Tenn. Comp. R. & Regs. 0780-01-68-.05

Current through June 26, 2024

Section 0780-01-68-.05 - SPECIFIC GUIDELINES

(1) Discharge Planning.

(a) Discharge planning should occur in a planned and systematic fashion for all postpartum mothers and new-borns in order to enhance care, prevent complications and minimize the need for rehospitalization. Prior to discharge a discussion should be held between the physician or another health care provider and the mother (and father if possible) about any expected perinatal problems and ways to cope with those problems. The parties should discuss plans for future and immediate care as well as instructions to follow in the event of an emergency or complication.

(b) Follow-up care must be planned for both mother and infant at the time of discharge. For patients leaving the hospital prior to 24-48 hours, contact within 48-72 hours of discharge is recommended and may include appropriate follow-up within 48-72 hours as deemed necessary by the attending provider, depending upon individual patient need. This follow-up visit will be acknowledged as a provider encounter.

(c) Maternal considerations. Prior to discharge, the mother should be informed of normal postpartum events including but not limited to:

1. Lochial patterns;

2. Range of activity and exercise;

3. Breast care;

4. Bladder care;

5. Dietary needs;

6. Perineal care;

7. Emotional responses;

8. Conditions to report to physician or other health care provider including:

(i) Elevation of temperature,

(ii) Chills,

(iii) Leg pains, and

(iv) Increased vaginal bleeding.

9. Method of contraception;

10. Coitus resumption; and

11. Specific instructions for follow-up (routine and emergent).

(d) Neonatal Considerations. Prior to discharge, the following points should be reviewed with the mother or, preferably, with both parents:

1. Condition of the infant;

2. Immediate needs of the infant; (eg., feeding methods and environmental supports);

3. Instructions to follow in the event of a newborn complication or emergency;

4. Feeding techniques;

5. Skin care, including cord care and genital care;

6. Temperature assessment and measurement with the thermometer;

7. Assessment of neonatal well-being;

8. Recognition of illness, including jaundice;

9. Proper infant safety including use of car seat and sleeping position;

10. Reasonable expectations for the future; and

11. Importance of maintaining immunization begun with initial dose of hepatitis B vaccine.

(2) Criteria for Maternal Discharge Less Than 24-48 Hours Following Delivery.

(a) Prior to discharge of the mother, the following should occur:

1. The mother should have been observed after delivery for a sufficient time to ensure that her condition is stable, that she has sufficiently recovered and that she may be safely transferred to outpatient care.

2. Laboratory evaluations should be obtained and include ABO blood group and Rh typing with appropriate use of Rh immune globulin and hematocrit or hemoglobin.

3. The mother should have received adequate preparation for and be able to assume self-care and immediate neonatal care.

(b) Factors which may exclude maternal discharge prior to 24-48 hours include:

1. Abnormal bleeding.

2. Fever equal to or greater than 100.4 degrees.

3. Inadequate or no prenatal care.

4. Cesarean section.

5. Untreated or unstable maternal medical condition.

6. Uncontrolled hypertension.

7. Inability to void.

8. Inability to tolerate solid foods.

9. Adolescent mother without adequate support or the establishment of appropriate follow-up. A nurse home visit within 24-48 hours of discharge would constitute appropriate follow-up.

10. All efforts should be made to keep mother and infant together to ensure simultaneous discharge.

11. Psychosocial problems (maternal or family) which have been identified prenatally or in hospital. If appropriate follow-up has not been established, a nurse home visit within 24-48 hours of discharge would constitute appropriate follow-up.

(3) Criteria for Neonatal Discharge Less than 24-48 Hours Following Delivery.

(a) The nursery stay is planned to allow the identification of early problems and to reinforce instruction in preparation for care of the infant at home. Complications often are not predictable by prenatal and intrapartum events. Because many neonatal problems do not become apparent until several days after birth there is an element of medical risk in early neonatal discharge. Most problems are manifest during the first 12 hours, and discharge at or prior to 24 hours is appropriate for many newborns.

1. Prior to discharge of the newborn at 24-48 hours, the following should have occurred:

(i) The course of antepartum, intrapartum, and postpartum care for both mother and fetus should be without problems which may lead to newborn complications.

(ii) The infant is a single birth at 37 to 42 weeks' gestation and the birth weight is appropriate for gestational age according to appropriate intrauterine growth curves.

(iii) The infant's vital signs are documented as being normal and stable for the 12 hours preceding discharge, including a respiratory rate below 60/minute, a heart rate of 100 to 160 beats per minute, and an axillary temperature of 36.1 degrees C in an open crib with appropriate clothing.

(iv) The infant has urinated and passed at least one stool.

(v) No evidence of excessive bleeding after circumcision greater than 2 hours.

(vi) The infant has completed at least two successful feedings, with documentation that the baby is able to coordinate sucking, swallowing, and breathing while feeding.

(vii) No evidence of significant jaundice in the first 24 hours of life.

(viii) The parent's or caretaker's knowledge, ability, and confidence to provide adequate care for the infant are documented.

(ix) Laboratory data are available and reviewed including:

(I) Maternal syphilis and hepatitis B surface antigen status.

(II) Cord or infant blood type and direct Coomb's test result as clinically indicated.

(x) Screening tests are performed in accordance with state regulations. If the test is performed before 24 hours of milk feeding, a system for repeating the test must be assured during the follow-up visit.

(xi) Initial hepatitis B vaccine is administered or a scheduled appointment for its administration has been made.

(xii) A physician-directed source of continuing medical care for both the mother and the infant is identified. For newborns discharged less than 24-48 hours after delivery, a definitive plan for contact within 48-72 hours after discharge has been made. A nurse home visit within 24-48 hours would be considered appropriate follow-up.

2. Maternal factors which may exclude discharge of the newborn prior to 24-48 hours include:

(i) Inadequate or no prenatal care;

(ii) Medical conditions that pose a significant risk to the infant;

(iii) Group B streptococcus colonization;

(iv) Untreated syphilis;

(v) Suspected active genital herpes;

(vi) HIV;

(vii) Adolescent mother without adequate support or the establishment of appropriate follow-up. A nurse home visit within 24-48 hours of discharge would constitute appropriate follow-up;

(viii) Mental retardation or psychiatric illness; and

(ix) Requirements for continued maternal hospitalization.

3. Newborn factors which may exclude discharge of the newborn prior to 24-48 hours include:

(i) Pre-term gestation (less than 37 weeks);

(ii) Small for gestational age;

(iii) Large for gestational age;

(iv) Abnormal physical exam, vital signs, color, activity, feeding or stooling;

(v) Significant congenital malformations; and

(vi) An abnormal laboratory finding such as:

(I) Hypoglycemia,

(II) Hyperbilirubinemia,

(III) Polycythemia,

(IV) Anemia, and

(V) Rapid plasma reagin positive.

Tenn. Comp. R. & Regs. 0780-01-68-.05

Original rule filed June 6, 1996; effective August 16, 1996.

Authority: T.C.A. §§ 4-5-101 et seq.,56-2-301, 56-32-218 and 56-7-2350.