QI project: Get babies home fast, yield savings

Cutting length of stay is a goal at most hospitals, but neonates usually are not a target because they are seen as too delicate and no one wants to risk sending a sick newborn home too soon. At a North Carolina hospital, however, the quality improvement staff found that an aggressive approach can benefit both patient and hospital alike, with little increased risk.

Carolinas Medical Center in Charlotte, NC, already was seeing great success in its use of a low birth weight clinical path that standardized the care of many neonates, reducing the length of stay by 46% over several years. But because North Carolina ranks high in the percentage of babies with low birth weight and in infant mortality, there still was plenty of room to improve, says Martha Whitecotton, RNC, MSN, vice president and chief nurse executive at the hospital. She previously worked as a nurse in the hospital’s neonatal intensive care unit.

"We started hearing about other hospitals discharging babies at a much lower weight, so we looked at that as a way to further lower our length of stay," she says. "One process that we had to put in place was a whole new process of thermoregulation. We thought we were holding these babies too long, not moving them from the bassinet to the open crib, not challenging them early enough."

The hospital started working on a program called "There’s No Place Like Home" that could accelerate the babies’ progress and send them home earlier. Not only would the hospital benefit, but the neonates and the families would benefit from limiting the expense and the stress of a hospital stay. In nearly all cases, a baby will develop better at home as long as certain needs are met, Whitecotton says. But for low birth weight babies and others with serious problems, the challenge was how to meet those needs without keeping the baby in the hospital for weeks or months.

"They needed home care if we were going to send them home any earlier. We previously had some home visits for discharged babies, but there weren’t a lot of home care nurses who were comfortable caring for premature babies," she says. "And the clinicians weren’t interested in discharging them sooner because they thought they would just end up back in the hospital. So we decided to cross-train our neonatal nurses to be neonatal home care nurses."

Nurses take NICU care to the baby’s home

Deciding it was easier to train neonatal nurses in home care than vice versa, the hospital trained five nurses in the particular concerns of home care, including documentation and other regulatory issues that were different from their usual work. The original idea was for each baby to be cared for at home by the same nurse who cared for him or her in the hospital, but that proved unfeasible. Instead, the five neonatal nurses split up the home care workload. Two of them do only home care for neonates, and the other three split their time between inpatient care and home care.

"The two nurses who do it full time were burning out in their positions before we started this program, and now they’re loving their work again," Whitecotton says. "So in addition to all the other benefits, we see it as great for staff retention."

The program started in 1996 and took a full two years of preparation. After the nurses were trained in home care for neonates, the hospital still had to choose participants carefully. Babies previously were discharged at a minimum of 5 lbs., but the goal in the new program was to discharge them at 4 lbs. to 4.5 lbs. That goal wouldn’t be realistic for all premature babies, however. For the early discharge to work, the parents had to be eager, motivated, and highly involved in the patient’s care. The baby had to be stable, able to maintain its body temperature, and gain weight at home.

About 250 babies have been discharged in the program so far, and the resulting data have been analyzed for the first 135. Those first babies were discharged an average of 15 days sooner than their hospitalized counterparts, and they actually gained more weight at home — about 35 g per day at home vs. 20 g per day in the hospital. The faster weight gain is a good indicator of overall health improvement, Whitecotton says, and most likely the result of more attention and a better overall environment at home.

Investment pays off for babies and hospital

The readmission rates were the most impressive sign of success. Carolinas already had a significantly lower readmission rate for premature babies than the industry average, but the rate fell even lower when the babies were sent home early. The early discharge babies were readmitted at an average rate of 0.74%, compared to 0.89% in the hospitalized group.

There was no doubt that the first year of the program brought great benefits to the babies, but then some number crunching revealed benefits to the hospital as well. For the first 135 babies, the charges for home care totaled $81,000 but the charges avoided in the hospital were $3.5 million, based on expected 15 days of stay for each baby.

Start-up costs for the program were about $38,000. Top administrators at Carolinas supported the program from the beginning, Whitecotton says, and it helped that the start-up costs were relatively low. The hospital did have to hire additional neonatal nurses because of the increased workload.

Program wins award from Joint Commission

Suzanne Freeman, president of Carolinas Medical Center, says the investment paid off for both the babies and the hospital. The program was successful largely because of the cooperative effort from the parents, clinicians, and administrators.

"Many people worked very hard to make this program successful, especially the parents of low birth-weight babies who meet the challenge to learn about home care and the special needs of their little ones," Freeman says. "I’m also proud of the neonatal intensive care nursery staff, the medical staff, and the home care nurses who worked together to make this successful from the clinical perspective."

Such good results did not go unnoticed by the Joint Commission on Accreditation of Healthcare Organizations. "There’s No Place Like Home" was the 2001 recipient of the Joint Commission’s Ernest A. Codman Award in the home care category. The Codman Award recognizes excellence in the use of outcomes measurement to achieve health care quality improvement. In announcing the award, Dennis O’Leary, MD, Joint Commission president, said the accomplishments of Carolinas Medical Center "underscore the productive innovations that can be achieved by measuring and using outcomes to improve patient care processes."

Benefits take time to build

The program has had unexpected challenges and benefits. When the babies first started going home early, parents complained that they couldn’t find local pharmacies to provide some of the special prescription drugs the babies needed. So Carolinas started a pharmacy outreach in which hospital pharmacists showed local drugstore pharmacists how to prepare some of the needed medications. Community physicians came to respect the program enough that they did not require as many visits as they normally did to monitor a neonates’s development.

"They knew a qualified nurse was coming and would weigh the baby and would look for any signs of a problem, so they allowed the parents to visit the doctor a little less often," she says. "That was a big thing to the parents, because it can be quite an operation to load up the baby in the car, take the other kids with them, and go to the doctor for that checkup."

Another unexpected benefit was that managed care groups looked favorably on Carolinas for discharging the babies quickly and safely, so much so that 10 have approved the hospital for out-of-contract neonatal care.

The Carolinas experience shows that even challenging patients can be the subject of an aggressive quality improvement project, Whitecotton says. With the program’s initial success, the hospital plans to proceed by expanding it to families that might not have been considered good risks before, such as single teenage mothers.

For peer review professionals who want to implement a similar quality improvement program, patience is a virtue, she adds.

"It was a full two-year process to get ready, and I don’t think we could have hurried that. You can’t rush it or you’ll make mistakes along the way," she says. "The results showed us that all the time we took in putting it together was worthwhile. My first advice is to be patient."