18 hr). For blood cultures, 1.3% grew after 24 hr (median time to positivity, 16 hr), and for urine cultures, 0.9% grew after 24 hr (median time to positivity, 16 hr). For neonates undergoing evaluation for HSV, it is reasonable to await results of HSV testing before discharge to home. For patients with identified bacterial infections or HSV infections, the duration of the hospital stay will be determined by the specific pathogen and site of infection.

Criteria for Discharge from Hospital

Discharge planning for the orthognathic patient should begin before surgery. There should be ample preoperative communication with the patient and the patient's family or significant others to prepare for the anticipated postoperative care requirements, including medications, diet, oral and body hygiene needs, and activity level. Basic criteria for discharge from the hospital include the following:

The ability to ingest sufficient liquids orally (i.e., hydration and nutrition)

The absence of significant fever

Stable vital signs, including the maintenance of pulse-oximetry documented oxygenation while sleeping

The absence of continued nausea and vomiting

Sufficient ambulation to carry out necessary activities of daily living in conjunction with a designated family member, friend, or caregiver

Adequate pain control with oral analgesia while in the hospital

The demonstrated ability to achieve required body and oral hygiene

Discharge Planning

Discharge planning should start on the day of a patient's admission to IPR. As noted, IPR length of stay and goal expectations will vary based on patients' injury level and prognosis of the tumor or cancer that led to his or her SCI. A family meeting (Table 10.2) is an essential part of discharge planning and of guiding family expectations of the immediate and long-term future. Family meetings are gatherings held with the patient, the patient's family or loved ones, and all members of the rehabilitation team. They are led by the physiatrist and should touch upon the patient's current status, the plan for IPR, and the plan for continued therapies upon discharging home.

Maximizing home and outpatient therapies is essential to achieving maximal functional recovery in patients with SCI secondary to cancer. Commonly, patients are discharged home with home PT and OT services. This aids in the transition home and also allows for therapists to assess a patient in his or her permanent environment and work on any problems that may arise in the home, for example, difficulty transferring in a bathroom that is more cramped than those in the hospital.

After a brief period of transition, usually a month or less, the patient should transition to outpatient therapies in order to work on higher level goals and tasks.

Patients should also follow up regularly with a physiatrist specialized in SCI that can not only continue to coordinate outpatient therapies but also continue to communicate with patients and families regarding resources, expectations, equipment, pain, patient decline, and any other new or changing issues that arise after discharge from IPR. The management and rehabilitation of patients with SCI secondary to tumor or cancer is difficult and unpredictable. No two patients are the same, and a watchful eye is necessary to achieve the best quality-of-life outcome.

Discharge Issues

Discharge planning after PCI represents an important opportunity to emphasize evidence-based medical treatment of atherothrombotic disease and coronary risk factor modification. All patients should receive aspirin (81 to 325 mg/day) indefinitely. For patients receiving bare metal stents, a minimum 2-week course of a thienopyridine (i.e., clopidogrel 75 mg daily or prasugrel 10 mg daily) is mandatory. If a drug-eluting stent is deployed, this dual antiplatelet therapy must be extended for at least 12 months, and then either aspirin alone or dual antiplatelet therapy must be continued indefinitely if possible.7 Prolonged use of aspirin, clopidogrel, angiotensin-converting enzyme inhibitors, β-blockers, and lipid-lowering agents should be considered on the basis of randomized trials showing improved long-term outcome, particularly in patients who present with unstable angina syndromes (Chapters 71, 72, and 73Chapter 71Chapter 72Chapter 73). Smoking cessation (Chapter 31), blood pressure control (Chapter 67), stress management, exercise, weight loss, changes in dietary habits, and strict blood glucose control for diabetic patients (Chapter 237) also are important elements of the discharge plan.

Activity restrictions after PCI are modest. If the femoral artery was instrumented, heavy lifting is discouraged for several days. Intense aerobic exercise is usually discouraged for 2 to 4 weeks (especially after stent implantation) because exercise can activate platelets and lead to formation of thrombus at the angioplasty site. Patients may return to work 1 or 2 days after the procedure if their occupation does not include heavy lifting or excessive physical exercise. There is usually no restriction on driving an automobile.

(h) Discussion

The National Hospital Discharge Survey is not a reliable source of data for acute pesticide-related illness and injury. Less than half of the sampled hospitals provide data on E-codes (NCHS, unpublished data). For this reason, E-code data are not published in the annual reports of the National Hospital Discharge Survey.

The Nationwide Inpatient Sample (NIS) is another source of hospital discharge data and may contain more complete information on hospitalized pesticide poisoning cases. The 2006 NIS contains all discharge data from 1045 hospitals located in 38 states, approximating a 20% stratified sample of U.S. community hospitals. NIS data are available for purchase through the Healthcare Cost and Utilization Project website (HCUP, 2009).

7.1.3.1 National Hospital Discharge Survey

The National Hospital Discharge Survey (NHDS)3 is an annual survey conducted by the National Center for Health Statistics (NCHS). Started in 1965, this survey program has continuously compiled a statistically representative sample of hospitalization from non-Federal and non-military short-stay community hospitals throughout the United States. As such, it is the oldest and most well-established inpatient discharge database in the country. Over the past decade, the number of hospitals included in NHDS has ranged from 430 to 490, with ~300,000 discharge records sampled per year. Information collected by NHDS includes patient demographics (eg, age and gender), disease diagnosis, type of procedure performed, institutional characteristics, and resource utilization. Based on the information collected by the survey, national and regional estimates of characteristics of patients and surgical and nonsurgical procedures in hospitals of various bed sizes and types of ownership can be estimated using the provided sampling weights.