INRODUCTION

Neonatal hospital readmissions, the hospital admission of a newborn less than 29 days old after getting discharged from birth admission, is a distressing event to parents and families of newborns and puts an undesirable cost on the hospital and health care system¹. Hence, discharge criteria and guidelines regarding birth admission discharge of neonates have been recommended to decrease the rates of these neonatal readmissions. The health care team must establish that the newborn has met set criteria for discharge of the newborn which include identifying potential problems of the newborn as well as ensuring the readiness of the mother and their support system to take care of the newborn child. Failure to do this may result in newborn readmission. This study described the different factors surrounding neonatal hospital readmissions in a private tertiary hospital over 9 years. It points out possible modifiable factors that may be altered to improve the health care provided to the families.

There is paucity in the local studies identifying the prevalence and determining the associated factors for readmission among term neonates. Most studies were done in other countries and focused on the association of the length of hospital stay during the newborn delivery admission with the risk for readmission. An unpublished study done by Vosotros LA in 2011 discussed the risk of readmission for healthy term neonates discharged from the nursery at less than 28 hours of life but only covered readmissions over a two year period between January 2009 and December 2010. Despite the relatively low incidence of neonatal hospital readmissions per live births, it puts undesirable costs to the newborn’s family, the hospital and the healthcare systems. Although not all hospital readmissions may be avoidable and some are foreseeable such as in cases where there are congenital anomalies, preventable readmissions in healthy term newborns is a quality and patient safety issue ². For these reasons, preventing hospital readmissions of healthy newborns should be a priority^1,2. This study described the clinical profile of neonatal readmissions in our hospital including patterns and trends in neonatal readmissions. It alluded factors for these readmissions which, can be used to pinpoint the additional support needed by the mothers and their newborns as they transition from delivery admission to home. Furthermore, the results and recommendations of this study can be used to develop best practices, interventions and cost-effective measures to decrease the frequency of neonatal readmissions among healthy term newborns.

The general objective of this study is to examine the trend and describe the clinical profiles of term neonates readmitted within 28 days after birth at in a single private tertiary hospital from 2012 to 2020. The specific objectives of the study are as follows: (1) to describe the trend of the annual rates of neonatal readmission from 2012 to 2020; (2) to identify the common chief complaints that led the patients’ family to seek health care; (3) to identify the perinatal factors that are present among the neonates readmitted, (4) to identify the final diagnoses during readmission of the readmitted neonates; and (5) to identify the outcome (during readmission) of these readmitted neonates.

METHODOLOGY

This a retrospective, single-centre, cross-sectional descriptive study of healthy term neonates born and readmitted in a private tertiary hospital in the National Capital Region of the Philippines between January 1, 2012 and December 31, 2020.

The study was started after approval of the study by the Institutional Review Board of the Makati Medical Centre. Using EpiInfo Companion™ sample size calculation, an aimed level of confidence of 95% and acceptable margin of error of 5%, and proportion of neonatal readmission at 1.6%³, the computed minimum sample size for the study is 24. A list of all neonatal admissions during the study period was obtained from the hospital’s Medical Records Department and reviewed to determine eligible participants in the study. Out of a list of 22,971 infant admissions given by the Medical Records Department, access to 434 charts of 216 neonates who met the inclusion criteria listed below were requested. These were quickly reviewed to determine eligibility in the study, i.e. if they will not be disqualified based on the exclusion criteria listed below.

Inclusion Criteria

(1) delivered in the study hospital between January 1, 2012 to December 31, 2020; and

(2) those that have at least one admission within 28 days of life (or that is, during the neonatal period) after being discharge from birth admission as healthy

Exclusion Criteria

(1) preterm neonates (maturity index less than 37 weeks);

(2) post term neonates (maturity index above 41 weeks);

(3) neonates with congenital anomalies, with suspected/proven syndromes or with history of perinatal asphyxias(neonates with APGAR score of five at 10 minutes with continued need for resuscitation, was diagnosed or suspected to have cerebral palsy, had metabolic acidosis upon delivery with a pH <7.0 or BE -12, was diagnosed or suspected to have clinical neurologic sequelae in the immediate neonatal period, had evidence of multi organ system dysfunction in the immediate neonatal period)⁴; and

(4) neonates transferred from another institution to the study venue/hospital for specialized care or further interventions.

A total of 87 neonates admitted from 2012 to 2020 were enrolled in the study; their charts were then extensively reviewed using the Archive One database and the electronic medical records (EMR) system of the hospital. The collected medical data were encoded in an encrypted Microsoft Excel Spread sheet File. Descriptive statistics was used to analyse the collected medical data. Data were summarized in tables and graphs and trends were described. Readmission rates, proportion of perinatal risk factors and readmission final diagnoses were described.

RESULTS

A total of 87 neonates were included in the study who were born and readmitted in our institution from 2012 to 2020. A higher percentage of the neonatal readmissions are female (54.02%) compared to male (45.98%); and the plurality are of Filipino race (96.51%). The majority of the neonates readmitted were private patients (78%) that comprise of those who availed of the birthing package as well as those who did not avail of the birthing package.

Figure 1 depicts the number of neonatal readmissions annually and the neonatal readmission rate (among health term newborns) per 1000 live births from 2013 to 2020. There was a noticeable peak in the readmission rate in 2018 followed by a gradual decrease in the following years.

Table 2 lists the chief complaints on readmission of neonates. The majority of the neonates readmitted had chief complaints of jaundice (49%) and fever (28%). Feeding concerns such as poor suck were only at 3% in our setting, based on data collection, 18 out of the 87 participants or 21% among neonatal readmissions had feeding concerns at home (poor suck, poor latch, perception that the baby is not satisfied after breastfeeding and decreased feeding) prior to admission regardless of their chief complaint. Significant weight loss was often discovered upon readmission; and it was found that 32.2% (28 out of 87) among readmitted patients had significant weight loss (more than 10% weight loss from birth weight) upon readmission.

The largest portion of neonates that were readmitted were born to mothers aged 30-34 years (41%), followed by those born to mothers 35-39 years of age (26%). More than half of the neonates that were readmitted were born to primarous mothers (56%). The majority of the neonates that participated in the study were delivered via caesarean section (55.2%) and less than half of the study population were delivered vaginally (44.8%). APGAR scores on the first minute of life were good (7-10) in the majority of the participants (97.7%); and on the fifth minute of life, all participants (100%) have good APGAR scores. Majority of the readmitted neonates were term at 37 to 39 weeks gestation by maturity index. The neonates included in this study were mostly appropriate for gestational age (87.36%); the neonates who are borderline small and small for gestational age comprises 2.3% each while the neonates who are borderline large and large for gestational age comprises 2.3% and 5.75%, respectively. ABO incompatibility set-up was only present in 33% of cases, while the rest had no blood group incompatibility set-up.

During the first hospitalization (birth) of the patients enrolled in the study, the minimum age on discharge is 1-day-old (a little more than 24 hours), the maximum age on discharge is 6-days-old, and the mode and median age on discharge is 3-days-old. Among patients delivered via cesarean section, the average length of stay is 3.2 days, while the median and mode length of stay is 3 days. On the other hand, among patients delivered via vaginal delivery – whether spontaneous or with instrumentation – the average length of stay is 2.5 days, while the median and mode length of stay is 2 days. Excluding the patient with missing data on weight, a little more than 50% of the patients (51 out 87%) had no significant weight loss, while onlly 39% of the study participants (34 out of 87) had weight loss of either more than 10% within the first week of life, more than 5% in a 24 hour period or both.

Among neonates readmitted who had significant weight loss on birth admission, 65% (22 out of 34) had a diagnosis of hyperbilirubinemia on readmission; while the rest had a diagnosis of nneonatal sepsis (5 out of 34), dehydration (2 out of 34), urinary tract infection (1 out of 34) and cow’s milk protein Allergy (1 out of 34).