FLUID/ELECTROLYTE MANAGEMENT



DISCHARGE FROM THE NICU

I. Discharge Planning

II. ROP Screening Guidelines

I. DISCHARGE

Notify one of the discharge coordinators as soon as you have a tentative discharge date set for a NICU patient. They will schedule all needed tests, parent teaching, home nursing visits, home supplies and equipment, and follow-up appointments.

Discharge coordinators are:

1) Karleen Maeurer, RN: Phone: 67930

Voicemail: 66218

2) Bobbi Pazzelli, RN: Phone: 67931

Voicemail: 66208

I. BACK TO SLEEP POSITIONING PROTOCOL:

Talk to parents and staff when infant is bottle/breast feeding at least ½ of feedings (in order to model appropriate positioning for home).

II. BILIRUBIN:

Every infant admitted to the NICU should have had at least one bilirubin level checked during its hospitalization.

III. CAR BED:

Discharge coordinator will arrange for car beds when indicated. Most infants < 1800 grams will be too short (from shoulders to hips) to fit the car seat straps. Rental car beds are available M-F 8am – 4pm in the family resource center on 4th floor of Garden View.

IV. CAR SEAT TRIAL:

a. For all infants < 37 weeks gestation at birth

b. Usually done the day the MMU/CR scan is read. If infant fails MMU, CR scan, then car seat trial will not be done. If monitor is d/c’d, notify the discharge coordinator to arrange for car seat trial.

V. CIRCUMCISION:

a. Parents must check with insurance re: inpatient/outpatient coverage for circumcisions. Medical Assistance and other carriers may not cover inpatient circs.

b. Discharge coordinator will arrange with primary MD. If primary MD doesn’t do circumcisions for newborns at Children’s, the discharge coordinator will check with the Children’s Group who will usually perform circumcisions if their schedule allows. Outpatient circumcisions can also be arranged.

VI. TRAINING FOR PARENTS:

a. CPR: up to 6 adults in class. Discharge coordinator can arrange with RCP for individual family class when requested by parents.

b. Reflux Class: a 2-hour class that teaches infant CPR and reflux precautions. Available M-F 8 am – 2pm (class ends at 4 pm). Allow extra time if using interpreter.

c. Monitor class: A 4-hour class that teaches infant CPR, use of home monitor, and caffeine administration.

d. Other equipment training: (oxygen/nebulizer/home equipment for GT/Trach) will be arranged by discharge coordinator.

VII. FEEDINGS:

a. Change to 22 calorie if infant is > 2 kg and discontinue HMF if infant is > 35 wks corrected age. (Transition is usually done when infant is feeding full bottles/breast 4-5 feedings per day)

b. Discontinue supplemental protein before discharge

c. 22 cal/oz: (in-house may NOT use powder)

Use Enfacare 22/Neosure 22 OR

MBM + Enfamil/Similac concentrate (to = 22 cal/oz)

d. **If infant is < 2kg discharge home on 24 calorie/oz. feedings

VIII. F/U TESTING:

a. Echocardiogram (? needed before discharge)

b. HUS: If gestational age < 30 weeks or birth weight < 1500 grams get a HUS at 1 week of life. Check with Neonatologist at 1 month to determine if second HUS is indicated at one month or at discharge.

c. Renal U/S: Check diagnosis to determine need for follow up renal u/s.

d. Hemoglobin: Obtain hemoglobin week of discharge

e. Eye exam: (See ROP Screening attachment)

f. Do any consultants need to see infant prior to discharge?

IX. HEARING TEST:

OAE in hospital, usually done when car seat trial is done. If infant fails OAE a BAER is done in the hospital. If infant fails BAER will need to have audiology follow-up scheduled.

X. IMMUNIZATIONS:

a. Per federal law, parental permission must be obtained prior to giving immunizations.

b. Current immunization information can be downloaded from (bedside RN can download this info and give to parents).

c. Give Engerix-B (0.5ml) IM at discharge or at one month of age if infant is thriving.

XI. MEDICATIONS:

Change from iron to Poly-vi-sol with Iron or Tri-vi-sol with Iron

* If infant is on iron at 35 weeks gestation, see Nutrition handout for specifics

XII. MMU vs. CR SCAN:

a. MMU for all infants < 34 weeks gestation and any infant (regardless of gestational age) who has experienced clinical apnea

b. CR scan for all infants being discharged home on oxygen or if there is concern over oxygenation, as in infant with BPD.

c. For both MMU and CR scan, specify whether head of bed should be elevated or flat.

XIII. NEWBORN SCREENS: (order on day of admission)

a. If birth weight < 1800 grams newborn screen should be obtained:

• DOL # 2

• DOL # 14

• DOL # 30

• If infant is discharged BEFORE day # 30, the 3rd newborn screen must be drawn on day of discharge (call unit coordinator to arrange)

b. Phone number for the Minnesota Department of Health for Newborn Screens: 612-676-5260

c. Repeat newborn screen before discharge if initial screen was invalid secondary to blood transfusions (metabolic diseases can be picked up). Repeat newborn screen 3-4 months after last transfusion (hemoglobinopathies can be detected at this time).

XIV. NICU NEURODEVELOPMENTAL FOLLOW-UP CLINIC:

Eligibility:

a. < 30 weeks and/or 1500 grams

b. Neonatal seizures or significant neurologic problem

c. Hypoxic-ischemic encephalopathy treated with total body cooling.

d. Complicated or prolonged mechanical ventilator course

e. Other situations will necessitate NICU F/U Clinic referral and eligibility should be determined with attending

II. ROP SCREENING GUIDELINES

EVIDENCE BASED/BEST PRACTICE ROP SCREENING

ROP screening criteria:

• All infants weighing 1500 grams or less at birth

OR

• Gestational age less than 31 weeks (30 6/7 weeks and less).

• No infants > 2000 grams at birth

• 1500 grams to 2000 grams birth weight and considered high risk for ROP with at least one of the following occurring at grade 2

o Use of inhaled nitric oxide for PPHN

o High frequency ventilation with significant PO2 or PCO2 lability

• Additional selected infants believed to be high risk by their treating neonatologist and are > 30 weeks gestation

• Retinal exams to classify, diagram and record, will be performed by an experienced ophthalmologist using the “International Classification of Retinopathy of Prematurity Revisited”.

• The initial exam will be based on gestational age at birth plus chronological age

Recommended Schedule for Initial Exams

|Gestational Age at Birth |Corrected Age |Chronological Age |

|(weeks) |(weeks) |(weeks) |

|22a |31 |9 |

|23a |31 |8 |

|24 |31 |7 |

|25 |31 |6 |

|26 |31 |5 |

|27 |31 |4 |

|28 |32 |4 |

|29 |33 |4 |

|30 |34 |4 |

a Tentative guideline; small number of survivors at this GA

GA 31 – 32 weeks will be seen at 4 weeks of age, when indicated.

• Follow-up exams and any necessary treatment will be determined by the ophthalmologist based on findings of the exam

• Parents of infants with ROP should be educated about ROP and the possible consequences of the disorder. They should be updated on an ongoing basis and understand the need for follow-up care even after discharge

• Services for follow-up ROP eye care needs to be available for each infant discharged or transferred. The accepting physician must be informed of the plan for the follow-up eye care.

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