HOSPITAL LENGTH OF STAY AND READMISSION RATES
By: Anna May A. Selga,MD
The Problem and Its Setting
Hospital stays for newborns and mothers after uncomplicated vaginal delivery have decreased steadily since birth in hospital setting became common.3 From a standard hospital lying-in period of between 8-14 days in the 1950s 20, length of postnatal hospital stay for an uncomplicated vaginal birth is now 2-3 days or less. In the United States, hospital stays after vaginal deliveries gradually decreased from an average of 4 days in the 1970s to 2 days in 1992.3 In 1995, the mean length of stay, vaginally delivered, and routinely discharged infants was 1.1 days. In the Western United States, stays of 12 to 24 hours after uncomplicated vaginal birth is now standard.2 Locally, the Philippine General Hospital and Saint Luke's Medical Center observe their babies at no less than 24 hours. Dr. Jose Fabella Memorial Hospital discharges newborns as early as 12 hours post partum.
For a variety of personal, social, and financial reasons, it is now very common for physicians to recommend or parents to request that their infants be discharged from the hospital shortly after birth. The American Academy of Pediatrics recommends at least 48 hours of hospital stay. Thirteen studies on discharge timing have been already published in international literatures.10 Critical reviews by Britton, Braveman and The Cochrane library conclude that the wide variations of the definition of early discharge (ranging from 2 to 96 hours) and the variation in additional interventions (e.g. home visits), make it difficult to combine the results and provide meaningful interpretation.2,4,10
The Ilocos Training and Regional Medical Center nursery discharges health term newborns no sooner than 24 hours post delivery. The breastfeeding policy is strictly implemented. The mother and the infant are not allowed to go home until the milk flow is established, with documentation that the baby is able to coordinate sucking and swallowing and has urinated and passed at least one stool. A follow up visit is scheduled at 2 to 5 days post discharge.
A retrospective review at ITRMC of early neonatal discharges at less than 48 hours post partum do not show a significant difference on the risk of future readmission compared with those with longer hospital stay.22 Earlier discharge, that is at 24 hours or less partum offers a variety of potential advantages like decreased exposure of the mother and the infant to nosocomial infections, they recover in a familiar home environment and reduced hospital costs of caring for the infant.10 With the hospitals present set up and follow up policies, whether early discharge of 12 to 24 hours post partum still needs to be evaluated.
There are two published literatures on newborn discharges at less than 24 hours.8,14 A nonrandomized prospective study done by Lemmer concluded that a twofold increase in infant complications occur among those discharged at 12 to 24 hours.12 Cotrell on the other hand concluded that less than 24 hours of nursery stay is safe, though the no show rate was at 26%.8
Literature review of foreign studies does not suffice for a local government tertiary institution to reformulate its own discharge policies. The socioeconomic factors, geography, nationality, ethnicity, birth setting, and other population characteristics vary widely, as do criteria for determining an infant's candidacy for early discharge.3,19,20 In the institutions' enthusiasism to formulate cost-saving strategies, the early discharge program promises potential benefits. Before its implementation, formal analysis of this alternative strategy is needed before an optimal policy can be identified. It is therefore imperative to evaluate the effect of the early discharge program at or less than 24 hours post partum.
To evaluate the effect of early hospital discharge at 24 hours or less post partum on the risk of infant readmission during the neonatal period in tertiary government hospital.
Ø To identify whether a policy of early postnatal discharge of 24 hours ore less increases the risk of readmission compared to discharge after 24 hours of observation at Ilocos Training and Regional Medical Center
Ø To evaluate if an early discharge program will not affect parents' compliance to breastfeeding and follow up policies
Ø To present the most common causes of neonatal readmission at ITRMC
Scope and delimitation of the Study
This study involved patients from a government tertiary hospital and would involve a majority of indigent patients. There breastfeeding policy is strictly implemented. The criteria for discharge and admission may vary with private institutions. The results may not be easily applied to private institutions where the breastfeeding policy is not practiced.
This study is a cohort analysis of all uncomplicated vaginal deliveries at ITRMC from July 1 to September 30, 2002. The primary outcome is the newborn readmission rate defined as any readmission within 28 days after discharge from the nursery service.
All infants delivered vaginally, term, with appropriate birth weight and found to be normal on examination were discharged early, defined as 12 to 24 hours post partum. The suggested guidelines by the American Academy of Pediatrics, Fetus and Newborn Committee on discharge of newborns at less than 24 hours1 of age were followed: (1) Only infants delivered at term of appropriate birth weight, single birth and found to be normal on examination were to be considered for early discharge. A nursery stay of 12 hours was required, (2) all infants were examined by the rotating nursery residents (3) the infants were able to maintain thermal hemeostasis and (4) the infants were able to feed normally and parents were educated as to normal newborn wellbeing (feeding, stooling, voiding, signs of acute illness). All infants who were ordered for early discharge were included in the study irregardless of their actual time of discharge