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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 233-238

Neonatal hospital readmissions: Rate and associated causes


1 Department of Pediatrics, King Abdullah Specialized Children's Hospital, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh; College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
2 College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
3 Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia
4 Neonatal Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia

Date of Submission18-May-2021
Date of Decision19-Aug-2021
Date of Acceptance25-Aug-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Manal Bawazeer
Department of Pediatrics, King Abdullah Specialized Children's Hospital, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_64_21

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  Abstract 


Background: The neonatal period is important for establishing a strong healthy foundation and is also associated with high mortality and morbidity rates. This study aimed to determine the rate of neonatal hospital readmission and to identify the associations between the neonatal age at readmission and the length of stay (LOS) during readmission, the outcome of readmission, and the associated maternal and neonatal factors. Methods: A cross-sectional study was performed by reviewing the medical records of 570 neonates who were born in and readmitted to King Abdulaziz Medical City, Riyadh, Saudi Arabia, through emergency and outpatient clinics from January 2016 to December 2018. Results: The neonatal readmission rate during the study period was 2.11%. The most common causes for readmission were respiratory diseases (24.9%), jaundice (22.1%), and fever to rule out sepsis (16.7%). Sex and breastfeeding were significantly associated with neonatal age at readmission (P = 0.025 and P = 0.017, respectively), but only breastfeeding was a significant predictor of age at readmission. Males were more likely to be admitted at the age >7 days, and exclusively formula-fed neonates were approximately three times the risk compared to exclusively breastfed neonates to be admitted at age >7 days (adjusted risk ratio 2.9, 95% confidence interval). Neonates readmitted at ages >7 days had double the LOS as those readmitted at ages ≤7 days (P < 0.001). The outcomes (discharge or pediatric intensive care unit admission) had no significant association with neonatal age at readmission. Conclusion: The readmission rate was 2.11% and was most commonly due to respiratory diseases. Age at readmission was significantly associated with sex, breastfeeding, and LOS. Assessment of the factors associated with readmission before discharge may reduce the rate of readmission.

Keywords: Age at readmission, causes of readmission, neonates, outcome of readmission, readmission rate


How to cite this article:
Bawazeer M, Alsalamah RK, Almazrooa DR, Alanazi SK, Alsaif NS, Alsubayyil RS, Althubaiti A, Mahmoud AF. Neonatal hospital readmissions: Rate and associated causes. J Clin Neonatol 2021;10:233-8

How to cite this URL:
Bawazeer M, Alsalamah RK, Almazrooa DR, Alanazi SK, Alsaif NS, Alsubayyil RS, Althubaiti A, Mahmoud AF. Neonatal hospital readmissions: Rate and associated causes. J Clin Neonatol [serial online] 2021 [cited 2021 Dec 2];10:233-8. Available from: https://www.jcnonweb.com/text.asp?2021/10/4/233/326613




  Introduction Top


The neonatal period is the most important period of life for establishing a strong foundation for overall health[1] and is also associated with high mortality and morbidity.

Neonatal readmissions are a global concern with rates as high as 10.1% outside the US.[2] Nevertheless, neonatal readmission rates in the US have been <1%.[3],[4]

Indeed, neonatal readmissions are costly to patients, their families, and the health-care system.[5] Prior to discharge from maternity units, a variety of tests and examinations are performed to evaluate the newborn's readiness for discharge.[6],[7],[8] In spite of that, readmission may occur among some neonates at any age; therefore, identifying the associated maternal and neonatal risk factors is essential for considering the impact of age on neonatal outcomes, caregivers, and economic burdens.[9],[10]

There are many studies that examined the causes of neonatal readmission. Between 2000 and 2010, a study from Intermountain Healthcare in Utah, USA, indicated that within 28 days, 5308 (1.8%) neonates were readmitted from a total of 296,114 births.[5] Feeding problems were the cause for the majority of readmissions (41%), followed by jaundice (35%).[5] Another study that took place in Kaohsiung Municipal Hsiang-Kang Hospital in Taiwan, between 2001 and 2003, found that among 1099 discharged neonates, 63 (5.7%) were readmitted within 14 days mostly due to jaundice (73%) and fever (19%).[11]

A study by Alsulami and Al Saif[12] conducted at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia, between 2010 and 2011, showed that 947 out of 16,844 neonates (1.34%) were either readmitted to the hospital or had visited the emergency room (ER) within 7 days from discharge. Moreover, jaundice was the most common cause of readmission/ER visits (38%).[12] Another study conducted in King Abdulaziz University Hospital, Jeddah, between October 2008 and September 2011, evaluated the effect of early discharge on readmission rates.[13] Of the 12,728 healthy newborns born during the study period, there were 166 (1.3%) readmissions, with neonatal sepsis (37.3%) being the leading cause of readmission.[13]

Previous studies have primarily investigated the incidence and causes of neonates' readmission, but with little focus on the maternal and neonatal factors of readmission, and length of stay (LOS) or outcome following readmission. Therefore, the aims of this study were to examine the association of the neonatal age at readmission with the readmission LOS and outcomes of readmission including the need for a pediatric intensive care unit (PICU). In addition, we wish to explore the maternal and neonatal factors that would have increased the risk of readmission.


  Methods Top


This cross-sectional study was conducted at King Abdullah Specialized Children Hospital, KAMC, NGHA, Riyadh, Saudi Arabia. Data collection from patients' medical records was conducted using the consecutive sampling technique. The medical records of all term and preterm neonates who were born in and readmitted to KAMC through emergency and outpatient clinics from January 2016 to December 2018 were reviewed. Readmission definition as per NGHA policy is an unplanned admission within 30 days of discharge. The following variables were collected: (1) neonatal data including gestational age (week), gender, weight (kg), length (cm), mode of delivery (vaginal, assisted, and cesarean section), breastfeeding (exclusive, none, and mixed), Apgar scores, readmission LOS (days), cause of readmission, number of readmissions, age at readmission (days), and readmission outcome (discharge or PICU admission) and (2) maternal data including maternal age, parity, and comorbidities including diabetes, thyroid diseases, obesity, asthma, anemia, and urinary tract infection.

Statistical analyses

Statistical analyses were performed using IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, NY, USA). Quantitative variables were summarized as means and standard deviations or medians and interquartile range (IQR) depending upon the normality of distribution of the data. Qualitative data were summarized as numbers and percentages. Cases with missing data at the age of readmission were excluded using list-wise deletion. The rate of readmissions for the period January 2016 to December 2018 was based on data for the total number of neonates discharged after birth during the study period. Chi-square and Fisher's exact tests were used to compare categorical variables. For the continuous variables, independent samples t-test or Wilcoxon rank-sum test were used. Variables with statistically significant associations were selected for further analyses using generalized linear model to estimate the adjusted risk ratios (RRs) with 95% confidence interval. P < 0.05 was considered statistically significant.

Ethics approval

Confidentiality and anonymity were maintained throughout the study, and no names or medical record numbers were documented. Only the research team had access to the data during the study and after completion. The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center. As this was a retrospective study, ethical consent was not required (Ref No: RYD-18-419812-88447.).


  Results Top


Of the 26,962 neonates born during the study period, 570 (2.11%) were readmitted through ER and outpatient clinics within 28 days. One hundred and fifty-seven infants (0.58%) were readmitted within 7 days after initial discharge, whereas 413 infants (1.5%) were readmitted more than 7 days following discharge from neonatal care [Table 1].
Table 1: Comparison of maternal and neonatal characteristics between neonates readmitted at the age of ≤7 days and the age of >7 days

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Of the readmitted newborns, 87.9% (n = 501) were terms, 54.7% (n = 312) were males, 72.1% (n = 411) were delivered vaginally, 32.3% (n = 184) were exclusively breastfed, and 3.7% (n = 21) were readmitted more than once. The mean maternal age was 30.9 (6.1) years, and majority of the mothers were multiparous 79.6% (n = 454). The most common comorbidities among the mothers were diabetes (19.8%), thyroid related disorders (9.6%), and anemia (5.6%) [Table 1].

Gender was significantly associated with early neonatal readmissions with males more likely to be readmitted at the ages >7 days than females (76.3% vs. 67.8%, P = 0.025). Rates of exclusive breastfeeding were significantly lower among infants readmitted within the first 7 days after discharge compared to those who were readmitted beyond the 1st week (33.2% vs. 66.8%, P = 0.017). Mode of delivery (P = 0.257), number of readmissions (P = 0.270) as well as the 1st (P = 0.880) and 5th (P = 0.495) min Apgar scores did not differ between early and late neonatal readmissions [Table 1]. In addition, gestational age at birth (P = 0.350), birth weight (P = 0.191), and birth length (P = 0.612) did not differ between infants who were admitted within the first 7 days compared to those who were readmitted beyond day 7 after discharge [Table 1].

The most common causes of neonatal readmission were respiratory diseases (24.9%, n = 142), followed by jaundice (22.1%, n = 126), and suspected sepsis (16.7%, n = 95). The most common causes of readmission are respiratory diseases (24.9), jaundice (22.1%) and suspected sepsis (16.7%). [Table 2] shows the causes of neonatal readmission.
Table 2: Causes of neonatal readmission in neonates readmitted at the age of ≤7 days and the age of >7 days

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[Table 3] shows the readmission outcomes (discharge or PICU admission), which had no statistical significance in both age groups. However, a significant association was observed between LOS of the readmission and the age at readmission. Neonates readmitted at the age of >7 days had double the LOS of readmission than those readmitted at the age ≤7 days (median [IQR]: 2[3] vs. 1 [2], P < 0.001).
Table 3: Outcome of readmission in neonates readmitted at the age of 𕟯 days and the age of >7 days

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A generalized linear model showed that exclusively formula-fed neonates had approximately three times the risk to be admitted at an age of more than 7 days in comparison to those exclusively breastfed neonates (adjusted RR 2.9, 95% confidence interval [CI] 1.3–6.4, P = 0.011). There was no difference in age at readmission between mixed-fed neonates and exclusively breastfed neonates (adjusted RR = 1.3, 95% CI 0.9–2.1, P = 0.201). Gender was not an independent risk factor [P = 0.136; [Table 4].
Table 4: Multiple logistic regression model of predictors of age at readmission

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  Discussion Top


Our study examined the rates of neonatal readmission within the first 7 and 28 days of life between January 2016 and December 2018. In addition, we report the associations between neonatal age at readmission and readmission LOS, the outcome of readmission as well as maternal and neonatal factors for readmission.

We report a readmission rate of 2.11% within the first 28 days of life during the 3-year study period. Indeed, this is less than the readmission rate from a Canadian study which reported a 4% readmission rate.[14] The authors of that study acknowledged that the high readmission rate represents a significant cost burden on the health-care system.[14] Our readmission rate in the first 7 days after discharge is 0.58%. A previous study from our hospital that examined readmissions rate in the first 7 days after discharge between 2010 and 2011 by Alsulami and Al Saif,[12] showed that the readmission rate within the first 7 days of life was 1.34%. Given that most of the readmissions within the first 7 days after birth were due to jaundice, we speculate that improvement in early detection of hyperbilirubinemia in recent years, particularly in babies with ABO incompatibility including cord analysis of the infant's blood group and direct Coombs's test status with subsequent transcutaneous bilirubin estimation within the first 12 h after birth, might have contributed to the reduction in readmissions due to jaundice.

Furthermore, we have identified jaundice as the most common cause for readmission within the first 7 days after discharge. Similarly, Alsulami and Al Saif[12] also found the most common causes of readmission to be jaundice (38%), followed by genitourinary tract (11.4%), and gastrointestinal tract (11.3%). In another single-center study by Perme et al.,[15] jaundice was the most common readmission for term infants following maternity unit discharge.

In our institution, we have a dedicated neonatal special laboratory clinic for follow of infants at high risk of hyperbilirubinemia following discharge. Indeed, this has helped reduce the initial LOS among high-risk infants and helped reducing readmission rates secondary to hyperbilirubinemia. A study from Italy for term infants with early discharge and a follow-up program after discharge found no readmissions for jaundice or dehydration in the first 28 days of life.[16] Furthermore, an American study found that infants who had an outpatient well-baby visit in their community shortly after hospital discharge were significantly less likely to be readmitted for jaundice.[17]

Rates of vaginal delivery were higher than cesarean section among infants readmitted in our study. This is likely due to the reason that infants born following vaginal birth were likely to be discharged home on day 1 or 2 of age compared to infants born following cesarean section who were likely to be discharged at a postnatal age of 3–4 days. We did not observe significant differences in the mode of delivery between infants readmitted within the 1st week after discharge and those admitted beyond the 1st week. This is contradictory to the findings from a population-based cohort study from Canada that observed higher rates of cesarean section birth among readmitted newborns.[18]

We observed low rates of exclusive breastfeeding among infants with early readmissions. Breastfeeding problems need to be anticipated and assessed prior to discharge from the hospital.

We report a longer LOS for the readmissions beyond the first 7 days compared to those readmitted within the first 7 days after discharge. This likely reflects differences in the causes of readmissions between the two groups. Jaundice was the most common cause of early readmissions, whereas respiratory causes dominated later readmissions and they were likely to require longer LOS and PICU admissions.

Majority of the mothers of the readmitted neonates were multiparous 79.6%. This could be due to the neglect in raising awareness among multiparous mothers as opposed to primiparous, assuming they have prior knowledge and experience.

Our study has limitations that include its retrospective design and it was conducted in a single center. Future prospective studies with larger populations should be undertaken to establish solid conclusions regarding causal relationships.


  Conclusion Top


This study showed a readmission rate of 2.11% over the 3-year study period. The most common causes of readmission were respiratory disease, jaundice, and suspected sepsis. Further assessment of the factors associated with readmission before the initial discharge and postdischarge follow-up can reduce the rate of readmission. There is a lack of evidence on current predischarge factors associated with neonatal readmission in term infants discharged home as healthy newborns. Predischarge policies have not been defined or described in the literature, and it is assumed that institutional policies are followed. The true scope of the number of avoidable neonatal readmissions and the factors associated with them in term infants discharged home as healthy newborns is not known.

Future prospective studies on the predictors of neonatal readmission are encouraged, which can be useful for the early identification and assessment of these predictors before discharge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Sword WA, Watt S, Krueger PD, Kyong SL, Sheehan DD, Roberts JG, et al. Understanding newborn infant readmission: Findings of the Ontario mother and infant survey. Can J Public Health 2001;92:196-200.  Back to cited text no. 14
    
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Perme T, Škafar Cerkvenik A, Grosek Š. Newborn readmissions to Slovenian children's hospitals in one summer month and one autumn month: A retrospective study. Pediatr Neonatol 2016;57:47-52.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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