family, focus groups, infant, intensive care, neonatal, patient discharge, premature



  1. Gaal, Barbara J. RN, BSN, MSc, ACNP, NNP


In Ontario, publicly funded, regionalized healthcare enables transfer of convalescing infants from level III neonatal intensive care units (NICUs) to regional level II nurseries prior to discharge home. To facilitate a timely transfer and allow time for preparation of families and regional hospital nurseries, NICU staff must recognize infant readiness early. This article describes the implementation process of a 4-part, multidisciplinary, discharge planning instrument that assists staff in early identification of infant readiness for transfer or discharge home. Titled the Discharge Planning Train, this interactive instrument encourages communication and collaboration between all levels of the multidisciplinary staff and with families and decreases confusion at the time of transfer. Barriers to and strategies for successful implementation are included. Evaluation methods and results are presented. The success of the instrument in improving communication and collaboration with the families is well described by the RNs.