Fran Lowry

October 08, 2013

Nursing staff at a large neonatal intensive care unit (NICU) has taken the boy scout motto — Be Prepared — to heart.

At the Texas Children's Hospital in Houston, nurses have developed a timeline outlining all the things that need to be done before a baby in the NICU can be safely sent home.

The discharge process is now smoother and less stressful for nurses and parents and, ultimately, safer for the babies.

Tanya Williams, RN, nurse manager at the hospital, described the NICU experience in a poster presented at the National Association of Neonatal Nurses 29th Annual Educational Conference in Nashville, Tennessee.

"We have a fairly large NICU here at Texas Children's, with 55 beds, and we were having some issues with our discharge," Williams told Medscape Medical News.

"We realized that we needed to streamline the process, make it simpler for the nurses to get our patients out in a timely manner. I think we accomplished what we wanted to do," she said, adding that "it's important to share our experiences, given the size of our NICU."

Tanya Williams

Williams and her colleagues noticed that screens and parent instruction were being left until the last minute. To address this issue, the team collected data from their level 2 NICU.

They found that although neonatal patients were identified as candidates for discharge at the daily 8 AM meeting, only 26% were being discharged before 2 PM.

In addition, even for patients who were in the NICU for several weeks or months, the bulk of the education of parents was done in the final 48 hours before discharge. "That was when the parents were getting their CPR education, or car seat education, or learning how to use medical equipment. We were scrambling to get all of those things done in a small time frame," Williams explained.

"Of course, you wonder how much of that last-minute education the parents actually remember, because there's so much going on that day, there is so much anxiety associated with going home," she noted.

Using the Define, Measure, Analyze, Improve, and Control (DMAIC) process, Williams and her team put timelines for the NICU nursing staff in place to ensure that all procedures and education programs were carried out and documented in the patient's record.

The nursing staff also verified that the parents understood all instructions regarding the proper care of their babies before they went home.

If everyone is consistent in what they are doing and making sure that the needs of the patient and the parents are addressed, we can have seamless discharges.

The timeline initiative included weekly project team meetings, emails, face-to-face meetings with the project head, weekly meetings with the project mentor, and periodic updates with the NICU medical director.

As part of the initiative, hearing screens were ordered for infants if they were in an open crib at 34 weeks of age, rather than during the week before discharge. In addition, parents were taught how to do CPR several weeks before their child was due to be discharged so that they would have enough time to digest what they had learned.

During teaching sessions, parents were be able to devote all of their attention to learning how to care for their child because the NICU child care service was available to supervise the neonate's siblings, Williams noted.

After the timeline initiative was implemented, the proportion of patients discharged before 2 PM rose from 26% to 48% (P =.007).

Ensuring that more patients were discharged before 2 PM increased the number of intensive care beds available for new patients meeting intensive care criteria.

"If everyone is consistent in what they are doing and making sure that the needs of the patient and the parents are addressed, we can have seamless discharges, we can decrease the anxiety for the parents, and we can have a safe discharge home," Williams said.

As can be seen from this research, "a decreased discharge time has the potential to improve care quality, bed availability, patient flow, and patient and family satisfaction," Amy Knupp, MSN, RN, from Akron Children's Hospital in Ohio, told Medscape Medical News.

Williams and Knupp have disclosed no relevant financial relationships.

National Association of Neonatal Nurses (NANN) 29th Annual Educational Conference: Abstract 1060. Presented October 3, 2013.


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