Review
Discharge planning considerations for the neonatal
Pediatrics Division of Newborn
Medicine, Boston Medical
Center, Boston, Massachusetts,
USA
Correspondence to
Dr Vincent C Smith, Pediatrics
Division of Newborn Medicine,
Boston Medical Center, Boston,
MA 02118, USA;
​vincent.​smith@​bmc.​org
Received 10 June 2020
Accepted 21 September 2020
Published Online First
12 October 2020
© Author(s) (or their
employer(s)) 2021. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Smith VC. Arch Dis
Child Fetal Neonatal Ed
2021;106:F442–F445.
F442   Smith VC. Arch Dis Child Fetal Neonatal Ed 2021;106:F442–F445. doi:10.1136/archdischild-2019-318021
intensive care unit
Vincent C Smith  ‍ ‍
ABSTRACT
Neonatal intensive care unit (NICU) discharge readiness
is the primary caregivers’ masterful attainment of
technical care skills and knowledge, emotional comfort
and confidence with infant care by the time of discharge.
NICU discharge preparation is the process of facilitating
discharge readiness. Discharge preparation is the process
with discharge readiness as the goal. Our previous
work described the importance of NICU discharge
readiness and strategies for discharge preparation
from an American medical system perspective. NICU
discharge planning is, however, of international
relevance as challenges in relation to hospital discharge
are a recurring global theme. In this manuscript,
we conceptualise NICU discharge preparation with
international perspective.
INTRODUCTION
In 2010, it is estimated that 11% of all live births
worldwide (approximately 15 million babies)
were born preterm (less than 37 completed weeks
of gestation).1 The majority of preterm infants
(84%) require care in a neonatal intensive care unit
(NICU).2 Our previous work described the impor-
tance of NICU discharge readiness and strategies for
discharge preparation from an American medical
system perspective.3 NICU discharge planning is,
however, of international relevance as challenges in
relation to hospital discharge are a recurring global
theme.4 5 In this manuscript, we will conceptualise
NICU discharge preparation with an international
perspective.
DISCHARGE PREPARATION
NICU discharge readiness is the primary caregivers’
masterful attainment of technical care skills and
knowledge, emotional comfort and confidence
with infant care by the time of discharge.3 NICU
discharge preparation is the process of facilitating
discharge readiness.3 Discharge preparation is the
process with discharge readiness as the goal.3 In
Iran, increasing discharge readiness was associated
with reducing the length of neonatal hospital stay,
decreasing the medical costs and improving the
availability of beds for admission of other infants.6
Discharge preparation begins at admission and
continues incrementally increasing throughout
the hospitalisation until the education is complete
and skill mastery is obtained.7 Family-­centred care
(FCC) and communication are vital components of
discharge preparation.
FCC is a philosophy that acknowledges that the
family is the most consistent factor in the infant’s
What is already known on this topic?
►► Neonatal intensive care unit (NICU) discharge
readiness and strategies for discharge
preparation are a vital part of the transition
from the NICU to home.
►► A standardised discharge programme that is
individualised for the needs of thefamily and
available local resources can help facilitate
discharge readiness.
What this study adds?
►► NICU discharge planning is, however, of
international relevance as challenges in relation
to hospital discharge are a recurring global
theme.
►► In this manuscript, we conceptualise NICU
discharge preparation with international
perspective.
life and that the family and staff are in a partnership
in caring for the infant.3 FCC encourages family
participation in all aspects of the infant’s life in the
NICU. Some consistent examples of FCC include
regular family participation in medical rounds and
bedside infant care.8 There are obvious benefits of
FCC to the family and the infant. With FCC, fami-
lies tend to feel more competent and confident with
infant care.8 In Iran, they use FCC tenets to increase
maternal empowerment and allow the needs of the
mother and the infant to be met while preventing
unfavourable consequences.6
The benefits of FCC may extend beyond the
NICU. In China, FCC in NICU continued to show
a developmental benefit to preterm infants up to
18 months of age.9 Despite this, in some parts of
China, Chinese health policy dictates that parents
are not allowed into the NICU during their infant’s
stay.10 Those regions have to be more creative in
how they can integrate families into the care of
their infant. In Colombia, South America, socially
and culturally fathers may be less involved with
infant care in the NICU.11 FCC in Colombia and
in places with similar cultural norms may need to
adapt the tenets of FCC to match the caretakers
involved with the infants in the NICU. FCC brings
the family to the centre of the discharge prepara-
tion process to participate in a comprehensive stan-
dardised discharge planning programme.

COMPREHENSIVE STANDARDISED PROGRAMME
A comprehensive standardised programme for discharge prepa-
ration that can be tailored to the needs of the family is the best
practice to achieve discharge readiness.3 5 11 12 The use of insti-
tutional guidelines and policies helps standardise the process
decreasing variability and inadvertent omissions in discharge
preparation.5 7 12
There is international evidence to support a standardised
approach. In Sweden, families felt better prepared for NICU
discharge when the staff used a structured discharge planning
programme.13 When surveyed, 83% of the Swedish families
from one study reported that after undergoing a structured
discharge planning programme they felt prepared for NICU
discharge.13 Similarly, Iranian mothers who learnt infant care at
the bedside and participated in a direct clinical empowerment
programme were more prepared to take care of their preterm
infant at the time of NICU discharge.6 The structured Iranian
discharge planning programme reduced the length of stay by
6 days.6 Sometimes the standardised approach is not formal
but still effective. For example, a NICU in Colombia did not
have a formal discharge protocol but did have a consistent set
of competencies that the family was expected to learn prior to
their discharge home that allowed families to achieve discharge
readiness.11
A comprehensive discharge preparation programme includes
an educational curriculum and discharge preparation process.
Educational curriculum
The educational curriculum covers the topics considered to be
important for parents to master before they go home with their
preterm infant.
Technical baby care skills: Families need technical baby care
skills including the following: feeding (breast and/or bottle);
attaining appropriate caloric density; bathing; donning suitable
clothing; tending skin, umbilical cord and genitalia; correctly
implementing a safe infant sleeping environment; and handling
any complex medical needs (eg, use of medical equipment,
gastrostomy and/or tracheostomy care).3 Of these, feeding issues
are paramount. In Iran, successful breast feeding has been iden-
tified as a key component to a successful transition to home,
so they attempt to provide breastfeeding support ‘as soon as
possible’.14 Similarly, healthcare providers in Colombia report
that one of the biggest barriers to a successful NICU discharge
is the establishment of breast feeding.11 In Sweden, families who
did not have a successful transition to home disproportionately
had tube feeding and breastfeeding-­related issues.13
Home environment preparation: Families should have the
supplies and equipment they will need to care for their infant.
The needs will vary by family, but most families will need the
following: feeding supplies (eg, a means for breast milk expres-
sion, nipples/bottles, formula, and so on), a safety-­ approved
sleep environment (eg, crib, bassinet, sleep box, and so on),
diapers, baby clothes and equipment for illness management (eg,
thermometer, suction bulb, and so on).3
A safe means of infant transport: Families need to have the
means and knowledge of how to transport their infant safely.3
For many preterm infants, this will be either in a car seat or a
car bed.15 16 Given that preterm infants are at risk for apnoea,
bradycardia and oxygen desaturation events, they should have
a period of observation in a car safety seat/bed.15 16 This period
of observation should be performed with the car safety seat
placed at an angle that is approved for use in a vehicle and the
infant optimally restrained.15 16 For places where infants are not
Smith VC. Arch Dis Child Fetal Neonatal Ed 2021;106:F442–F445. doi:10.1136/archdischild-2019-318021
Review
routinely transported in vehicles, safe infant transport must be
assessed within the context of the local travel norms.
Preterm infants’ normal and abnormal behaviours: Because
they can be different from term infants, preterm infant patterns
(eg, feeding, voiding and stooling, and sleep–wake cycles) need
to be discussed with the family.3 Some preterm infant behaviours
are different from the term infants and may appear abnormal to
an untrained observer.3 Families also need to understand when
preterm infant behaviours are abnormal focusing specifically on
sign and symptoms of illness so that, when appropriate, they
may seek medical attention in a timely manner.3
Anticipatory guidance: To aid the transition to home process,
give parents a realistic expectation of what they will experience
at home based on the ongoing medical needs of the infant and
the specific features of the family. In Sweden, many families felt
concerned during the first period at home because they were not
prepared for the ongoing care that was needed for their infant.
Being without the NICU monitoring equipment and staff was
very hard for many of these families.13 These Swedish families
were concerned about their infant’s breathing, food intake and
weight gain. It is important to cover this type of anticipatory
guidance to allow families to prepare appropriately.
Anticipatory guidance could also include the anticipated
number and frequency of healthcare maintenance visits, commu-
nity resource utilisation and potential growth and development
monitoring.3 5 When it is known that the infant will require
technological support and/or have significant outpatient medical
follow-­up, outpatient therapies or other diagnostic procedures,
the family may have to coordinate multiple subspecialty appoint-
ments and schedule routine deliveries of durable medical equip-
ment or supplies.8
Anticipatory guidance may also include some parental mental
health issues that may be present or arise around the time of
discharge. Some families may have mental health issues (eg,
anxiety, postpartum depression, post-­traumatic stress disorder,
and so on) as well as psychological effects of illness (eg, pain,
nightmares, and so on) that are barriers to discharge planning.12
In Sweden, family anxiety and lack of emotional support from
the nursing staff were known barriers to the discharge process.13
Parental mental health issues often arise in association with a
NICU hospitalisation and the eventuality may be addressed as
part of the anticipatory guidance. Some Swedish families felt
they had received adequate discharge preparation, but were
not mentally ready for discharge.13 Because some mental health
issues arise after NICU discharge, families may benefit from
education about warning signs and symptoms.
Emergency contingency planning: Despite adequate planning
for the transition from the NICU to home, problems could arise
after the family has been discharged from the NICU. As part of
the discharge process, the family will need to have contingency
plans in place to handle urgent and emergent crises.3
Discharge preparation process
Internationally, bedside teaching is one of the most effective
ways of teaching.3 5 13 14 Bedside teaching involves demonstrating
to the family how to perform a task, assessing their under-
standing and having them perform the task.5 Swedish families
were able to feel better prepared for NICU discharge when they
had the opportunity to provide care under the guidance of the
NICU staff where the family’s participation and responsibility
was gradually increased during the NICU stay.13 Some Swedish
parents suggested that a gradual reduction in healthcare provider
intervention along with an increase in parental responsibility
F443
 Review
would have helped facilitate parental independence and improve
the mental preparation for going home.13
Using supplemental materials, multiple modalities, room-
ing-­in and group learning opportunities may help strengthen the
teaching process:
►► Supplemental materials: To maximise the benefits achieved
with bedside teaching, staff may supplement it with other
educational modalities such as written or video materials.5
To circumvent literacy issues, one may use iconography. In
Iran, formal and informal discharge education that incor-
porated written and video supplemental discharge teaching
materials was found to increase retention.14
►► Multiple modalities: It can be helpful for families to see
multiple ways to provide infant care, and then they can
develop a method that best suits them. This principle is
demonstrated by Iranian formal and informal discharge
education from multiple sources including nurses, physicians
and other parents.14
►► Rooming-­in: Rooming-­in is a way for families to spend a
significant amount of time caring for their child and learning
to manage their child’s needs.8 13 Frequent rooming-­ in
experiences spread throughout the infant’s hospitalisation
(as opposed to solely clustered in the last few days prior to
discharge) help minimise fatigue in the days leading up to
discharge and allow for additional teaching time and return
demonstration of competence by parents.8 Being able to
spend time rooming-­in with their infant and managing their
infant’s care, Swedish families felt it was of great benefit in
preparing for discharge from the NICU.13
►► Group learning opportunities: Some families may benefit
from having discharge teaching to occur in protected health
information compliant groups.11 14 This may allow families
to hear the other families’ questions and answers. Some
families will feel less pressure when they are in a group as
opposed to one on one.
Inform the family of discharge planning process: Many fami-
lies may not be aware the discharge planning is underway
and report that the discharge date came up suddenly without
warning. Discharge planning meetings are a way to help fami-
lies understand where they are in the discharge process.3 8 The
discharge planning meeting can be used to help families under-
stand what they have already accomplished and what still needs
to be completed.3 When the approximate date of discharge is
known, formally beginning the discharge planning process with
a discharge planning meeting can be beneficial.12 The meeting
could be a time to introduce the family to the support people
(eg, outpatient care coordinator, social worker, discharge plan-
ning coordinator, and so on).8 This meeting could also be used to
facilitate interaction between the hospital providers and commu-
nity providers who will be part of the ongoing care management
team.8
Time can be used to assess any specific needs of the family
that may affect discharge planning. In Sweden, parents asked for
more preparation before discharge as well as a planning meeting
early enough in the discharge process that they could, together
with the staff, go through what had been prepared at home and
what else they needed to do.13 Furthermore, some Swedish fami-
lies felt unprepared for discharge mainly when they did not have
time to make the necessary practical preparations at home.13
Have a consistent method to document discharge teaching
progress: It is an efficient means of communicating what has
been done and what is yet to be completed.3 This information
can allow continuity of teaching among different providers. In
Iran, discharge preparation process was improved by consistent
F444 Smith VC. Arch Dis Child Fetal Neonatal Ed 2021;106:F442–F445. doi:10.1136/archdischild-2019-318021
Table 1  Examples of discharge planning tools and their use/
indication
Tool Use/indication
Discharge guidelines or Help standardise discharge planning.
checklists5 12 Ensure all necessary steps in the discharge
planning are completed.
Transfer brochures5 Raise familiar awareness of available community
resources.
Family educational aids3 5 Supplement and reinforce bedside teaching.
Discharge questionnaire to Assess a family’s readiness for hospital discharge
assess readiness for discharge3 including:
4 12 13
►► Home and home environment.
►► Food and supplies.
►► Infant and family transportation needs.
►► Families’ physical and mental ability to provide
the necessary care for the infant at home.
Discharge summary3 5 12 Is a communication tool that provides information
to:
►► The family.
►► Community/medical home providers.
►► Specialty medical providers.
Provides a summary of the hospital course
including:
►► Pertinent maternal and birth history.
►► The infant’s discharge diagnoses, medications,
follow-­up appointment schedule needed and
any ongoing medical needs.
►► Any pending test results.
►► Any medical and/or social issues that require
follow-­up.
teaching, adequate documentation of teaching and coordination
in the discharge process among different providers.14
Make use of discharge tools: Discharge planning tools help with
the preparation, evaluation and summary aspects of discharge
preparation5 12 (table 1).
Assess the family for any circumstances that could impact
discharge planning: Family assessment is a central compo-
nent of the discharge planning process. This assessment helps
to understand, relatively speaking, which families are and are
not prepared to discharge and what further needs to be done.
Sometimes there are infant, family and/or community-­related
circumstances that could impact the transition from the NICU
to home. When it is known that any of these factors are relevant,
the knowledge should inform the discharge planning process.
Some examples are in table 2.
Educate all the staff about the discharge planning programme:
Staff members should be familiar with all the aspects of the
discharge planning programme.11 12 There should also be a plan
for ongoing staff education and regularly scheduled updates as
the programme changes over time.11
Transition care to the community providers: When families
transition from one healthcare setting to another, they become
more vulnerable. This susceptibility is heightened in places
where there is not sufficient care coordination between the
hospital and community providers.5 For example, in Colombia,
the link between hospital and community-­ based resources is
often not reliably present,11 so discharge planning in Colombia
has to account for that potential deficit.
It is well documented that most families follow-­up with a
community provider after hospital discharge.17 In the period
right after NICU discharge, families often do not know if
they should call the NICU or the community with questions
that arise.17 During the discharge planning process, families
can benefit from guidance about when to contact community
 Review

Table 2  Further discussion of family circumstances that could impact discharge planning
Circumstance Further insight
Limited proficiency in the prevailing In the USA and UK, this would be limited English proficiency. Providers should try to make sure, whenever possible, that discharge
language teaching and supplemental materials are in the families’ preferred language. In Colombia, language and cultural barriers are
particularly salient for indigenous mothers who spoke native dialects and understood little or no Spanish.11 Understanding how to
communicate with a family is vital in the discharge planning process.
Migratory families For these families, it is important to know where they will physically be in the period right around discharge as well as where they
anticipate they will have their ongoing care for their infant. Some examples include military, ambassador, nomadic and seasonal
immigrant families.
Illiteracy For these families, written communication alone may not be helpful.12 If it is known that members of the family are illiterate then
discharge planning should include supplemental materials that do not rely on an ability to read to follow. Some families may be
literate but lack functional health literacy. These families are at risk of not understanding the discharge teaching and consequently at
risk for problems with caring for the infant at home.
Cultural, religious or social belief system For these families, it is important for the healthcare providers to understand what having a ‘sick’ infant means to the family and the
different from the main culture of the community that the family comes from.19 That knowledge can affect the healthcare-­related decisions that the family makes.19 In
hospital/region Colombia, indigenous or poor families may view a ‘sick’ infant as being too much of a burden to the family and their community.11
The family may respond by becoming less engaged with or detached from the infant and/or the discharge process or even abandoning
their infant.11
Other at-­risk groups Some known groups that may need additional consideration during discharge planning include families affected by substance use,
mental health issues, domestic violence and socioeconomic instability.3 In South America, healthcare providers identified adolescent
mothers, indigenous parents and working fathers as being particularly challenging to reach and engage in discharge planning
process.11

providers and hospital providers about medical-­related issues REFERENCES

that arise or are present after discharge.3 This is especially true
when there is an identified need for ongoing services, support
and/or information.18
Because community providers may not yet be as familiar
with the infant, family or specific medical issue, the transition
accountability and responsibility for ongoing care also requires
communication of important information (eg, diagnoses, tests
results and pending studies, treatments, goals of care, and so
on) so that care plans can be continued in an uninterrupted
manner.12 Provider-­to-­provider communication helps facilitate
continuity of care for medically or socially complex infants/fami-
lies as does sharing a formatted discharge summary.3 5 12
CONCLUSION
NICU discharge readiness and strategies for discharge prepara-
tion are a vital part of the transition from the NICU to home.
NICU discharge planning has international relevance as chal-
lenges in relation to hospital discharge are a recurring global
theme. While it is not feasible to describe a discharge planning
programme that will work in every circumstance, our goal is to
raise awareness of the elements needed for a discharge planning
programme. Therefore, it is important to use local information
when developing and implementing a discharge preparation
programme.
Contributors  VS is responsible for writing, revising and approving the final
manuscript as submitted.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Commissioned; externally peer reviewed.
Data availability statement  No data are available.
ORCID iD
Vincent C Smith http://​orcid.​org/​0000-​0002-​1056-​8121
1 Blencowe H, Cousens S, Oestergaard MZ, et al. National, regional, and worldwide
estimates of preterm birth rates in the year 2010 with time trends since 1990 for
selected countries: a systematic analysis and implications. Lancet 2012;379:2162–72.
2 Howson C, Kinney M, Lawn J. Born too soon: the global action report on preterm
birth. Geneva: World Health Organization, 2012.
3 Smith VC, Hwang SS, Dukhovny D, et al. Neonatal intensive care unit discharge
preparation, family readiness and infant outcomes: connecting the dots. J Perinatol
2013;33:415–21.
4 Galvin EC, Wills T, Coffey A. Readiness for hospital discharge: a concept analysis. J Adv
Nurs 2017;73:2547–57.
5 Stelfox HT, Perrier L, Straus SE, et al. Identifying intensive care unit discharge planning
tools: protocol for a scoping review. BMJ Open 2013;3:e002653.
6 Moradi S, Arshdi-­Bostanabad M, Seyedrasooli A, et al. The effect of Empowerment
program on maternal discharge preparation and neonatal length of hospital stay: a
randomized controlled trial. Iran J Nurs Midwifery Res 2018;23:172–7.
7 Berry JG, Blaine K, Rogers J, et al. A framework of pediatric hospital discharge care
informed by legislation, research, and practice. JAMA Pediatr 2014;168:955–62.
8 Bowles JD, Jnah AJ, Newberry DM, et al. Infants with technology dependence:
facilitating the road to home. Adv Neonatal Care 2016;16:424–9.
9 Li Y, Gao XY, Xiang XY, et al. [Effect of family integrate care on the development of
preterm infants at 18 months of age]. Zhonghua Er Ke Za Zhi 2016;54:902–7.
10 Hei M, Gao X, Gao X, et al. Is family integrated care in neonatal intensive care
units feasible and good for preterm infants in China: study protocol for a cluster
randomized controlled trial. Trials 2016;17:22.
11 Raffray M, Semenic S, Osorio Galeano S, et al. Barriers and facilitators to preparing
families with premature infants for discharge home from the neonatal unit.
perceptions of health care providers. Invest Educ Enferm 2014;32:379–92.
12 Stelfox HT, Lane D, Boyd JM, et al. A scoping review of patient discharge from
intensive care: opportunities and tools to improve care. Chest 2015;147:317–27.
13 Larsson C, Wågström U, Normann E, et al. Parents experiences of discharge readiness
from a Swedish neonatal intensive care unit. Nurs Open 2017;4:90–5.
14 Hagen IH, Vadset TB, Barstad J, et al. Development and validation of Neonatal
Satisfaction Survey--NSS-13. Scand J Caring Sci 2015;29:395–406.
15 Bull MJ, Engle WA, et al, Committee on Injury, Violence, and Poison Prevention and
Committee on Fetus and Newborn. Safe transportation of preterm and low birth
weight infants at hospital discharge. Pediatrics 2009;123:1424–9.
16 Durbin DR, Hoffman BD, COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION.
Child passenger safety. Pediatrics 2018;142:e20182460.
17 Enlow E, Herbert SL, Jovel IJ, et al. Neonatal intensive care unit to home: the transition
from parent and pediatrician perspectives, a prospective cohort study. J Perinatol
2014;34:761–6.
18 Kuo DZ, Lyle RE, Casey PH, et al. Care system redesign for preterm children after
discharge from the NICU. Pediatrics 2017;139:e20162969.

Smith VC. Arch Dis Child Fetal Neonatal Ed 2021;106:F442–F445. doi:10.1136/archdischild-2019-318021 F445
© 2021 Author(s) (or their employer(s)) 2021. No commercial re-use. See
rights and permissions. Published by BMJ.