Infant Care Following NICU Discharge

Survey: Infant Care

During Perinatal Clinical Reviews RCP often has discussions about coordination of care. Recently the question of discharges from the NICU has come up in several sites.  The IWK staff and physicians have asked RCP to assist with gathering information about criteria for pediatrician referral by the NICU team and the best approach to sharing discharge information with care providers in the baby’s home community.

We recognize that resources differ by site. Although an infant’s primary care provider can, and often does, refer to a local pediatrician there may be certain diagnoses that warrant referral from IWK to avoid delay in the infant being seen by a pediatrician. The IWK’s goal is to develop a consistent provincial approach to notifying care providers about infants discharged from the NICU.  Please provide your thoughts about the categories of infants for which the IWK NICU team should initiate a pediatrician referral at the time of discharge from NICU.

Preterm infants

  • Please identify the gestational age below which there should be a referral to a local pediatrician.  Note: All infants born at < 31 weeks gestation or < 1500 grams birth weight are followed for growth and neurodevelopment by the Perinatal Follow-up Program.

Infants with surgical, cardiac or gastrointestinal conditions (e.g. repaired tracheo-esophageal fistula, congenital diaphragmatic hernia, gastroschisis, ostomy, cyanotic congenital heart disease, pulmonary hypertension, cow’s milk protein allergy). 

  • Should infants that have undergone complete repair of a major anomaly be referred to a local pediatrician, in addition to ongoing follow up with the surgical service? 

  • Should infants that have undergone partial repair of a major anomaly be referred to a local pediatrician, in addition to ongoing follow up with the surgical service?

Infants with an ongoing medical condition that is primarily being managed by a pediatric subspecialist (e.g. seizures, arrhythmia, hypertension, hemolytic disease of the newborn, etc.).

  • Should infants with ongoing care by a pediatric subspecialist be referred to a local pediatrician as well?

Are there any other patient groups that are not being referred to a local pediatrician at discharge from NICU but should be?

All infants discharged from the NICU will have a discharge summary available at the time of discharge. Are there patients whom you feel should have a verbal handover in addition to a copy of the discharge summary? If yes, please list the criteria to initiate verbal handover.

If verbal handover is required, how can you be reached in a timely fashion?

If there is no pediatrician in your centre, how can IWK best assist with transition back to the community?

Other comments:

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Thank you for completing this survey.