THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Friday, November 25, 1994 TAG: 9411250048
SECTION: FRONT PAGE: A1 EDITION: FINAL
SOURCE: By DEBRA GORDON, STAFF WRITER
LENGTH: Long : 188 lines
Ruby Garnett's first child was born five weeks premature, so the Portsmouth woman was sure she'd have an extended hospital stay to recover and learn how to care for a premature infant.
And by today's standards, she did have a long stay - about 32 hours.
Two days after she and the baby went home, he was admitted to Children's Hospital of the King's Daughter. Suffering from dehydration, he stayed at the hospital for 11 days.
The problem, says Garnett, was that she didn't have enough time to absorb the myriad details involved in breast-feeding and caring for a new baby.
Early-discharge policies aren't new; they've been around for about four years in this area. But as their popularity around the country has grown, a debate has sprung up over their effectiveness and safety, with medical professionals asking: Are we sacrificing the health of women and children just to save a few dollars?
Next week, the Maternal and Child Health Bureau, a division of the Public Health Service, is hosting a meeting of the nation's major medical, nursing and insurance organizations to discuss early-discharge policies.
And early next year, the American Academy of Pediatrics will release more stringent guidelines for early discharge of infants, updating those first issued in 1980.
In Hampton Roads and around the country, insurance companies and hospitals require that new mothers and babies go home 24 hours after birth if there are no complications. Even women who deliver by Caesarean section are usually home within two or three days.
And in some parts of the country, postpartum stays are shrinking to 12 hours - or even eight.
Some plans send a home-health nurse to visit moms after they're home - if their doctor requests it. And that level of support, say pediatricians and maternal nurses, isn't enough.
No one is suggesting that mothers and babies routinely extend their hospital stays. Today's cost-conscious health-reform atmosphere just won't allow that. But medical experts are suggesting that there hasn't been enough study, enough evaluation of the way early discharge programs are designed, to measure their effectiveness.
``We are concerned that there may be unappreciated consequences around early discharge, such asnewborns being discharged before breast milk comes in, before all neonatal screenings can be done, that maybe there's a higher rate than expected of rehospitalization,'' said Michele Kiely, epidemiologist for the Maternal and Child Health Bureau.
``We'd like to figure out how to guarantee that all infants have healthy outcomes, that all these things we've worked so hard to implement - breastfeeding, newborn screening - aren't lost.''
In Sweden, women spend a few days after birth in a `Ringblomman,' or a maternity house. In Japan, they go to their mother's house. But in the United States, they go home, often to other young children, husbands who have to go back to work and mothers who live 2,000 miles away.
``We have one of the most regressive models for health care after delivery in the world,'' said Laurel S. Garzon, director of Old Dominion University's perinatal/neonatal graduate program.
Garzon wrote her dissertation five years ago on the effects of early discharge on new mothers, noting that while women may not have medical problems upon early discharge, they often remain exhausted months or even a year after delivery because they never have a chance to recover.
Insurance companies initiated early-discharge policies in the 1980s, as a way to save an extra hospital day and reduce costs.
But today, most insurance companies pay hospitals a fixed rate for delivery, regardless of how long mother and baby stay. So it's often the hospital - not the insurance company - prodding mothers to leave.
``If the insurance company is paying you (a flat rate), then it behooves you to find ways to get them home sooner,'' said Terry McCenna, nurse manager of the mother/baby unit at Virginia Beach General Hospital.
At VBGH, doctors and nurses were so concerned about early-discharge pressures that eight months ago, they formed a team to discuss how they could provide quality care and education in just 24 hours.
The team wrote and filmed a video on postpartum and newborn care which it gives to every new mother, and began a home-health nursing program in which maternity unit nurses visit new mothers at home.
``Initially, the pediatricians were hesitant about letting the babies go home at 24 hours,'' said Dr. John W. Knispel, a Virginia Beach obstetrician. ``But there wasn't any choice with the insurance. This helps them feel more comfortable.''
The hospital is absorbing the cost for the nurse, said Knispel. ``It costs the hospital a lot more for the woman to stay there than to provide a home nurse.'' One hospital administrator in another state, he said, found it cheaper to send women in a limousine to a hotel for a couple days of rest and pampering, than to keep them in the hospital.
Knispel said the hospital will monitor readmission rates closely to determine if the policy jeopardizes the health of mothers or babies.
At Southwestern Medical School in Dallas, director of neonatal/perinatal medicine Dr. Charles Rosenfeld is in the middle of just such a study, examining the effects of early discharge on 45,000 full-term, healthy babies. Early results, he said, are disturbing, although he won't release any details yet.
And at the University of Cincinnati's medical school, neonatology chief Dr. Reginald Tsang has seen five newborns admitted in the past few months with dehydration. ``I haven't seen that in 20 years,'' he said.
So the American Academy of Pediatrics' Fetus and Newborn Committee is re-examining its 14-year-old guidelines on early discharge.
``We've gotten an incredible number of queries from pediatricians around the country about early discharge,'' said Dr. Barry Kirkpatrick, professor of pediatrics at the Medical College of Virginia and a member of the committee.
``Pediatricians are caught on the horns of a dilemma: they don't want to have families burdened with expenses they have to pay out of pocket; yet they don't want to send babies home at a time when they aren't stable, and often to a mother who hasn't fully recovered from childbirth.''
And there's more to taking care of a baby than making sure it hasn't picked up an infection or that it's gained the appropriate weight, said Norfolk pediatrician Robert Fink.
``A lot of education takes place in the nurseries, not only by the physicians, but especially by the nursery staff.
``It's a horrible message we're giving to parents that the only thing we're worried about is infection. What about bonding, accident prevention, feeling comfortable holding the baby and interacting with the baby? All of those parenting skills are crucial, and once they're out of the hospital we've lost the opportunity to teach some of those things.''
And while the American Academy of Pediatrics recommends that early-discharge babies be seen in the pediatrician's office two to three days after birth, that practice isn't the standard for this area, Fink said.
``We clearly see some moms who are not ready to go home; but we can't give them a medical diagnosis that says that. It would be nice if we could individualize it and say, `This mother seems much less ready to go home than another mother,' and order an extra hospital day or additional home-health visits,'' Fink said.
Garzon would take it a step further.
Videos, even a single home-health visit, are just not enough, she said.
``We need a more cooperative model that allows nurses from the delivery site to be more involved with the patient postpartum,'' she said.
And that would entail an entirely different way of thinking about and paying for postpartum care. ``The issue is more access to information and more nursing before and after the time of delivery,'' she said. ``And there has to be sharing of costs because the hospital isn't going to do it for free.'' ILLUSTRATION: Color staff photo by MARTIN SMITH-RODDEN/
Ruby Garnett holds Lewis, now 9 months old. They were sent home from
the hospital 32 hours after he was born - five weeks premature. He
was back in the hospital two days later, suffering from
dehydration.
AVERAGE STAY
Average days of stay for normal delivery in the area's hospitals for
February 1994
Chesapeake General Hospital: 1.5
DePaul Medical Center 1.6
Maryview Medical Center: 1.7
Obici Memorial Hospital 2.2
Portsmouth General Hospital: 1.6
Sentara Bayside Hospital: 2.1
Sentara Leigh Hospital: 1.6
Sentara Norfolk General Hospital: 2.6
Virginia Beach General Hospital: 1.7
Norfolk Community Hospital: 2.2
Statewide 2.0
Source: Annual Survey of Hospital Charges, the Virginia Health
Services Cost Review Council
CRITERIA FOR DISCHARGE IN 24 HOURS
The American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists recommend that these criteria be met
if a mother and baby are discharged within 24 hours of delivery:
The mother should have had an uncomplicated vaginal delivery
following a normal pregnancy and should have been observed for a
sufficient time after delivery to ensure that her condition is
stable.
Family members or other support persons should be available to
the mother for the first few days following discharge.
The mother should be aware of possible complications and should
have been instructed to notify the appropriate doctor, as
necessary.
The mother should be ready to take care of her baby, as evidenced
by her skills at feeding, skin care and cord care, taking the baby's
temperature, and her ability to assess the newborn's well-being and
recognize common neonatal illnesses.
The infant should be delivered at term, be of appropriate birth
weight, and found normal by examination.
The infant should be able to maintain a normal temperature as
well as suck and swallow normally.
A physician-directed source of continuing medical care for both
mother and baby should be identified and arrangements made for the
baby to be examined within 48 hours of discharge.
KEYWORDS: NEWBORN HOSPITAL DISCHARGE by CNB