Introduction

Infants born preterm (before 37 completed weeks of pregnancy) often require additional care and may be admitted to a neonatal unit soon after birth. Depending on their gestational age (GA) at birth and medical needs, preterm infants have varying lengths of hospital stay (LOS) from days to months. Most go home between 37 and 40 weeks’ post-menstrual age (PMA, the time elapsed between the first day of the mother’s last menstrual period and the infant’s current age) [1].

Although neonatal care is life saving and the survival of infants born very preterm has improved markedly over time [2], staying in hospital longer than necessary can be detrimental. Bright lights, noise, and lack of one-to-one care can adversely impact infant development [3]. Prolonged hospitalisation means prolonged family separation and continued parental stress [4]. Having a child in hospital incurs unanticipated and unbudgeted costs. Bliss, the UK’s largest charity representing families of sick and preterm infants, estimated this to be £2,256 for the average 8 weeks of neonatal stay in 2008 [5]. With cost-of-living increases, this is likely to be significantly higher now. Prolonged hospitalisation is also costly to the health service. In the UK, one day of neonatal ‘special care’ costs from £727.72 (with a carer, e.g., a parent present to support nursing staff) to £1222.84 (without an external carer present) [6]. Around 39,000 preterm infants are admitted to UK neonatal units each year [7]. If LOS could be reduced by just one day per infant, the NHS would save a minimum of £28 million per year.

Reducing LOS would also help alleviate the constant pressure in UK neonatal units for cot space and staff [5]. In 2014/15 (the most recent available data), 15% of all emergency transfers between neonatal units (974 infants) were due to lack of capacity at the transferring neonatal unit rather than due to medical need [5]. On one weekday in 2019, 10% of neonatal units had gaps in medical staffing and 15% gaps in nurse staffing [8]. These pressures expose babies to unnecessary risk from inadequate staff-patient ratios and harms from transfer. Preterm infants transferred in the first few days after birth have increased risk of brain injury [9] and transfers worsen anxiety and economic hardship for families who travel long distances to be with their infants [5].

There are no formal UK recommendations for criteria for discharge of preterm infants. Whilst there are some recommendations from similar settings (e.g., Canada [10]) there is no accepted consensus. However, ‘discharge readiness’ typically requires a level of physiological maturity such that the infant can:

1. Breathe on their own: preterm infants often have pauses in their breathing (apnoea of prematurity) and many require breathing support. As they mature, infants can breathe on their own. Some may continue to need additional oxygen, and some go home on oxygen therapy.
2. Maintain body temperature: initially preterm infants are nursed in incubators. As their ability to generate and preserve heat matures, they move into heated cots and finally into regular cots with normal clothing and blankets.
3. Feed adequately: preterm infants take time to establish feeding. Initially they may need parenteral nutrition. Milk is slowly introduced via a gastric tube. As their ability to suck and swallow matures, they learn to feed orally (on the breast or by bottle). To be discharged without additional support, infants should be able to take their milk requirements orally. Occasionally, where the service is available, infants can go home with partial nasogastric feeding.
4. Gain weight: most infants are considered ready for discharge if they consistently gaining weight and are above a certain weight cut-off, typically 1700-1800g.

Infants mature at variable pace and may become mature in some aspects but not all, e.g., be able to breathe well, maintain their temperature, and gain weight, but still be unable to take sufficient oral feeds. The final reason that keeps an infant in hospital is referred to as the ‘final discharge barrier’ [11]. Apart from our recent single-centre audit [12], little is known about when infants reach each of the physiological milestones listed above, or what is the most common final discharge barrier for preterm infants in the UK. Knowing what the most frequent barriers are that keep infants in hospital longer will help inform and develop targeted interventions that are most likely to support safe and early discharge home.

Studies from elsewhere have highlighted variations in LOS and the potential to intervene with strategies to support safe, early discharge. In California, infants born at 30-34 weeks’ GA are discharged, on average, 4 days earlier compared to the UK, a difference attributed to the integrated healthcare approach implemented by the Kaiser Permanente Medical Group, which requires an understanding of the reasons discharge is delayed [13]. In another study in the USA, independent oral feeding was identified as the final discharge barrier and a Quality Improvement (QI) project to support independent oral feeding reduced the average LOS by 1 week [11].

Earlier discharge can be safe, improve infant and family well-being [4,14] and simultaneously save healthcare resources. The FAST Home Study will analyse routinely recorded clinical data held in electronic patient records (EPR) to investigate LOS for preterm infants and identify the final discharge barrier(s) that require preterm infants to remain in hospital the longest. We will explore the characteristics of infants, mothers and neonatal units that are associated with extended hospital stays beyond physiological readiness for discharge. The results will help us identify and target areas to focus work to enable sooner and safer discharge.

Materials and methods

Patient, professional and public involvement

This study originated from PPI consultations carried out during the set-up of the FEED1 trial [19], a large, ongoing randomised controlled trial of early enteral feeding for preterm infants. In a survey of 248 parents, we found that length of hospital stay was overwhelmingly the major focus for families. Over 80% said that research that could help get infants home sooner should be a priority. They said that reducing the time spent in the hospital “by even a day” would improve parental and family wellbeing significantly. Our ongoing PPI work with parent groups such as Bump2Baby and Derby Bliss groups further supports this.

We initially planned to include only infants born at < 34 weeks’ GA as they are routinely admitted for neonatal care. However, on consultation, parents said all preterm infants should be included. They felt that although not all infants born at 34–36 weeks’ GA need neonatal care, those who do have similar problems to more immature infants. Therefore, study inclusion criteria were changed to include all infants born at < 37 weeks’ GA who are admitted for neonatal care.

Our study team, parent advisory group and authors of this protocol include the parents of preterm infants who received neonatal care. Their perspective, in their own words, is summarised in Table 1.

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Table 1. Parent co-investigators’ perspectives on lived experience of neonatal care.

https://doi.org/10.1371/journal.pone.0318309.t001

Discussion

The results of this study will allow ODNs to identify local priorities and areas to target to achieve a safe reduction in length of hospital stay, and at a national level will support the development of evidence-based recommendations to guide optimal discharge practices in all neonatal units. The results will identify the discharge barrier that is the reason most infants stay in hospital longer and inform the development of interventions that could help infants and their families overcome these barriers sooner and therefore go home early.

These benefits will directly improve the lives of preterm infants and their families by decreasing unnecessary separation and empowering parents to take their babies home sooner. Reduced hospital stay will improve cot capacity, reduce transfers for non-medical reasons, and families will avoid the anxiety and cost associated with having to travel long distances. Neonatal services will benefit from improved patient flow and more productive use of resources such as nursing time and transport teams. The NHS will benefit from significant cost savings from the fewer days of care and avoided transfers. The benefits of reduced burden on families, and improved care of preterm infants, will improve long term outcomes that have benefits for the wider society.

The results will inform future work to understand the interplay between physiological readiness for discharge and family readiness to care for their child independently (including keeping the baby warm, feeding, bathing, safe travel, and giving medicines) and being emotionally ready and confident to take their infant home. This will support the development of discharge guidelines that reunite families at home as soon as is safely possible, balanced against the risk of unintended consequences such as emergency hospital readmission.

Acknowledgments

Electronic patient data recorded at participating neonatal units that collectively form the United Kingdom Neonatal Collaborative are transmitted to the Neonatal Data Analysis Unit to form the National Neonatal Research Database (NNRD). We are grateful to all the families that agreed to the inclusion of their baby’s data in the NNRD, the health professionals who recorded data and the Neonatal Data Analysis Unit team. We also extend our thanks to the Bump2Baby and Derby Bliss groups who have supported the development of this study.