How Long Are Babies Kept in the Hospital

N Am J Med Sci. 2011 Mar; 3(iii): 146–151.

Length of postnatal hospital stay in healthy newborns and re-hospitalization post-obit early on discharge

Rawad Farhat

Department of Pediatrics, Makassed General Infirmary, Beirut, Lebanese republic.

Mariam Rajab

Department of Pediatrics, Makassed Full general Infirmary, Beirut, Lebanon.

Abstract

Background:

The length of postnatal hospital stay for salubrious newborns remains controversial. Proponents of early hospital belch merits that it is safe, decreases the take chances of iatrogenic infection, promotes family bonding and attachment, and reduces hospitalization care and patient costs. Disadvantages include delayed breastfeeding, manifestation of new atmospheric condition affecting newborns after early on discharge, and improper belch planning.

Aim:

The chief aim of the study was to compare early on discharge versus late discharge with the take a chance of readmission.

Patients and Methods:

The length of infirmary stay was recorded for all healthy newborns and infants and followed by investigation of any medical trouble arising after discharge. Factors associated with readmission to the infirmary were analyzed by Chi square and Mantel-Haenszel Common Odds Ratio Guess (OR) with Confidence Limits (CL).

Results:

A total of 478 babies were enrolled, of which 307 were discharged ≤ 48 hours. The overall length of stay was 39 hours (ane.vi days). Thirty-viii (7.9%) newborns were re-hospitalized, with the most common cause being neonatal jaundice. Factors associated with readmission for jaundice were breastfeeding (OR: 10.3 CL3.10to32.xx) and length of stay ≤ 48 hours (OR: xiii.8, CL4.04 to 47.05).

Decision:

Hospital discharge at any time ≤ 48 hours significantly increases the risk for readmission likewise as the take a chance for readmission due to hyperbilirubinemia. Planning and implementing a structured program for follow up of infants who are discharged ≤ 48 hours are vital in social club to decrease the hazard for readmission, morbidity and neonatal mortality.

Keywords: Length of Postnatal Stay, Re-hospitalization afterward discharge, hyperbilirubinemia

Introduction

The length of infirmary stay for newborns and mothers after uncomplicated deliveries has decreased and has go commonplace worldwide. In the Usa, the mean length of stay reported in 1992 was 2.6 days and declined to one.1 days in 1995 for vaginal deliveries[1]. This tendency towards early on newborn discharge has also been reported in 22 other countries[ii].

Proponents of early discharge claim that it is prophylactic, decreases the risk of iatrogenic infection, promotes family bonding and attachment, and reduces the hospitalization care and patients costs. However, concerns accept also been expressed about potential disadvantages of early belch: one) breastfeeding is not established until the third or later postpartum day[3]; two) a number of conditions do not manifest themselves until 2 or more days afterwards delivery; three) time is reduced for in-hospital teaching on breastfeeding, infant care and women'south health. Braveman[4] concluded that "the currently available literature provides little scientific evidence to guide discharge planning for most apparently well newborns and their mothers". Lee[5] recorded that shorter hospital stays were associated with increased number of readmission, within 14 days of life and the severity of these re-hospitalized infants was increased. Liu[half-dozen] found that discharging healthy infants within thirty hours of birth increased the risk of readmission within 28 days by 22%.

To our noesis, no previous studies or published guidelines by the Lebanese Neonatal and Perinatal Societies be that determine the optimal timing of discharge or follow-up period post-obit early on belch. The main goal of this written report was to compare early belch versus tardily discharge with the risk of readmission. This study also examined the preventable causes of readmission, the mean cost of readmissions and the pause-fifty-fifty point for preventing readmission.

Patients and Methods

A prospective written report was conducted for a period of 7 months (September 2009 - March 2010). This study covered all good for you neonates later on their discharge from the Nursery ward at Makassed General Hospital (MGH) in Beirut. On average, our hospital conducts 1200-1500 deliveries per annum. Infants were followed by investigating any medical trouble arising after belch past contacting their caregivers until the infants' age of fourteen days.

Newborn infants admitted to Neonatal Intensive Care Unit (NICU) for prematurity ≤ 34 weeks, intrauterine growth retardation (IUGR), respiratory distress, asphyxia, pathological hyperbilirubinemia, congenital malformations, and those requiring admission to NICU immediately after nascence, were excluded from the study population. Data recorded for each subject included maternal factors (parity, mode of delivery, adequacy of antenatal check up, presence of maternal medical disease (e.thou. chronic hypertension, diabetes mellitus, asthma and anemia), obstetric complications (eastward.g. gestational hypertension and diabetes, pre-eclampsia and eclampsia, lacerations, urgent cesarean section) and neonatal factors (such as nascence weight and gestational age) .

Equally per our hospital policy, the female parent-infant pair is discharged at the same time. A newborn was considered fit for discharge if he/she was on breast milk/canteen feeding, had urinated and passed meconium, with no physical abnormalities and normal vital signs (respiration<60/min, HR<100-160/min, rectal temperature 36-37C), had been vaccinated with hepatitis B vaccine, received vitamin M, and metabolic screen was taken. The mother and relatives are counseled regarding breastfeeding.

Length of stay (LOS) was defined as the interval between nativity and discharge (in completed hours) and noted for all written report subjects. Early discharge was defined as the postpartum length of stay at or before ≤ 48 hours, following the American Academy of Pediatrics (AAP) definition[seven].The newborn was re-hospitalized if at that place was jaundice requiring intervention or any other major morbidity, including sepsis. The admitting diagnoses of such newborns were recorded. This written report was approved by the Institutional Review Board (IRB) Committee of the Makassed General Hospital.

Statistical Analysis

Chi square and Mantel-Haenszel Mutual Odds Ratio Approximate (OR) with Confidence Limit (CL) were practical to determine the factors contributing to NICU readmission. Factors contributing significantly to readmission were included as independent variables. P<0.05 was considered significant.

Results

During the study menstruation, a total of 686 deliveries were performed. Of these, 107 neonates required access to NICU immediately later on nativity and were excluded. 5 hundred lxx nine neonates were followed, of these 101 were lost for follow upwardly; the remaining 478 newborns were enrolled in our study.

2 hundred threescore four (264) were born by normal vaginal delivery (NVD) and 214 by cesarean department (C-department). Figure ane illustrates the subjects' characteristics. Of the 478 neonates, 307 (64%) were discharged at or before ≤ 48 hours. While 171 neonates were discharged after 48 hours, the mean length of stay was 39 hours (ane.half dozen days) of all deliveries. Total number of patients readmitted to NICU was 38 (7.9%), out of which 34 patients were early discharged ≤ 48 hours (Figures ​ 2 & three).

Patients characteristics. Data presented as numbers.

Written report flow chart. Information presented as numbers and percentages.

Number and percentages of admissions according to the etiology.

Factors associated with increased gamble of readmission to the infirmary were: ane) Vaginal delivery (OR: 2.x; CL i.08 to four.34), 2) Birth weight < 2500 gram (OR: 3.25 CL 1.23 to viii.52), 3) Pre-existing maternal complications (OR: 2.0 CL one.01 to 3.98), and 4) Gestational age≤ 37 weeks (OR: 3; CL 1.45 to 6.64 (Tabular array 1).

Table ane

Gamble for readmission by the age of fourteen days

Thirty-two subjects (84.two%) were readmitted due to hyperbilirubinemia, four (ten.5%) with a diagnosis of "rule out sepsis" and ii (five.3%) for respiratory distress. Discharge diagnoses among xxx-two hyperbilirubinemic patients included two with Rhesus (Rh) hemolytic disease, eight with ABO hemolytic illness and 22 with idiopathic jaundice; 16 (72%) were chest fed. The mean bilirubin level in infants readmitted for phototherapy was 16.three mg/dL (range 14.v to 19mg/dL). Hyperbilirubinemia accounted for the majority of readmissions. Since this is potentially preventable, we compared 32 infants readmitted for jaundice with a randomly selected group who were not readmitted. The factors associated with readmission for jaundice in these infants are shown in Table 3. All infants admitted for hyperbilirubinemia received phototherapy; none of the cases needed commutation transfusion.

Table 3

Factors associated with readmission for jaundice

All four cases of sepsis were early discharged ≤ 48 hours and were readmitted to NICU inside ane.5 days following discharge. These neonates underwent septic screen and received antibody therapy ranging from three to 10 days according to biological parameters (complete blood count and differential, C-reactive protein and blood culture results). All re-hospitalized infants were discharged within 4 to 12 days (Table 2).

Table 2

Diagnoses in 38 infants readmitted within xiv days of belch

Discussion

This study showed that early discharge ≤ 48 hours was associated with increased likelihood of readmission during the first two weeks of life every bit compared with later on discharge. The average length of stay for good for you newborn infants for all hospital deliveries was 39 hours (1.6 days) and readmission rate was 7.9%. Our findings are like to the study done past Gupta[2] in Republic of india where the mean length of stay was reported to be 46 hours (1.9 days) and the readmission charge per unit was 8.three%. This is in contrast to other studies that had been conducted in developed countries, such as the United States and Canada, where the mean length of stay was 62 hours (2.six days)[ane] and 64 hours (2.7 days)[v], with a readmission rate of 0.8% and 2.7%, respectively.

In our written report, the readmission rate is 10 times greater than that in developed countries. This difference is due to bereft education provided to lactating mothers, and mainly due to lack of mail service-discharge habitation nursing visits that assess the babe's general wellness, hydration, jaundice and feeding issues. Therefore, hospital readmission rates are reduced among infants who receive early on follow-up visits or home visits[8–10]. In addition to belch timing, other factors were found to be associated with the increased gamble of readmission.

One of the well-nigh contributing factors to the pregnant ascent in readmission is vaginal delivery. 94% of all healthy vaginally delivered are routinely discharged at or before ≤48 hours, and more than than 8.7% were readmitted to NICU. Vaginal commitment increases the probability of readmission as compared to neonates who were delivered past cesarean section. Soskolne and Kring[11,12] reported that vaginal delivery is a run a risk factor for readmission. Anthony[13] constitute that the about strongly associated factor with a decreased likelihood of readmission for jaundice was cesarean delivery. Bragg[14] found that implementation of a structured program for early on neonatal discharge does not have an association with increased risk of neonatal readmission to the hospital.

Late preterms are physiologically and metabolically young. They are at higher gamble than term infants to develop medical complications and are more than likely than term infants to be admitted to NICU[15]. Several case control studies designed to evaluate risk factors for neonatal hospital readmission after nativity have identified late preterm nascence as a meaning risk factor[11,15,16]. In our study, we plant that late preterms were re-hospitalized 2.7 times more than term infants, similar to Anthony et al. who concluded that late preterm gestation was associated with ≤ 3 times increment in the risk of readmission[13]. Our results apropos late preterm risk of re-hospitalization were 1.v times more than than those presented by Tomashek et al.[16].

We found a significantly increased chance of readmission for low birth weight (<2500 gram) newborns of two.viii times greater than that of normal nativity weight. This is similar to the results published in California by Beate[three] and Anthony[thirteen].

The presence of maternal complications was also associated with increased adventure of readmission. Our results were comparable to Beate[3]. In this study, male person sex activity was not found to be an associated factor in increased readmission rate. Of all of the conditions plant to account for readmission to the hospital within fourteen days, only hyperbilirubinemia is susceptible to a type of intervention that might forbid readmission. In our information, we found that neonatal jaundice is the first crusade of re-hospitalization, accounting for 84% of all admissions. A similar cause of readmission was reported in the literature, in which jaundice accounted for l% of the subjects[2,12,17] .We more than closely examined the factors associated with readmission for jaundice every bit shown in Table 3. LOS≤ 48 hours was an important factor associated with the take chances of readmission, the aforementioned significance was institute for breastfeeding, like to the results published by Jeffrey et al[12]. In fact, breastfeeding is not established until the tertiary or after postpartum solar day[3], and it is likely that mothers discharged early exercise not have the opportunity to establish proper lactation on the commencement postpartum day under the guidance of nursing staff and lactation counselors[12]. In add-on, Eidelman et al. have demonstrated that women on the first postpartum day score significantly lower than not-pregnant women on standardized tests of cognitive function, and these mothers will not be able to reliably integrate data given to them by caregivers, which could take an impact on the infant's well-being in the side by side several days[18]. To evaluate the possible effects of inadequate nursing, we observed the weight loss of infants readmitted for hyperbilirubinemia in the start 7 days. At that place were xx such infants and we compared them with xv infants who had been readmitted inside 7 days for reasons other than jaundice, dehydration, or failure to thrive. The jaundiced babies had a mean weight loss (from birth weight) of 2.6% versus 0.1% in the not-jaundiced babies (with a divergence of 2.five%; CL:10.7 to 3.5; P=0.0001). The departure between the two groups suggests less adequate fluid and caloric intake in the jaundiced group, which is consequent with previous observations[12].

Moreover, the exercise recognized by our population, mainly replacing breastfeeding with glucose water solution, causes constipation and afterwards increases the enterohepatic apportionment that leads to an increase in jaundice. Another common exercise is covering of the infant with a yellow scarf instead of advisable direction. Recent data suggest the readmission rate for breastfeeding problems is approximately 0.three% to 2% of term or nearly term infants[6]. Hall[19] confirm that short hospital stays are hazard factors for readmission of insufficiently breastfed infants with hyperbilirubinemia.

Attempts to subtract the risk of hyperbilirubinemia should be directed at the early on institution of effective lactation, besides as closer surveillance for those infants who have hazard factors for readmission. These include vaginal commitment, gestation <37 weeks, length of stay ≤48 hours, and birth weight <2500 gr.

In our report, the increased rate of readmission due to sepsis is 0.8% versus 0.2% as shown by Jeffrey[12]. This is secondary to poor prenatal care, and lack of group B streptococcus (GBS) screening. Saoud and Yunis[twenty] institute that pregnant women in Lebanon appear to take a relatively loftier prevalence of GBS colonization with no identifiable chance factors for its acquisition. These results could provide a basis for a national policy for universal maternal GBS screening in order to reduce neonatal morbidity and mortality.

Decreases in the length of infirmary stay for newborns may result in a substantial increase in the readmission rate[21]. Lee and colleagues establish that with a decrease in length of stay from 4.5 to 2.7 days, there was an associated increase in the rate of hospital readmission[five]. In our study, we compared the group discharged early and the group discharged after 48 hours. Nosotros institute that the quondam is at higher risk of readmission. At this point, several disadvantages are related to readmission: 1) the psychological effect of mother - newborn pair separation and parental feet; 2) the hazard of nosocomial infection that tin can be acquired during hospitalization with increased baby mortality and morbidity, in addition to the complications of hyperbilirubinemia (kernicterus); and 3) elevated expenses due to breast milk replacement by bottle formula.

The decrease in length of stay leads to a higher run a risk for re-hospitalization unless in that location is a change in mail service discharge intendance, such equally dwelling visits by healthcare professionals and early follow-upwardly. Kotagal et al[22] found that reductions in length of stay for full-term Medicaid newborns in Ohio have non resulted in an increment in re-hospitalization rates in the firsthand postnatal period. This was explained past changing patterns of post discharge intendance, such as dwelling house visits, to encourage optimal lactation and the use of home phototherapy. The take chances profiles and sheer numbers of births should encourage hospitals to consider the cost-effectiveness of preventive strategies. If the hospital stay is increased by an additional day, the number of readmissions can exist decreased from 8.7% to 2.three%, and the cost from 174 million Lebanese Pounds (LP) to 121 million LP per 1000 infants discharged.

Conclusion

This study may provide an important attribute on the quality of care implications of current discharge policies and practices. We conclude that the major reason for hospital readmission in the showtime ii weeks of life is hyperbilirubinemia - the nigh common cause which is potentially susceptible to intervention in the commencement few days of life. Attempts to decrease the risk of hyperbilirubinemia should be directed at the early establishment of constructive lactation.

Recommendations

1. It is cost-effective and efficient to prolong hospitalizations in at-risk patients for readmission, particularly those born prematurely, having low birth weight <2500 gram and infants developing jaundice in the nursery.

2. To found a structured strategic plan for the infants discharged ≤48 hours; this includes changing the patterns of mail service discharge care such equally home visits by healthcare professionals or early follow-upwards.

3. To encourage and to brainwash lactating mothers by healthcare professionals.

4. Maternal GBS screening to reduce neonatal sepsis and related morbidity and mortality.

Finally, nosotros suggest that morbidity and mortality resulting from early neonatal discharge can be markedly decreased and managed by following appropriate national guidelines.

Acknowledgement

The authors would similar to thank Zouhair Naja, Doc., Aouni Alameddine, MD., and Fouad Ziade, PhD. for their support and assistance in this work.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3336902/

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