Executive Summary
An initiative in which the entire treatment team focuses on moving premature babies through the continuum has resulted in a drop of four days in the average length of stay at Cedars-Sinai Medical Center’s Neonatal Intensive Care Unit.
• The treatment team has daily rounds on every patient and a multidisciplinary early discharge team assesses every patient at the bedside to determine who is ready to go home and what is holding up the discharge, and to take action to move things along.
• The bedside nurses assess the babies several times a day for feeding readiness and to determine if they are ready to move along in the clinical protocol.
• The team gets parents involved in daily care and gives them hands-on experience so they won’t be nervous about caring for the child at home.
The average length of stay for premature infants in Cedars-Sinai Medical Center’s 45-bed Neonatal Intensive Care Unit (NICU) has dropped from 21 days in 2011 to 17 days, following a series of initiatives to improve care coordination and throughput, along with changes in treatment protocols. The unit is part of the Maxine Dunitz Children’s Health Center.
Medical advances in the treatment of premature infants are part of the reason for the decrease, but a major factor in the shorter length of stays is the entire multidisciplinary team’s focus on coordinating each baby’s complex healthcare needs and moving them along the treatment protocol as soon as they are ready, says Ellen Mack, RNC, MN, neonatal nurse specialist.
Initiatives include daily rounds by the treatment team, weekly rounds by a multidisciplinary early discharge team, training the bedside nurses to assess the infants for feeding readiness several times a day, and engaging parents in infant care early in the stay.
The unit has an average census in the low 30s. About 30% of babies are covered by MediCal, California’s Medicaid provider, Mack says. About 10% of the remainder of babies in the NICU were conceived with reproductive technology, she adds.
The hospital is participating in a subgroup of the California Perinatal Quality Care Collaborative.
“We have been working on shortening the length of stay for many years. Participating in the Collaborative gave us an opportunity to share information with other hospitals and to learn what has been successful for them,” Mack says.
The NICU team includes a pediatric case manager, a dedicated RN discharge coordinator who is an experienced neonatal nurse, and lactation consultants who are skilled with working with premature babies.
One of the changes the Cedars-Sinai team has made is to use physiological criteria, rather than weight and length of gestation, to decide if the babies are ready to move to the next step in the treatment protocol, Mack says. “We move patients along based on how they are doing, rather than using set criteria,” she says.
Another change is to assess the premies for oral feeding readiness at 32 weeks, two weeks sooner than their old protocol. “Not every baby will be ready to feed, but many are able to take at least one feeding a day,” she says.
The bedside nurses have been trained to assess the babies several times a day for feeding readiness, to determine their condition and whether they are ready to move along in the clinical protocol. In the past, an occupational therapist or physical therapist assessed the babies once a day or less frequently.
“Having the nurses assess the infants gives us a more accurate picture of how the babies are doing. A baby might be sleepy when the therapist assesses him but awake later in the day,” she says. In addition, the treatment team conducts rounds every day on every patient.
Once a week, a multidisciplinary early discharge team assesses every patient at the bedside for milestones that signal they are closer to going home. The team includes Mack, the case manager, a social worker, a dietitian, the discharge coordinator, representatives from physical therapy and occupational therapy, a lactation consultant, and the physician champion.
Mack reviews the charts the night before the meeting and identifies areas the team needs to discuss. “I look at what is going on with the patients, are they still in the incubator, how they are eating, and where we are in parent education. We know that when we provide care in an organized fashion, we get where we want to be much quicker and safer,” she says.
The team looks at whether the patient is meeting discharge criteria and, if so, what is holding up the discharge. “The rounds help us identify areas where we need to intervene and remove any obstacles to discharge,” she says. For instance, the baby is approaching the weight needed for surgery but it hasn’t been scheduled. In that case, the physician champion discusses the situation with the surgeon. If the parents need help communicating with the durable medical equipment supplier, the case manager gets involved.
In some cases, the parents are delaying the discharge but instead of saying they are nervous about taking care of the baby at home, they offer other excuses, such as that they have to paint the baby’s room, Mack says.
“The social worker or case manager helps the parents think about the situation differently and tells them that the baby needs to be at home. Hospitals are not the best place for anyone, and the safest and best place for babies is to be at home with their family as long as they are physically ready,” she says.
The team gets parents involved in daily care whenever possible and engages them in rounds so they’ll be aware of what’s going on with their infants and the potential for discharge. The team is working on a process that will allow parents to attend rounds by video conferencing when they can’t be present. They plan to try the process on a trial basis.
“These babies have never been home before, and their parents have never taken care of them. They are eager to have them home but often are nervous. We start the education process early in the stay and do more than just encourage them to be at the bedside. We involve them in actually providing care for the babies,” she says.
The discharge coordinator and case manager work together to coordinate the care of the infants. The case manager works with parents to prepare them for discharge, sets up medical equipment and other services needed after discharge, and coordinates with insurance companies. The discharge coordinator follows the clinical progress of the babies, sets up post-discharge physician appointments, and educates parents on complex issues.
“There is some overlap between the case managers and the discharge coordinator, but both of them work together to make sure that parents are prepared to care for their babies, not just from a practical standpoint but also emotionally,” Mack says.
The team tracks readmissions within 30 days and any unscheduled medical interventions the baby needs within 72 hours after discharge. “We look for patterns that give us clues as to what we can do better to avoid the problems,” she says.
