CLINICAL GUIDELINES Register No: Status: Public GUIDELINE FOR DISCHARGE FROM THE NEONATAL UNIT

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1 GUIDELINE FOR DISCHARGE FROM THE NEONATAL UNIT CLINICAL GUIDELINES Register No: Status: Public Developed in response to: Best practice Contributes to CQC Outcome 4 Consulted With Post/Committee/Group Date Anita Rao Clinical Director for Women s, Children s and August 2014 Sexual Health Directorate Deputy Clinical Director/head of Midwifery Medical Staff Lead Nurse for Neonatal unit Neonatal Sister & Ward manager Practice development Nurse Alison Cuthbertson Consultant Paediatricians Toni Laing Joyce McIntosh Lillian Wager Professionally Approved By Dr. H. Hassan Dr. J. Cyriac Neonatal Lead Consultant & Lead for Risk Management Clinical lead for Paediatric Department August 2014 Version Number 1.0 Issuing Directorate Women and Children s Services Ratified By Document Ratification Group Ratified On 6th December 2014 Trust Executive Board Date November/December 2014 Next Review Date November 2017 Author/Contact for Information Sharon Pilgrim, ANNP Policy to be followed by (target staff) Neonatal nursing staff, Paediatricians Distribution Method Hard copies to all ward areas and managers Intranet & Website. Notified on Staff Focus Related Trust Policies (to be read in Standard Infection Prevention conjunction with) Hand Hygiene Examination of the New born Version No Authored/Reviewed by Review Date 1.0 Sharon Pilgrim November

2 INDEX 1. Purpose 2. Equality and Diversity 3. Assessment 4. Discharge Planning 5. Discharge criteria 6. Prior to discharge 7. Check list for discharge 8. Documentation 9. Babies who can be warded on Postnatal ward 10. Community Paediatric Nursing Team 11. Criteria for outpatient appointments 12. Discharge against medical advice 13. Safeguarding Children 14. Information given to parents and Children 15. Communication with Primary care 16. Staff and Training 17. Infection Prevention 18. Audit and Monitoring 19. Guideline Management 20. References Appendix Discharge Plan for High Risk Infants 2

3 1.0 Purpose 1.1 The discharge of infants from hospital will be individually planned to ensure that the need for continuing care will be met within the community environment, supported by primary care services within the available resources The parents will have acquired knowledge, confidence and practical skills to meet their babys continuing needs for health care in the community The parents will be supported and feel secure in continuing to care for their infant in the community. 1.4 The Primary Care professionals and family will have received appropriate information from the hospital to enable them to provide continuity of care within the community environment To facilitate early discharge of the low birth weight baby 2.0 Equality and Diversity 2.1 Mid Essex Hospitals Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Assessment 3.1 The nurse will assess the child s and family s individual nursing care/social needs from admission through to discharge in partnership with family/carer and other agencies. 3.2 The Neonatal Discharge Plan will be started on admission and updated daily by the nurse caring for the infant 4.0 Discharge Planning 4.1 Discussion should take place between the allocated nurse and paediatric team to reach an agreement about discharging home. 4.2 When primary care nursing services are required for the infant and family these will be documented in the child s hospital records, including contact points for key personnel. 4.3 All discharge preparation, teaching and planning will be supervised by the allocated nurse, and should be documented in the appropriate places: Using the discharge checklist, Recording other agencies contact numbers in care plan and/or nursing notes If necessary complete collaborative care plan All parent and/or the carer training, competence and education entries will be signed by the nurse giving the instruction 4.4 The nurse caring for the infant will be responsible for communicating all information from the ward; to the individual family and other agencies involved in the child s care. 3

4 4.5 For infants with complex needs, a Multi Disciplinary Team (MDT) discharge planning meeting should be held and discharge should correspond with community start of service for family. 4.6 If MDT discharge planning meeting is held the following should be invited to attend: Parents Named consultant. Senior Neonatal Nurse/Sister GP Health visitor Member of Children Community Nursing Team (CCNT) Social worker (if appropriate) 4.7 The parents will be given reasonable notice that their infant is ready for discharge home and advice on who to contact in the event of the infant needing further treatment. 5.0 Criteria for Discharge Stable clinical condition, not requiring any IV medications Discharge planned following consultant review Established on full enteral feed for 48 hours. Maintaining own body temperature in a cot in a normal household environmental temperature Less than 35 weeks gestation weight should be >1.800 kgs Greater than 35 weeks gestation weight should be >1.700 kgs and gaining weight Suitable home environment Social service plan in place where necessary 6.0 Prior to discharge 6.1 The family will be informed if hospital follow up is needed and an appointment will be sent. 6.2 The allocated nurse should make the parents aware that it is the parents responsibility to arrange their transport home from hospital. 6.3 All documentation will be completed and filed in the patient s notes on discharge. 6.4 All infants transferred out from MEHT must have the discharge checklist completed and filed in their notes and primary care informed of the transfer. 4

5 7.0 Check list for discharge Ensure discharge examination completed Parents given a copy of the Mid-Essex child health record (red book) Community team aware if appropriate and co-ordinated discharge plan in place. Liaise with social services if necessary Discharge letter written and copy put into red book. Follow-up with appropriate consultant made if necessary Any medications including vitamins and iron needed at home prescribed and ordered Has had hearing test which is documented in red book. Ophthalmology follow-up organised if necessary Hip scan organised if necessary Renal scan organised if necessary (and prophylactic antibiotics commenced if necessary) BCG given if required Hepatitis B vaccine given if required Inform health visitor and GP of discharge Complete discharge care plan. Arrange 36 week blood spot to be taken by community nursing team if required following discharge. Inform midwife if discharged under 28 days Ensure outpatient appointments are made and appointment card given to parents where appropriate. High risk infants such as those on oxygen or with naso-gastric tubes should not be discharged home immediately prior to the weekend or public holidays 8.0 Documentation Documented in the medical notes that baby is fit for discharge. A discharge examination sheet should be completed by the paediatric doctor/ ANNP and added to the medical notes ensuring they are in chronological order. Document any outpatient appointments required in notes and on discharge letter. 5

6 Complete SEND discharge letter. Put one copy in medical notes and send a copy to mothers GP, a third copy should be put into the babys red health record for the health visitor Complete the Community midwife referral form if the baby is less than 28 days of age and take completed form to the post natal ward Discharge on SEND and PAS 9.0 Babies who can be discharged to the post natal ward Well term babies at risk of sepsis receiving intravenous antibiotics (after infection screen has been performed on NICU) Infant of IDDM (insulin dependant diabetic mother) who are not hypoglycaemic Babies with cleft lip/ palate Down syndrome Dysmorphic babies not requiring monitoring Stable babies with cardiac anomalies after antenatal / postnatal assessment has documented this Jaundiced babies requiring phototherapy 10.0 Children s Community Nursing Team The Neonatal Unit has no access to dedicated Neonatal community nursing team. Post discharge family support is provided primarily by the Health Visitors, with exception of the cases accepted by the Children s community nursing team according to their set criteria. If prolonged community nursing input is anticipated beyond four weeks from discharge - early referral and liaison with the paediatric community nurses should occur. NCS team are available Monday to Friday 8am and 5pm Ext Referral criteria (Children s Community Nurses Team) Nasogastric feeding support, Babies must be able to take two good breast / bottle feeds per day to be eligible for discharge. Infants to be discharged home requiring oxygen therapy. Stoma care 6

7 Significant cardiac lesions Terminal care if parents wish to take their baby home. Blood tests RSV Prophylaxis Exclusion criteria Family live out of catchment area Parents decline early discharge 11.0 Criteria for outpatient s appointment < 32 weeks gestation Those with significant RDS who required mechanical ventilation CPAP > 24 hours Hypoxic Ischaemic Encephalopathy (HIE) Abnormal cranial ultrasound Convulsions requiring medication Severe IUGR/SGA (significantly deviant away from 3 rd centile) Cardiac anomalies Known congenital malformations detected antenatally Babies discharged on Home oxygen. All Babies of HIV positive mothers. Babies who required surgery/with stoma. All babies being treated for gastro-oesophageal reflux Hemolytic Disease of the Newborn to monitor for late anaemia Discharges Against Medical Advice 12.1 Discharge Against Medical Advice : Please refer to child protection team when the child is at significant medical risk, if removed from hospital medical care. Children who are not at significant medical risk, whom the team decide could be safely cared for at home are to be discharged. The discharging nurse should provide the family with appropriate advice, information and treatment to care for their child at home with contact details for advice or readmission to the ward within 24 hours if required. The discharging nurse should also assess whether referral to the children s community team is appropriate. 7

8 13.0 Safeguarding children 13.1 Where there have been issues raised about the safety of a child, the safeguarding childrens team must be notified and where appropriate referral should be made to Social Services, Whenever an EC999 referral is made a pre discharge meeting planned prior to the infant being discharged from hospital should take place A record must be made of the discussion and decisions made. A handwritten copy of the decisions agreed at a Pre-Discharge Planning Meeting to be placed on the child s medical notes directly after the meeting and left at the hospital. If an incident number has been raised with the Police, this should also be recorded. Additionally the Social Worker should ensure the decisions of the meeting are recorded on SWIFT immediately and consider raising an EDS alert if SWIFT recording is not immediately possible 14.0 Medicines and consumables 14.1 Medicines to take away will be clearly labeled for individual children with dose and frequency of administration The allocated nurse will ensure that the child/family that requires consumables on discharge receives a maximum of 14 days supply and arranges for ongoing supplies Information given to Parents and Child 15.1 The parent will be given clear and concise verbal and written information, if appropriate on Medications dosage, frequency of medicine Importance of complying with and completing all treatment and medications Basic Life Support training where required. Training and education to become competent in performing specialised care (e.g. Nasogastric tube feeds, inhaler, oxygen and suction etc.) 15.2 Parents will have access to relevant health education leaflets and leaflets and contact details for support groups dependant on the infants condition Provide parents with ward contact details and who should be contacted if their child s condition changes or there is increasing parental concern Communication with Primary care 16.1 The family doctor will be sent a SEND discharge letter, within 72 hours of discharge The nurse co-ordinating the child s discharge from the ward will hand the parent a copy of the SEND discharge letter to be put into the child health record 16.3 Health Visitor will be informed of the discharge by telephone by the nurse responsible for the discharge. 8

9 17.0 Staff and Training 17.1 All nursing and paediatric staff are to ensure that their knowledge and skills are up-to-date in order to complete their portfolio for appraisal Paediatricians and neonatal staff should attend training on PAS and SEND as required 18.0 Infection Prevention 18.1 All staff should follow Trust guidelines on infection prevention by ensuring that they effectively decontaminate their hands before and after each procedure All staff should ensure that they follow Trust guidelines on infection prevention. All invasive devices must be inserted and cared for using High Impact Intervention guidelines to reduce the risk of infection and deliver safe care. This care should be recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork (Medical Devices) Audit and Monitoring 19.1 The risk management lead will review all risk event forms and complaints. Any immediate training or educational issues relating to lack of compliance with this guideline will be addressed on a one to one basis All incidents and trends analysis will be reviewed at the Risk Management Group meeting Audit of compliance with this guideline will be undertaken annually in accordance with the annual audit work plan. The Audit Lead in liaison with the Risk Management Group will identify a lead for the audit A review of 10 sets of health records will assess compliance with the guideline The findings of the audit will be reported to the Risk Management Group and an action plan developed to address any identified deficiencies. Performance against the action plan will be monitored by this group on a monthly basis Guideline Management 20.1 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the Trust s intranet site Quarterly memos are sent to line managers to disseminate to their staff the most currently approved guidelines available via the intranet and clinical guideline folders, located in each designated clinical area Guideline monitors have been nominated to each clinical area to ensure a system whereby obsolete guidelines are archived and newly approved guidelines are now downloaded from the intranet and filed appropriately in the guideline folders. Spot checks are performed on all clinical guidelines quarterly. 9

10 20.4 Quarterly Clinical Practices group meetings are held to discuss guidelines. During this meeting the practice development midwife can highlight any areas for further training; possibly involving workshops or to be included in future skills and drills mandatory training sessions Communication 21.1 A quarterly newsletter is issued and available to all staff including an update on the latest guidelines information such as a list of newly approved guidelines for staff to acknowledge and familiarise themselves with and practice accordingly Approved guidelines are published monthly in the Trust s Staff Focus that is sent via to all staff Approved guidelines will be disseminated to appropriate staff quarterly via Regular memos are posted on the Risk Management notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders References Toolkit for High-Quality Neonatal Services. Department of Health (2009) Quality standard for specialist neonatal care. National Institute for Clinical Excellence (NICE) (2010) HM Government (2006) Working Together to Safeguard Children: A Guide to Interagency Working to Safeguard and Promote the Welfare of Children. London, Stationery Office Department of Health (2003) Getting the Right Start: National Service Framework for Children - A Standard for Hospital Services. London. DH. 10

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