1

Discharge Planning in the NICU

A Multidisciplinary Three-Phase Approach

2

Discharge Begins on Admission We all know that discharge planning starts

at admission, but when we see a small preemie with a long road ahead it is hard to begin thinking about the discharge process. To help clarify what should be done, a multidisciplinary discharge process has been developed, using a three-step approach. It is designed to have an easy and logical flow.

3

Multidisciplinary Form The new discharge form will allow for all

disciplines involved in the discharge process to document progress being made toward the goal of discharge.

It is a one stop check to see the progress being made by nursing, family services, nutrition, PT, OT, developmental services, medical staff, speech therapy, and even NB pictures.

4

Family Centered Care Because we are a family centered care facility it

is important that we involve the parents in this process from the start.

In the corner of the baby’s name tag there will be an image depicting what phase of discharge their child is in.

As the baby progresses from one phase to the next the image on the name tag will be changed to reflect the progress being made towards discharge.

5

Family Centered Care The image is designed to allow all

disciplines involved to know the phase of discharge and to encourage parent involvement.

Parents will see the picture and ask its purpose, opening the communication of discharge.

6

Family Centered Care If parents are too overwhelmed initially the image

is a good opening for staff to introduce the topic of discharge with the family.

As the image changes parents will be prompted to ask what is expected in the new phase.

This will help to make parents feel a part of their child’s care. It will also be exciting for them to see that they have moved into the next phase, a step closer.

7

The 3 Phases of Discharge Caterpillar

Cocoon

Butterfly

8

Moving Through the Phases As you will see there is a lot of information

being documented for discharge. Not all of it will be applicable for every baby. The white areas on the sheet will be required, the grayed out areas are only if applicable to the case, the X’d out boxes are not required.

9

Moving Through the Phases The time spent on each phase will be

determined by how critical the baby’s condition is. Critically ill infants may spend awhile in the

first phase before moving on. An infant who recovers quickly could

potentially move through two phases in a day.

10

Phase 1: The Caterpillar This is started with the admission of the infant to

the NICU. Initially it is an information gathering phase. The

family assessment and special considerations are filled out. Although this was completed by family services in the past, it can be done by any of the disciplines (nursing, medical, etc.) that has the opportunity to acquire the information.

11

Phase 1: The Caterpillar Family services will do their assessment

and plan and arrange any necessary community services or referrals.

Families will be oriented to the unit and given their education packet.

The initial newborn screen is documented here.

12

Phase 1: The Caterpillar Initial referrals for lactation consultant,

OT, PT, family and developmental services are made in this phase.

Families are started on their education of signs and symptom of pain and illness. Comfort measures are taught.

13

Phase 2: The Cocoon This phase starts with the successful

extubation of the infant. Parent education will involve bathing,

diapering, skin care/cord care, back-to- sleep, and immunizations.

Shaken baby video should be shown and documented in this phase.

14

Phase 2: The Cocoon The patient care manager is introduced in

this phase. Scripts for meds and supplies are written

by the MD.

15

Phase 2: The Cocoon Feeding education and reflux precautions

are taught. Family services evaluates parent’s comfort

level with discharge and check that baby supplies are in place.

Need for and information given on services in OT, speech, and developmental.

16

Phase 3: The Butterfly This phase starts when the infant is on full feeds

and is in a crib. Hearing screening is completed. Car seat challenge is done. Final newborn screen is completed and

documented. Note the baby may receive several newborn screens

during their stay but only the initial (phase 1) and final (phase 3) screens are documented in the discharge.

17

Phase 3: The Butterfly The MD/NP/PA will:

Notify parents of pending discharge. Arrange for circumcision. Write orders for follow up appointments,

CPR/Monitor training, and pharmacy teaching. Write discharge summary and review with attending. Have discharge orders written and signed day before

discharge.

18

Phase 3: The Butterfly Circumcision care is taught. WIC referral is made. Baby is “back- to-sleep”. Special formula instructions are given. Scripts are filled and printed education

sheets are reviewed with parents by pharmacy.

19

Phase 3: The Butterfly Family services will confirm discharge

address and get CPS clearance if needed. Discharge planner will arrange and confirm

completion of CPR, monitor, and oxygen training. Home care referrals will be done and equipment delivery confirmed.

20

Phase 3: The Butterfly Developmental services will provide

information on recommended positioning and “tummy time”. Referrals to early intervention and information on developmental clinic will be given.

Infant should be signed up and have pictures taken.

21

Day of Discharge Document discharge weight, length and

head circumference. Complete and sign nursing discharge

orders and patient instruction form. Confirm identity of parent and infant. Give follow up appointment sheet to

parents.

22

Consistency With consistent attention to the phases of

discharge and documentation by all disciplines involved, the process for discharging infants from the NICU will develop into a smooth and easy process.