Variation in Discharge Timing
Michael N. Musci, Jr, DO, MBASharon Kirkby, MSN
Michael Kornhauser, MD
Paidos Health Management Services
Paoli Executive Green II
Paoli, PA 19301
Alan R. Spitzer, MD
Division of Neonatology
Department of Pediatrics
Health Sciences Center
SUNY at Stony Brook
Stony Brook, NY 11794
To the Editor.—
We were pleased to see the article by Eichenwald et al 1 on variation in discharge timing. We recently published variation on discharge by day of the week and agree that variation exists and matters. 2 Individual practitioner variation may be even a bigger influence than institution-specific variation. This article continues the clarion call for widely accepted discharge guidelines.
Although we commend Eichenwald et al for examining their discharge practices, several issues are worth commenting on. In particular, the use of the phrase "margin of safety," defined as "the number of elapsed days until discharge after infants were first documented to have reached physiologic maturity," causes some concern.
The concept of observation after reaching physiologic maturity is generally accepted in neonatology, although the ideal duration has not been established. Previously we demonstrated in a controlled, randomized trial 3 that "accelerated discharge" could successfully take place without reaching physiologic maturity, defined by Eichenwald as "maintaining temperature in open crib, being free of apnea or bradycardia events, and taking full-volume feeds orally." Furthermore, they make no mention of readmission rates for the infants in that study. It strikes us as premature to label an interval as "margin of safety" without knowing how this time period correlates with a need for readmission. Paidos Health Management Services has case-managed >3000 healthy premature infants between 30 and 34 weeks since 1997. The average time from physiologic maturity to discharge for this population was nearly 50% lower than that reported by Eichenwald. Our unplanned readmission rate within 14 days was less than that reported by Escobar4 in a large population-based study of infants in the neonatal intensive care unit. Using the phrase "margin of safety" without readmission information adds a potentially litigious phrase to the neonatalogy lexicon.
Finally, although the authors concede that their results are related to variation in care practices, they speculate no further. A recent study by Clark et al5 that examined inter-hospital variability in weight gain sheds further insight into a specific area where care practices differ. This suggests that by identifying "best demonstrated process" with regard to feeding, improvements could be made. Our own data supports this concept by observing variations in time to reach full enteral and oral feeds in a severity-adjusted cohort of infants. It is gratifying, however, to see the neonatal literature increasingly grapple with process outcome measures. This will undoubtedly lead to improvements in the quality of care delivered.
REFERENCES
- Eichenwald EC, Blackwell M, Lloyd JS, Iran T, Wilker RE, Richardson DK. Inter-neonatal intensive care unit variation in discharge timing: influence of apnea and feeding management.
Pediatrics.2001; 108
:928
–933
[Abstract/Free Full Text] - Touch SM, Greenspan JS, Kornhauser MS, O’Connor JP, Nash DB, Spitzer AR. The timing of neonatal discharge: an example of unwarranted variation?
Pediatrics.2001; 107
:73
–77
[Abstract/Free Full Text] - Gibson E, Medoff-Cooper B, Nuamah IF, Gerdes J, Kirkby S, Greenspan JS. Accelerated discharge of low birth weight infants from neonatal intensive care: a randomized, controlled trial. J Perinatol.1998; 18(6 pt 2) :S17 –S23[Medline]
- Escobar GJ, Joffe S, Gardner MN, Armstrong MA, Folck BF, Carpenter DM. Rehospitalization in the first two weeks after discharge from the neonatal intensive care unit. Pediatrics.1999; 104(1) . Available at: http://www.pediatrics.org/content/full/104/11e2
- Clark RH, Bloom BT, Thomas P, Peabody J. Application of the best demonstrated process method to a neonatal growth quality improvement project. J Perinatol.2000; 20 :487 –488
Variation in Discharge Timing
Eric C. Eichenwald, MDBrigham and Women’s Hospital
Harvard Medical School
Boston, MA
Mary Blackwell, MD
Lowell General Hospital
Lowell, MA
Tufts New England Medical Center
Boston, MA
Janet S. Lloyd, MD
South Shore Medical Center
Weymouth, MA
Tai Tran, MD
Beverly Hospital
Beverly, MA
Richard E. Wilker, MD
Newton-Wellesley Hospital
Newton, MA
Douglas K. Richardson, MD, MBA
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
In Reply.—
We appreciate the correspondents’ interest in our article, and wholeheartedly agree with their call for more evidence-based discharge criteria for premature infants. We agree that both individual, regional, and institution-specific variation in discharge practices influence hospital length of stay for premature infants. It is likely that all of these factors influenced the variation we observed in discharge timing in our study of Massachusetts neonatal intensive care units (NICUs).1
We used the term "margin of safety" to describe the time period between recognition of physiologic maturity and discharge. As the correspondents acknowledge, this concept is widely accepted in neonatology, although seldom explicitly defined. The term has been used previously to describe the in-hospital observation period before discharge after the last apnea spell.2 As we point out in our article, there is no agreement on what constitutes the ideal interval, and we were not attempting to define it in our study. Rather, we characterized current practice in different NICUs, knowing that there are undoubtedly individual practitioner, hospital, and regional differences. We feel it is essential to accurately measure what is occurring, before discussing what can be done. We agree that readmission data would help better define what constitutes a safe interval and are actively exploring that in an ongoing prospective study. However, we disagree that this term "adds a potentially litigious phrase to the neonatology lexicon." We believe that the term "margin of safety" accurately reflects what is actually occurring in the clinical decision-making around discharge of premature infants. This observation period is used to reassure caretakers and parents that an individual infant is indeed "mature," and thus ready for "safe" discharge to the home environment. What constitutes "maturity" and " safety" may be altered by differing interpretations of existing evidence, technologies for measurement of maturity, practitioner preferences, or hospital-specific practices, as illustrated by our data.
The correspondents also point out how important regional differences in practice are in decision-making around the discharge of premature infants. This is precisely why methodologically rigorous studies are needed. We urge the correspondents to contribute their own quantitative data to the literature. We speculated in our article that differences in monitoring practices among the NICUs we examined influenced the recognition of mature cardiorespiratory behavior, and thus discharge timing. The "best demonstrated process" approach may be easier to apply to feeding strategies. It is likely that apnea management will require development of consensus-based national guidelines for "safe" discharge of premature infants because of the medicolegal issues mentioned.
REFERENCES
- Eichenwald EC, Blackwell M, Lloyd JS, Tran T, Wilker RE, Richardson DK. Inter-neonatal intensive care unit variation in discharge timing: influence of apnea and feeding management. Pediatrics.2001; 108 :928 –933
- Darnall RA, Kattwinkel J, Nattie C, Robinson M. Margin of safety for discharge after apnea in preterm infants.
Pediatrics.1997; 100
:795
–801
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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