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PEDIATRICS Vol. 108 No. 4 October 2001, pp. 928-933

Inter-Neonatal Intensive Care Unit Variation in Discharge Timing: Influence of Apnea and Feeding Management

Received Jan 8, 2001; accepted Mar 22, 2001.

Eric C. Eichenwald*, Dagger , Mary Blackwell§, parallel , Janet S. LloydDagger , , Tai TranDagger , #, Richard E. WilkerDagger , **, and Douglas K. Richardson§§

From the * Department of Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Dagger  Harvard Newborn Medicine Program, Children's Hospital and Harvard Medical School, Boston, Massachusetts; § Department of Pediatrics, Lowell General Hospital, Lowell, Massachusetts; parallel  Division of Neonatology, Boston Floating Hospital for Children, Tufts New England Medical Center, Boston, Massachusetts;  Department of Pediatrics, South Shore Medical Center, Weymouth, Massachusetts; # Department of Pediatrics, Beverly Hospital, Beverly, Massachusetts; ** Department of Pediatrics, Newton-Wellesley Hospital, Newton, Massachusetts; Dagger Dagger  Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and the §§ Department of Maternal and Child Health, Harvard School of Public Health, Boston, Massachusetts.

Background.  Premature infants need to attain both medical stability and maturational milestones (specifically, independent thermoregulation, resolution of apnea of prematurity, and the ability to feed by mouth) before safe discharge to home. Current practice also requires premature infants to be observed in hospital before discharge for several days (margin of safety) after physiologic maturity is recognized.

Objective.  To compare postmenstrual age (PMA) at discharge in a homogeneous population of premature infants cared for in different neonatal intensive care units (NICUs) and to assess the impact on hospital stay of the recognition and recording of physiologic maturity and the required margin of safety.

Methods.  We studied premature infants delivered at 30 to 34 6/7 weeks gestational age (GA), free of significant medical or surgical complications. Medical records of 30 eligible infants consecutively discharged from the hospital before July 1997 from each of 15 NICUs in Massachusetts (9 level 2 and 6 level 3) were reviewed.

Results.  A total of 435 infants were included in the study sample. Mean (± standard deviation) GA and birth weight of the study population were 33.2 ± 1.2 weeks and 2024 ± 389 g, respectively. Infants were discharged at a similar PMA regardless of GA at birth. Considerable variation in the PMA at discharge between hospital sites was observed (range, 35.2 ± 0.5 weeks to 36.5 ± 1.2 weeks). Despite the homogeneous study population, hospitals in which infants had the latest PMA at discharge also recorded mature cardiorespiratory and feeding behavior at an older age. Longer duration of pulse oximetry use was associated with later resolution of apnea. Differences in the duration of the margin of safety between sites did not contribute to variation in hospital stay.

Conclusion.  NICUs vary widely in length of hospital stay for healthy premature infants. We speculate that this variation results in part from differences in monitoring for and documentation of apnea of prematurity and feeding behavior.  Key words:  newborns, apnea of prematurity, practice variation, hospital discharge, neonatal intensive care units.




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