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Three Part Question

For [well, near-term babies] are there [strategies or policy changes]to [safely reduce length of stay]?

Clinical Scenario

As part of a bench-marking exercise in your neonatal network, the length of stay (LoS) for babies born at 30+0 to 34+6 weeks' gestation was measured over a 12-month period (only babies who were inborn and admitted within the first 24 h and had their care on the same unit were included). Corrected gestational age at day of discharge was compared between the seven units.
The bench-marking results show variation of LoS in these babies from 35.5 weeks to 36.7 weeks with a network average LoS of 36.2 weeks. Although this is less than the UK mean LoS of 36.3 weeks, it is higher than the California average of 35.9 weeks.1 You decide to review the LoS in your own unit for this same defined group for the years 1995, 1998, 2001 and 2004. The median LoS for these years is fairly constant at 36.4, 36.6, 36.8 and 36.1 weeks, respectively. You note that 60% of all neonatal admissions comprise babies in this group and that they account for 6000 cot days per year.
You wonder whether you can implement any changes locally to reduce the LoS, safely, for these babies.

Search Strategy

The primary source was Medline using PubMed
(length of stay OR hospital stay) AND (neonatal OR newborn) AND (reduce or reducing OR shortens).

Search Outcome

Outcome: 228 items (last checked in January 2007) were found of which seven were selected as relevant.
Secondary search using Cochrane, EMBASE, CINAHL and SUMSearch found no additional relevant articles.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Casiro et al, 1993	Total of 100 infants under 2000 g birth weight (50 in intervention group)	Randomised trial (1b)	Feasibility, safety, efficacy and cost benefit of earlier discharge with community based follow-up	Reduction in length of hospital stay (17 days vs 24 days) for infants of 1501–2000 g (p<0.02), but not <2000 g.1-year follow-up revealed no difference in terms of rehospitalisation. Significant improvement in home environment in intervention group.Cost analysis showed huge savings.	Limitations:It included only healthy infants. Inability to blind the patient group may have introduced a bias.
Rieger et al, 1995	Two groups of families were examined, one before and one after instigation of the NEDP. Preterm infants in SCBU for >4 days were included.	Retrospective case controlled study (3b)	To facilitate early discharge of preterms from SCBU with NEDP and support for families, and to provide cost analysis.	Families with support were discharged earlier (2.1 days).Rooming in time was reduced by 0.61 days per mother (p = 0.01).Visits to family doctor were less frequent in support group (p = 0.017).No increase in maternal anxiety.Infants in support group were less difficult regarding temperament (p<0.05).Early discharge seemed cost effective.	Non-randomised.Control group and patient groups were chosen from different periods of time. 95% CI not stated.
Cruz et al, 1997	ncluded 27 well babies during 8 months <1300 g at birth; enrolled at 1300 g weight if maintaining body temperature and nipple feeding at least 120 cal/kg/day.Exclusion: for geographical reasons	Randomised clinical trial (1b)	Feasibility of early discharge for selected very low birth weight infants.	No difference in weight gain or incidence of infection in the home group.Average hospital stay was reduced by 3 weeks (p<0.001).	Babies weighing as low as 1300–1350 g were safely discharged.Study included a small number of babies.42 babies were excluded due to geographical reasons.
Ortenstrand et al, 2001	75 families were included (37 in early discharge group). Data were collected up to 1 year. Inclusion: <37 weeks, stable, no apnoea	Prospective study (4)	To evaluate effect of early discharge followed by domiciliary care on parent's anxiety, their assessment of infant's health and breast feeding.	No statistically significant differences in parents' emotional well-being, anxiety, confidence in handling the baby or periods of mental imbalance.Fathers in early discharge group perceived their babies as healthier.	70 families completed study to 1-year follow-up.Follow-up complete.
Langley et al, 2002	32 neonatal units with CNS in England and Wales. Infants <1500 g who received level 1 care for 48 h were included	Retrospective multicentre survey (2b)	LoS on neonatal unit and readmission to hospital during first year of life.	The median LoS was reduced by 12.6% when adjusted for infant's and parents' characteristics (95% CI 5.3% to 19.3%)There was a non-significant reduction in the odds of readmission of 1.6% when a CNS was provided.	Validity is limited due to retrospective nature of study. The findings of this study cannot be definitely attributed to the presence of a CNS, however, the results do suggest that such a service may be beneficial.
Pinelli et al, 2005	21 studies of which 15 were RCTs	Cochrane review (1a)	To determine whether NNS in preterms influences weight gain, energy intake, length of hospital stay, intestinal transit time or age at full oral feeding.	A significant decrease in LoS (WMD –7.1 days) in infants receiving NNS (95% CI –12.6 to –1.7).Did not reveal benefit of NNS on other major clinical variables. Other positive outcome was transition from tube to bottle and better bottle feeding performance.	Only 2 studies checked outcome regarding LoS.No long-term data available.NNS does not appear to have any short-term negative effects.
Melnyk et al, 2006	260 families with preterms from 2001–2004 in 2 NICUs (60% >1500 g). Assigned to either COPE (4-phase educational behavioural program) or comparison intervention program.	Randomised controlled trial (1b)	Parental stress, depression, anxiety and beliefs; parent–infant interaction during NICU stay, NICU LoS.	Parents in COPE group had 4 days' shorter NICU stay (p = 0.05), and also reported less stress, depression and anxiety.	Strengths: use of RCT to test theoretically based program, both parent self-report and observational measures were used to evaluate.Limitations: conducted only in 2 level-3 NICUs. Relatively healthier infants. Statistically significant results were found on further subgroup and secondary analysis.

Comment(s)

The advantages of earlier discharge include improved parental bonding, decreased exposure to nosocomial infections and significant savings in health care costs. Family support is an integral part of early discharge. Of the cited studies, five aimed at early discharge with community based support. These studies are based on birth weight rather than gestational age. In the study by Cruz et al, infants weighing as low as 1300–1350 g were successfully discharged; however, this study only included 27 babies. Early discharge requires close liaison by a multidisciplinary team. This should include the neonatal paediatrician, neurodisability/developmental paediatrician, paediatric physiotherapist, nutrition specialist, clinical psychologist, speech and language therapist, family support nurse and social worker (Rieger, Ortenstrand). With effective team work, early discharge was achieved by discharging on any day of the week, discouraging mothers from rooming-in and discharging selected babies while they were still receiving intragastric feeds (Rieger). The validity of this study is limited by its retrospective nature. Langley et al reported that community neonatal services (CNS) can reduce the LoS without any subsequent increase in readmission. The retrospective nature of this study means the findings cannot be attributed with certainty to the availability of CNS. Non-nutritive sucking (NNS) in preterm babies appears to have some clinical benefit in reducing LoS, as stated by Pinelli et al. However, in this Cochrane review only two RCTs examined the effect of NNS on the LoS. NNS appears to facilitate the transition to full oral/bottle feeds and bottle feeding performance in general. NNS does not appear to have any adverse effect in the short term. No long-term data on the effects of NNS are currently available. Evidence has now accumulated to support the view that an educational behavioural programme not only results in parents caring for and interacting with their infants in a developmentally sensitive manner but also reduces hospital LoS (Melnyk). Early intervention with such programmes is needed because once negative behaviour is initiated, changes are difficult to implement and even harder to sustain. This is the first RCT to demonstrate the effectiveness of a theory-based intervention with the parents of premature infants that commences early in the NICU stay. It is reasonable to assume that early discharge of preterm infants would increase parental stress. However, early discharge followed by domiciliary nursing care did not seem to have any major effect on parents' anxiety or their assessment of their infant's health (Ortenstrand).

Editor Comment

CNS, community neonatal services; COPE, Creating Opportunities for Parent Environment program; LoS, length of stay; NEDP, neonatal early discharge plan; NICU, neonatal intensive care unit; NNS, non-nutritive sucking; RCT, randomised controlled trial; SCBU, special care baby unit.

References

1. Profit J, Zupancic JA, McCormick MC, et al. Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom. Arch Dis Child Fetal Neonatal Ed 2006; 91: (4): F245–50.
2. Casiro OG, McKenzie ME, McFadyen L, et al. Earlier discharge with community-based intervention for low birth weight infants: a randomized trial. Paediatrics 1993; 92: 128–34.
3. Rieger ID, Henderson-Smart DJ. A neonatal early discharge and home support programme: shifting care into the community. J Paediatr Child Health 1995; 31: 33–7.
4. Cruz H, Guzman N, Rosales M, et al. Early hospital discharge of preterm very low birth weight infants. J Perinatol 1997; 17: 29–32.
5. Ortenstrand A, Winbladh B, Nordström G, et al. Early discharge of preterm infants followed by domiciliary nursing care: parents' anxiety, assessment of infant health and breast-feeding. Acta Paediatr 2001; 90: 1190–5.
6. Langley D, Hollis S, Friede T, et al. Impact of community neonatal services: a multicentre survey. Arch Dis Child 2002; 87: F204.
7. Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev 2005;(4): CD001071.
8. Melnyk BM, Feinstein NF, Alpert-Gillis L, et al. Reducing premature infants' length of stay and improving mental health outcomes with the Creating Opportunities for Parent Environment (COPE) NICU program: a randomized controlled trial. Paediatrics 2006; 118: (5): e1414–27.