Physiotherapist on the move: where babies at risk are referred for follow-up after hospital discharge

Introduction: Two facts may influence a newborn’s development. One is to be a newborn at risk and the other is to be hospitalized in Intensive Care Unit. Objective: To examine where at-risk infants are being referred for longitudinal follow-up after hospital discharge, and to carry out an analysis of the epidemiological and care profile of these babies. Methods: Documentary, descriptive and retrospective study, comprising the medical records of 479 newborns (NBs) hospitalized Hospital Materno Infantil Presidente Vargas from January 2019 to May 2020. The variables studied were: gender, baby's race/color, type of delivery, prenatal consultations, classification according to gestational age, weight, Apgar of the 1st, 5th, 10th minute, hospitalization diagnosis, main diagnosis, outcomes, length of stay, multidisciplinary follow-up during hospitalization, post-discharge referrals (specialized and non-specialized). Social and environmental data were: maternal age and race/color, maternal and paternal education. Results: Higher prevalence of full-term male babies born by cesarean delivery, declared as white, with high Apgar scores, with varied diagnoses, with prematurity prevailing. Maternal mean was 26.2 years, (SD ± 7.3), the most reported race/color was also white, the mean of mothers' studies was 8.1 years (SD ± 2.4). Only 14% (n = 67) performed motor physical therapy at the hospital and 2.1% (n = 10) were referred for evaluation and early intervention for post-discharge physical therapy. The specialized service with the highest referral was the hospital's neuropediatrics graduates' outpatient clinic (17.3%, n = 83) and, for the non-specialized, it was the Basic Health Unit/BHU (39.7%, n = 190). Conclusion: Most NBs are referred to the specific medical team or post-discharge BHU. The physiotherapist was the professional little remembered for monitoring this public in the hospital and after discharge.


Introduction
The first days of extrauterine life (neonatal period) take place at a time of great vulnerability, decisive for the baby's importance. The Neonatal Intensive Care Unit (NICU) is the service designed and organized to receive newborns (NBs) with chances of future complications or death. 1 Babies at risk due to biological factors (intrinsic and related to pre-and postnatal events) are considered: low birth weight, prematurity, brain damage during childbirth, severe bacterial infection, jaundice and/or congenital conditions, mechanical norms and prenatal exposure to maternal infections, alcohol and drugs; and social and environmental factors (extrinsic): adolescent mother (< 18 years old), a mother with low education (< eight years of schooling), social vulnerability and behavioral state anomalies. 2 Regarding the hospitalization of this public, the National Register of Health Establishments states that Brazil has 9,037 NICU beds (public and private). 3 The Brazilian Society of Pediatrics states that at least 2,657 beds are lacking so that hospital care is within the ideal. 4 However, these NB need care beyond hospitalization.
For this, there are post-discharge follow-up services, known as Follow-up or Follow-up Programs, 5 where a multidisciplinary team can identify early changes in the baby's growth and development, supporting the family and intervening whenever necessary. 5  It is important to highlight that the NB's initial care has to do with protecting their brain, among other precautions. The central nervous system (CNS) may change its maturational process, involving different short, medium, and long-term disorders. Premature or late delivery, specific genetic and peripartum conditions can interrupt or modify the natural formation of the CNS, leading to changes in motor and social development, making them more evident over the months. 5 Later, motor, language, behavioral and cognitive problems may appear. The physiotherapist must be one of the professionals working in this initial phase of life promotion and early intervention (EI) of the NB.
As shown in the title of this manuscript, "Physiotherapist on the move" dictates the theme of the study, based on the concern of physiotherapists in the hospital area, realizing that many NBs at risk were not referred to follow-up service and EI after hospital discharge. The first problem raised was: where is this population being sent after hospital discharge? And the second: Is the physiotherapist included in this referral?

Assessment procedures and instrument
The instrument for data collection were consultations to the Hospital Information System and electronic records of babies from the NICU. The collection procedure took place after authorization from the institution and from secondary data in medical records of NBs who met the inclusion criteria (all the newborns that were hospitalized at the NICU of HMIPV, between may 2018 and may 2020), totaling a sample of 479 records. The variables studied were: gender, baby's race/color, type of delivery, prenatal consultations, classification according to gestational age, weight, Apgar score of the 1st, 5th, 10th minute. Social and environmental data were: maternal age and race/color, maternal and paternal education. The hospitalization diagnosis, main diagnosis, outcomes, length of stay, the multidisciplinary team that accompanied him during hospitalization and postdischarge referrals (specialized and non-specialized) were also analyzed. All records made in the medical record of where the NB were taken after discharge were compiled. For this, specialized services were considered (outpatient clinic -neuropediatrics, pediatrics outpatient clinic, other medical specialties, speech therapy, physiotherapy -EI, psychosocial care network, public prosecution service, guardianship council) and non-specialized (joint accommodation, inter-referrals) hospitals, Basic Health Unit (BHU)/Family Health Team (FHT).
Afterward, the team of collectors, composed of physical therapist residents, stored the information in a database and, finally, they were statistically analyzed.
The study was submitted and approved by the Research Ethics Committee of the HMIPV, with the opinion number 3.984.410 (CAAE: 29836920.1.0000.5329).

Statistical analysis
Analyzes were performed using Statistical Package for Social Sciences (SPSS) version 21.0 and analyzed using simple descriptive statistics. Quantitative variables were described as mean and standard deviation or median and interquartile range. Categorical variables were described by absolute and relative frequencies.
Due to the descriptive character of the study, statistical tests were not performed.

Results
To answer our research problem of where at-risk babies are being referred for follow-up after hospital discharge from the NICU of the service in question and whether the physiotherapist is included in this referral, 479 medical records were analyzed. First, it was necessary to know these babies and then to verify these referrals, recorded in the medical record. The sample calculation was 242 records; however, the study included 479 medical records for analysis.
Still in sociodemographic characteristics, regarding social data, the mean maternal age was 26. Based on the above data and compared to the requirements for considering an infant at risk, 206 preterm would be considered as such in total and 195 for being underweight (calculation done in Table   1, considering all preterm and low birth weight), 62 with respiratory dysfunction, 36 with jaundice, 27 with maternal exposure to drug use, and 23 with low social status (data referring to Table 2). It is understood that most subjects would need specialized monitoring.
The different specialties of the multidisciplinary team that makes up the framework of multidisciplinary residency and NICU care are shown in Table 3. Likewise, the profile of post-discharge referrals (specialized and non-specialized), that is, for which specialties the patients are intended for outpatient care. There were 279 In Table 2, the main diagnoses that lead the NB to hospitalization (hospitalization diagnosis) were presented, different from the main diagnosis, which characterizes their need for greater care and assistance, the outcome of the cases of babies hospitalized in the NICU, and the length of stay of the same in the unit. babies referred to some specialized service (which could overlap) and 228 babies to non-specialized services (without overlapping).
What was evident to the authors is that only 14% babies (n = 67) performed motor physiotherapy at the hospital and, even more intriguing, is that only 2.1% babies (n = 10) were referred for evaluation, EI and for the physiotherapy after hospital discharge. Was not consider not even for a possible multidisciplinary team where the physiotherapist was included. The referral is carried out by the medical team. Speech therapy, which is a professional core very similar to physiotherapy and

Discussion
In the reality studied, some findings were found. One The length of stay in days was shorter than that found in the literature. The common way of all of them is that the infant is already evaluated and diagnosed in the NICU stage, which is what the MH advocates in Brazil. 7 The physiotherapist professional is included in this referral. A study showed the perception of professionals from PHC teams in the care of this population, especially preterm and with low birth weight. 25 The main concern of these professionals was concerning the long interval between appointments, mainly related to the baby's profile. Older data could not be analyzed either due to the recent computerization of the system and the lack of specific personnel to update the records in the system, which would facilitate the mapping of information.
But, based on this study, a multidisciplinary discharge protocol and a follow-up team were organized to receive the NICU graduates, which will be important for future research. Other services can be mobilized for this same movement.

Conclusion
The sociodemographic profile of babies at risk born in this hospital is composed mostly of NBs: male, white, born by cesarean delivery, at term, with a high Apgar score, with the main causes of hospitalization and stay in the NICU being prematurity and early respiratory dysfunction. The few information contained in the medical records of the vulnerability risks of the family and, in the post-discharge period, shows that most of these NBs were guided to primary care or to the specific medical team.
The physiotherapist was a professional little remembered for monitoring this public in the hospital and after discharge, which made physiotherapists in general uncomfortable, and motivate them to understand the reason of it and also act in order to these findings could change. With this study, a multiprofessional discharge protocol and an outpatient follow-up clinic for patients discharged from the NICU were created, being an invitation for future research. Other services can be mobilized for this same movement.

Authors' contribution
AQM and TQCL were responsible for the study organization, application of instruments, and analysis of the collected data. CSA e LRG were responsible for data analysis, writing correction and article submission, analysis of collected data and managing the study.