Neonatal Intensive Care Unit Graduate Home Visit: A Learning Opportunityfor Pediatric Interns

Margaret Parker, MD, MPH1, Karen Kamholz, MD, MPH1, Dara Brodsky, MD2, and Barry Zuckerman, MD1

From the 1Department of Pediatrics, Boston Medical Center, Boston UniversitySchool of Medicine; and 2Department of Neonatology, Beth Israel Deaconess

We created a neonatal intensive care unit (NICU)graduate home visitation program in April 2010to increase awareness among pediatric first-year

residents (ie, interns) of the difficulties parents face when car-ing for recently discharged infants. One year later, we sur-veyed the participating interns to examine the feasibility ofthe NICU Home Visit Program and determine whether par-ticipation in this program improved resident self-report ofcomfort with anticipating needs of NICU infants after dis-charge. We will describe our NICU Home Visit Programand survey results in this commentary.

Does Home Visitation Play a Role in PediatricResidency?

The hospitalization of an infant in the NICU is extremelystressful for parents and caregivers, who may be separatedfrom their child for weeks at a time. Shaw et al demonstratedthat one-third of these parents experience acute stressdisorder during the early stages of hospitalization.1

Discharge from the NICU can also be challenging, asparents of medically complex infants need to providecontinued medical care to their child. In fact, many parentswith acute stress disorder will meet the criteria forposttraumatic stress disorder for months after birth.2 Othersreport increased rates of “vulnerable child syndrome”among NICU graduates. In this condition, parents maydevelop separation anxiety toward their “vulnerable child,”struggle with limit setting, and exhibit excessive concernsover trivial illnesses.3 Understanding and anticipating theseissues are of utmost importance to medical providers whocare for these infants and families after discharge.

We found that residents were unaware of the magnitude ofstress and anxiety experienced by many parents of NICUgraduates and were subsequently unequipped to support par-ents through the transition-to-home process. Home visita-tion has been described as a learning model for internalmedicine and family medicine residents to understand thechronic care of elderly patients.4-7 Assessment of theseprograms found that residents rated home visits positivelyand reported that they were able to provide their patientswith better care.5 Residents also thought that participationin home visits improved their understanding of the impactof environmental, familial, and social factors on patient

NICU Neonatal intensive care unit

health.7 We found only one report of home visitation as aneducational tool for pediatric residents. Pediatric internsvisited patients who were homebound (eg, ventilator-dependent), had missed follow-up appointments, or hadtransportation difficulties. Similar to previous studies,interns reported these home visits as a worthwhile andfeasible experience.8

We developed an NICU graduate home visitation programto improve pediatric resident awareness about the stressesfaced by parents of NICU graduates and to enhance theirability to provide care in a family-centered, compassionatemanner. We hoped that exposure to the home environmentshortly after discharge would help trainees understand thedepth of the psychosocial, economic, and medical needsfaced by NICU graduates and their families.

Our NICU Graduate Home Visit Program

We initiated our program in April 2010 at Boston MedicalCenter, 1 of the 2 hospitals in which our pediatric interns com-plete a 4-week NICU rotation. This inner-city hospital servesa predominantly minority, low socioeconomic population.Our pediatric interns first identified an infant and family andarranged a home visit within 1 to 2 weeks of discharge. Theinterns selected a family that lived within a 30-minute drivefrom the hospital and spoke a language that they were comfort-able speaking.We assigned a facultymember to accompany theintern on the visit. Faculty members were neonatologists,primary care or developmental pediatricians, or general aca-demic pediatric or developmental-behavioral pediatric fellows.Prior to the visit, interns received a concrete list of objec-

tives and potential topics to discuss with the family(Appendix; available at www.jpeds.com). We emphasizedthat transitioning to home from the NICU is an extremelystressful process and that many families will have concernsabout normal infant behaviors (eg, sleeping and feeding)and medical (eg, medication administration, multiplefollow-up visits), social (eg, care of other children in thehouse, lack of social support), financial (eg, shortened mater-nity leave), or transportation issues. We also conveyed to the

Medical Center, Harvard Medical School, Boston, MA

The authors declare no conflicts of interest.

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residents that parents may show signs of anxiety or depres-sion. Upon completion of the visit, we asked the interns tocomplete a 1- to 2-paragraph reflection on their visit.

One-Year Evaluation

One year after starting the program, we electronically surveyedresidents todetermine feasibility of the programand assess theiropinions about the visit. Of 42 second-year residents who hadrecently finished their intern year, 25 (60%) completed the sur-vey.Thirteen (52%)of the 25participated ina visit, and7 (28%)completedNICU rotations at a different hospital with no homevisit program. The remaining 5 (20%) were unable to schedulea visit because of unexpected inclementweather, difficulty find-ing time for the visit when the census was high, and inability toidentify an infant who was discharged during the intern’s4-week rotation and lived within 30 minutes of the hospitaland whose family spoke a language with which the intern wascomfortable. To address someof these barriers, we sent periodice-mail reminders to the interns about scheduling their homevisit. We also reminded the junior or senior residents and neo-natologists that they should collectively “cover” patient care re-sponsibilities for the interns during the home visit.

Among interns who did attend a home visit, most traveledby car (50% used their own car, and 42% were driven by theaccompanying faculty member) and 92% had no difficultyfinding the home. Including travel time to and from the hos-pital, 58% of the visits required 1 to 2 hours and the remain-ing visits lasted 2 to 3 hours. Ninety-two percent of theparticipants reported that they had no concerns for their per-sonal safety and that the family was receptive.

We found that 83% of the interns felt supported by the ac-companying faculty member and 17% felt somewhat sup-ported. Because a breadth of pediatric faculty membersaccompanied interns, it is possible that interns felt less sup-ported from faculty who had less experience caring forNICU graduates. In addition, many of the faculty membersdid not know the families prior to the visit. We have subse-quently sent the home visit objectives to both the facultyand interns and made efforts to review the patient’s clinicalcourse with the accompanying faculty member prior to thevisit. We also found that 67% of interns reported they wouldnot feel comfortable attending the visit without an accompa-nying faculty member, and we have, therefore, continued ourpractice of home visits with faculty members present.

Overall, most interns reported that their experience wasexcellent (17%), very good (50%), and good (17%). Fiftypercent thought the experience was beneficial and 33%thought the experience was somewhat beneficial. Whenasked, “To what extent did your NICU home visit improveyour ability to care for NICU infants, beyond what youhave learned during your NICU rotation?” most thoughtthat the visit increased their ability to prepare caregivers forpostdischarge care (58%), understand challenges faced byfamilies after discharge (75%), build rapport with caregivers(75%), and provide advice to caregivers (59%). Interns alsothought that the visit improved awareness of economic

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(58%) and social (67%) issues, awareness of the home envi-ronment (83%), and empathy for families (83%).Whenwe surveyed all interns, we found that 85%of interns

who attended a home visit, compared with 67% of internswho did not attend a visit, felt comfortable anticipating med-ical issues of NICU graduates (P = .44). Interns who did anddid not attend a home visit had similar comfort levels with an-ticipating social (50% vs 53%, P = .13) and economic (33%versus 23%, P = .58) issues. We were surprised that we didnot observe greater differences between the groups becauseof the extremely positive reports by home visit participants,but acknowledge that we had relatively few interns who par-ticipated in our program in the first year. Perhaps our pro-gram could have had a stronger impact if the participatinginterns continued to care for the infants after their home visit.Furthermore, nonparticipating interns were possibly moreconfident in caring for NICU graduates than were partici-pants because they did not experience the complex needs ofthe infants in their homes. We will continue to assess the fea-sibility and impact of our program to continue to improvethis learning experience. We did not attempt to interviewfamilies of NICU graduates to assess caregiver satisfactionand whether the visit helped in the transition-to-home pro-cess. In the future, incorporation of feedback from familieswill further improve our NICU home visit program.

Discussion

Home visitation for NICU graduates is a novel method to ex-pose pediatric interns to the issues faced by parents and care-givers of NICU graduates. A home visit program is feasible ina busy urban health center and well received by interns asa valuable learning experience. We strongly encourage otherpediatric residency programs to implement such a programfor NICU graduates or other medically complex hospitalizedpatients after discharge. n

References

1. Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute

stress disorder among parents of infants in the neonatal intensive care

nursery. Psychosomatics 2006;47:206-12.

2. Shaw RJ, Bernard RS, Deblois T, Ikuta LM, Ginzburg K, Koopman C. The

relationship between acute stress disorder and posttraumatic stress disor-

der in the neonatal intensive care unit. Psychosomatics 2009;50:131-7.

3. Maypole J, Trozzi M, AugustynM. Prematurity and parental expectations:

too early andnow toomuch. JDevBehavPediatr 2011.Epub aheadof print.

4. Matter CA, Speice JA, McCann R, Mendelson DA, McCormick K,

Friedman S, Medina-Walpole A, Clark NS. Hospital to home: improving

internal medicine residents’ understanding of the needs of older persons

after a hospital stay. Acad Med 2003;78:793-7.

5. Laditka SB, Fischer M, Mathews KB, Sadlik JM, Warfel ME. There’s no

place like home: evaluating family medicine residents’ training in home

care. Home Health Care Serv Q 2002;21:1-17.

6. Neale AV, Hodgkins BJ, Demers RY. The home visit in resident education:

program description and evaluation. Fam Med 1992;24:36-40.

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Fam Med 1986;18:361-2.

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Parker et al

Appendix

Questions that Interns are Asked to Explore with theFamily on Their NICU Home Visit

1. What was the pregnancy like for this family?(Many of the pregnancies of NICU babies arecomplicated.)

2. What was it like having their child in the NICU?Whatwas most difficult about the NICU stay?

3. Did the family feel prepared to take the child home?What were their biggest concerns?

4. What is the family structure? What is the role of thefather in caretaking? What are the roles of other ex-tended family members and children? How havethey participated or supported the mother in caringfor the new infant?

5. What is the physical environment of the home andneighborhood? How does this impact the care of theinfant?

6. Do community supports exist that may help in thecare of the infant?

7. How does the family feel about the arrival of their in-fant into the home? Is the family adapting to life witha new infant at home?

8. What concerns does the family have about their infant?9. How do the cultural or religious/spiritual beliefs of

the family impact the care of the infant?10. How has the family changed its daily schedule to ad-

just to the needs of the infant? Does the mother, fa-ther, or other caretakers get paid or unpaid time offof work to care for the infant at home or attend med-ical appointments? Is transportation to and from ap-pointments difficult?

11. What medications or special formula is the infant re-ceiving? How is the family administering or preparingthese?

12. Is there any evidence of exhaustion that may be wor-risome? Is there any evidence of post-partum “blues”or depression?

August 2012 NOTES FROM THE AMSPDC

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