Title: A neonatal discharge package to increase parental confidence in caring for their infant
Funder: Department of Health (England)

Abstract: 1. The parent-centred neonatal discharge package: the Parent PackThe parent pack is designed as a response to the reactive and poorly planned nature of existing discharge planning identified in our 2010 study outlined above. It provides a focal point around which planning for discharge to home can be discussed and consists of a teaching aide in the form of a parent-focused neonatal train-to-home and gestational age appropriate pathway. a) The neonatal train-to-home has been developed with agreement from a model used in Hamilton Canada and is a washable plastic 2-dimensional image. The train is designed to be kept up to date by the parents and is a representation of a train with five windows relating breathing feeding growth temperature and sleeping areas the baby must be able to “manage” before discharge. Soon after admission a provisional discharge date will be marked on the train and parents and staff can focus the parental education needed to ensure that parents are ready for that date. b) The gestational age-appropriate care pathways provide the multi-disciplinary neonatal team with a focus for the education of parents. There are two pathways to home: 27-30 weeks gestational age and 31-33 weeks gestational age which will be used by parents and staff in facilitating parents’ care of the baby improving their understanding of the baby’s progress and acquiring the knowledge and skills need for discharge home by the specified date. 2. The proposed intervention study.We propose using a before and after design for two 10-month periods with an intervening 2 month ‘washout’ period and staff training to investigate the effects of introducing a parent-centred neonatal discharge pack in four LNUs in the Southwest region (Bath Taunton Exeter and Swindon) on the self-efficacy of parents in caring for their infant. Parents with infants of gestational ages 27wk 0days to 33 wks 6 days inclusive will be included.The primary outcome will be the change in maternal and paternal confidence from admission to discharge as measured by the Perceived Maternal Parenting Self-Efficacy tool (PMPS-E) (Barnes 2007). Parents will complete the PMPS-E soon after admission at discharge and 8 weeks later. Secondary outcomes will be :i) LOS from birth to discharge;ii) Healthcare resource utilisation in hospital and the 8 week period after discharge.iii) Perceptions of the ease of delivery and use of the intervention from qualitative interviews with staff and parents; and documentation of any improvements that could be made. Recruitment. Two ‘nurse champions’ in each unit will identify and recruit families to the study in the initial (pre-intervention) and the subsequent (intervention) 10 month periods. A “wash out” and staff training period of 2 months will ensure that almost all infants born during the study period have been discharged before implementation of the intervention parent pack commences. The intervention period (10 months) starting 12 months after the first will include all babies born at 27-<34 weeks gestation admitted to the intervention units. LOS will be measured directly from the units. Post-discharge data on health service utilisation will be collected through postal questionnaires and extra sheets inserted into the infants’ red books in which parents will record all health and social care contacts. To encourage completion of the self-efficacy tool parents will be given a £5 voucher on completion of the PMPS-E at discharge and another 8 weeks later on completion of the PMPS-E and health care resource use data sheets. They will also be reminded fortnightly by text/phone to complete the data sheets. Data cleaning will be continuous throughout the data collection period.Statistical considerations: Assuming a moderate effect size of 0.4SD (equivalent to a 4 point improvement in PMPS-E scores more than the controls) and 80% power with a 5% significance level and 2-sided test we would need 100 parents in each group (200 in total). In 2010 181 singletons and 81 twins were born between 27 weeks and less than 34 weeks and admitted to our 4 intervention units within the first week of life over a 10 month period (audit data from the Badger system). This suggests we will have in excess of 220 mothers to invite into the study for each arm of the trial over each of the 10 month recruitment periods of which at least 80% (n=176) would be eligible for the study. If we recruit 70% of mothers with 20% loss to follow-up we will recruit around 100 mothers per group. Analysis will include multivariable regression modelling to assess the influence of different covariates on the PMPS-E measure including family maternal and infant factors. Qualitative interviews: A nested qualitative study involving parental interviews 6-8 weeks after discharge and staff focus groups in both study periods will explore parents’ and staff views of the intervention and its delivery in greater detail. Economic analysis will identify measure and value the before-after costs and cost-savings that arise for parents and health services in the pre-intervention and intervention periods in the intervention units during the hospital stay and the eight week period after discharge. Utilising a newly developed resource use tool we will estimate the differences in these costs and cost savings between the pre-intervention and intervention periods. To ensure that data on levels of inpatient care are captured with clarity we will implement a standardised approach to recording data on levels of dependency (based on the BAPM guidelines 2001) for all infants in the study.


Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH