According to the Agency for Healthcare Research and Quality (AHRQ, 2016a), being discharged from the hospital can be dangerous. We often think of elderly Medicare recipients and of 30-day readmission rates when this topic is discussed; however, new mothers and babies are at risk as well. Adverse events most commonly encountered in hospital discharges in the United States are medication reconciliation errors, hospital-acquired infections, morbidity from procedural complications, and failure to follow-up with pending test results or a diagnostic work-up ordered as an outpatient. Systematic problems in care transitions are cited by AHRQ as the most common root cause. Inadequate discharge teaching is one of those systematic problems. When health literacy and language barriers are included, communication of vital information can be less than ideal. Mother-baby nurses report that discharge planning is one of the aspects of care that can be missed, rushed, or unfinished when unit census and acuity exceed nurse staffing resources and warned that inadequate knowledge of self-care and newborn care can lead to adverse events such as newborn hyperbilirubinemia being overlooked and untreated, and unsuccessful breastfeeding (Simpson, Lyndon, & Ruhl, 2016).

For some mothers, length of stay (LOS) based on mode of birth makes sense. Generally mothers and babies do well with LOS time frames covered by their insurance (e.g., 2 days for vaginal birth and 3 to 4 days for cesarean). However, some patients may need more time, yet they are sent home because of preset LOSs. Postpartum home visits by nurses are not the norm in the United States, but should be. For some women, breastfeeding takes longer to establish and not all babies develop breastfeeding skills at the same rate. Being discharged without several successful breastfeeds to promote maternal confidence can lead to short breastfeeding duration or the mother giving up on breastfeeding despite her initial intentions. Not all women have a family member or friend to provide help during the immediate posthospitalization discharge period. A woman family member staying in the home and caring for the new mother and baby for weeks or months is not part of the culture in the United States.

What can be done to enhance the postpartum discharge process? Clear, concise materials with important information highlighted, with pictures and at the appropriate literacy level are essential, rather than pages of computer printouts from the electronic medical record (EMR) system that few new parents have time to read. Discharge processes that meet patient needs are not based on arbitrary discharge times. Nurses need enough time to make sure discharge teaching is comprehensive and individualized. A nurse to mother-baby couplet ratio of 1 to 3 should allow for adequate discharge teaching. Scheduling follow-up appointments before discharge can be invaluable. Some parents may not have transportation, so ability to get to the clinic should be assessed. If English is not the primary language, efforts should be made to make sure the information that is conveyed is understood. Translation services should be offered as needed. A list of local resources for breastfeeding assistance is useful if the hospital does not offer this service, as is a list of maternal and newborn signs and symptoms that should warrant a call to the provider along with their telephone numbers. With EMR use more widespread, transitions in care from inpatient to outpatient should be easier and more accurate; however, many EMRs in the outpatient setting still do not "talk" to hospitals' EMRs. Recommendations from AHRQ (2016b) for other populations apply to mothers and babies: use whole-person transitional care for all patients, adapt processes as needed, identify patients at risk for readmission, communicate simply and effectively, link patients to follow-up and posthospital services, and give accurate, real-time information to receiving providers. A high-quality discharge process for new mothers and babies is a vital part of excellent maternity nursing care

References