QI project lowers neonate hospitalizations
QI project lowers neonate hospitalizations
A hospital-based home care agency in Suffolk, VA, decided to tackle the problem of newborn babies being readmitted to the hospital or going to the emergency room for minor problems.
Many of these babies had teen-age and indigent mothers who did not have a pediatrician and family support. So when their babies became ill or cried too often, they would take the baby to the emergency room, says Sherry Parker, MSW, director of Obici Home Health, based at Obici Hospital in Suffolk, VA. The agency makes 1,000 to 1,200 visits per month and serves a rural and suburban region.
"These new moms were taking their babies to the emergency room for things like diaper rash and thrush," Parker says.
This was an inefficient use of the hospital and its emergency room, so together the hospital and home care agency developed a quality improvement project to solve the dilemma, says Paulette Vann, RN, Obici quality improvement nurse. So far, the project has had some success, Vann says.
Vann did a study of live births at Obici Hospital from July 1, 1995, to June 30, 1996, and found that 55 neonates, or 6.8% of 813 newborns, were seen in the hospital's emergency room within 30 days of their birth. Another 10 babies, or 1.2%, were admitted to the hospital within 30 days of their birth.
Then during 12 months of 1997, the home health agency saw 77 mothers and babies. Of these, none were admitted to the hospital, and three, or 3.9%, were seen in the emergency room, Vann says.
So the home health baby program appeared to have some effect on reducing the rate of hospitalization and emergency room visits, Vann says.
Here's how the staff at Obici set up the program:
1. Set goals.
The agency listed five goals related to improving outcomes among newborn infants:
· Prevent or decrease the number of hospital readmissions and emergency room visits within 30 days of the neonates' date of birth.
· Prevent or decrease the number of home health agency readmissions to the hospital and emergency room visits within 30 days of neonates' date of birth.
· Increase staff competency for special population groups, i.e., neonates, infants, children, adolescents, pre- and postpartum, and behavioral patients.
· Develop assessments for special population groups, i.e., neonates, infants, children, adolescents, pre- and postpartum, and behavioral patients.
· Develop written neonate educational materials.
Vann also wrote an action plan that listed the project's requirements, measurement, action, solutions, and effectiveness. (See Obici action plan, inserted in this issue.)
2. Identify high-risk mothers and infants.
The hospital and home health agencies asked community physicians to refer high-risk new mothers to the home care baby program so a nurse could visit the home and make sure the babies were all right. For the first year, physicians referred mostly teen-age mothers, says Becky Carpenter, RN, case manager and admissions nurse. Carpenter is the main nurse to visit the new mothers and babies.
"The physicians were referring patients to us that had a low socioeconomic background and who didn't have prenatal care and pediatricians," Carpenter explains.
About 75% of the clients are families in which a 15- or 16-year-old girl had a baby. The new mother has no or little income and usually is living with an extended family with several other children in the home. Typically she has dropped out of high school, Carpenter says.
The home care agency follows up on the referrals by faxing the referring physicians a one-page assessment form that lists vital statistics about the newborn baby. "If there's anything wrong, we discuss it then," Carpenter says. (See Obici's baby program letter to physicians, inserted in this issue.)
3. Train nurses to assess mothers and infants.
The training involved a 1.5-hour inservice in which the agency gave nurses all the documents they needed to compile a clinical record of the baby, including information on how to do various assessments and patient education materials, Vann says.
Home care nurses fill out a three-page assessment form during the first visit. The form includes areas to write a detailed medical history, a psychosocial assessment, safety items, expected outcomes, and skilled interventions. It also has room for documentation of a complete physical assessment that includes information about the baby from head to toe. The baby's nutritional status and sleep/activity patterns also are recorded on the form. (See Obici neonate nursing assessment, inserted in this issue.)
Nurses also conduct a safety assessment that is documented on a separate page. This assessment includes details about domestic abuse, prenatal care, drug abuse, home heating, mother bonding with infant, and whether child protective services was called. (See Obici safety risk assessment, inserted in this issue.)
But the assessment involves more than what needs to be documented, Carpenter says.
"First you have to meet their needs before they will listen to you, and that means, No. 1, finding out how to get them back in school," Carpenter says.
Then Carpenter will look closely at the family situation to see if there is support for the young mother. "So on the first visit I kind of get a picture of where they are and then I try to hook them up with the hospital's healthy families program, a community education program."
She also puts the mothers in touch with the county's health services and volunteer programs in which experienced mothers go out to homes and adopt young mothers to help them get through child-rearing trouble spots.
"Every new home you go to is a different situation, and there's a whole new set of obstacles you have to get through," Carpenter says.
The agency also has a two-page form for follow-up visits. This form includes information about the baby's physical status, nutritional and hydration status, psychosocial information, and skilled teaching documentation. (See Obici neonate follow-up visit form, inserted in this issue.)
4. Find each patient a physician or clinic.
These teen-age mothers typically have no primary care physician or pediatrician. The physician they might see at the hospital or in the emergency room would not be the one who would be taking care of their babies.
"So these moms were going to have to find a pediatrician and make an appointment," Carpenter says. "But instead, when they needed a doctor they simply went to the emergency room."
One of Carpenter's goals was to help them choose a pediatrician. She asked them to make the phone call and to have an appointment lined up by the time she returned for their second visit.
"But it wasn't working," Carpenter says. The mothers simply did not make those calls.
Resource list facilitates better infant care
So she put together a list of community resources with names and phone numbers of physicians and clinics that accepted Medicaid and other insurance. The list also includes phone numbers for social services in the city of Suffolk, the county, and the state.
The women started to make the calls from the resource list, Carpenter adds.
Soon after the agency began to use the list, an incident occurred that highlighted how it might help to prevent emergency room visits. Carpenter had given the list to a new mother whose baby was on a special formula. The mother had no idea where to find this formula. But the list had a number for the Women, Infant, Children (WIC) program in Suffolk, so she tried that number and found what she needed.
"Without the list, more than likely she would have taken the baby back to the emergency room, saying the baby was sick and she didn't have any special formula for the baby," Vann says.
5. Teach mothers how to handle minor problems.
The agency's extensive patient education also helped cut back on unnecessary emergency room visits, Vann says.
Each new mother receives a baby program packet that includes clear and concise information about child care. For example, the packet has a handout about immunizations that includes an explanation about why immunizations are necessary, and a chart of the various types of immunizations with check marks at the age at which the baby should receive them.
Obici nurses also focus on teaching new mothers about some common, minor illnesses that most babies have at some time or another and how they can take care of these themselves.
Patient teaching covers signs and symptoms of infections, complications, and dehydration, as well as information on how to call the physician, advice on feeding and nutrition, and ongoing medical needs.
Vann says this is especially important because so many of these mothers will take their babies to the emergency room to have them treated for such minor problems as colds, colic, feeding problems, and constipation caused by the mothers not burping the babies.
"One case involved a baby that the mother said was vomiting," Vann says. But when the emergency room people observed the baby they saw that the baby was only spitting up a little. And they saw that the mother wasn't burping the baby and was laying the baby down flat, causing some minor diarrhea.
Obici nurses tell new mothers that if they are concerned about some problem with their child then they should first call their physician or a nurse at Obici Home Health before running over to the emergency room.
"We said, 'You can call us 24 hours a day,'" Vann says.
Still, no matter how much education an agency gives patients, some won't listen and learn. Three new mothers who were involved in the baby program still took their babies to the emergency room, and all three visits were unnecessary, Vann says.
"When we looked at the individual reasons why we had three people who went to the emergency room, we saw they went for constipation, thrush, and colic," Vann says. "They didn't call us as they were asked to do."
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