Bronchopulmonary dysplasia, commonly abbreviated as BPD, is one of the most common long-term complications of extreme prematurity. It develops when the immature lungs of very preterm infants are damaged by prolonged mechanical ventilation and oxygen exposure, leading to inflammation and impaired alveolar development. Infants with moderate to severe BPD often leave the neonatal intensive care unit still dependent on supplemental oxygen, and their ongoing respiratory management requires coordination among neonatologists, pediatric pulmonologists, primary care providers, and families. Previous national surveys of experts have documented striking variability in how institutions manage the discharge of these medically complex infants, from when pulmonology consultation occurs to what written instructions families receive.

That variability is precisely what the North Carolina team set out to eliminate. During the hospitalization, infants with BPD are managed by neonatologists, but once they go home, responsibility shifts to outpatient specialists, most importantly pediatric pulmonologists. If that transition is poorly coordinated, the medical team’s inconsistent care can lead to gaps in treatment, delayed follow-up, and adverse outcomes. The researchers reasoned that a comprehensive, standardized discharge framework could reduce this risk by ensuring that every infant leaving the unit with BPD receives the same core set of services before crossing the hospital’s threshold.

The centerpiece of the intervention is the SAFER Discharge Score, an acronym that packs five essential criteria into a memorable checklist. The S stands for seeing the patient, meaning that a pulmonology consultation must take place during the hospital admission itself. The A calls for an action plan, a written document provided to the family that includes emergency contact information so caregivers know exactly what to do if respiratory symptoms deteriorate. The F requires that pulmonology follow-up be scheduled before the infant is discharged, not left to happenstance after the family arrives home. The E represents education, ensuring that caregivers receive hands-on training in managing oxygen equipment. Finally, the R mandates a repeat chest radiograph prior to discharge, giving the care team an updated picture of the infant’s lung status at the moment they leave the hospital.

Each of the five elements earns one point, allowing the team to track discharge readiness as a simple numeric score. Behind the score lies a broader set of BPD Discharge Guidelines that articulate the full process, and the implementation followed the plan-do-study-act cycle methodology familiar from quality improvement work across medicine. The project leadership designed successive plan-do-study-act cycles to test and refine the guidelines, collected monthly data, and analyzed trends over time. According to the contributions statement in the paper, the project leads conceived the intervention, designed the improvement cycles, implemented the change, and analyzed the monthly data, while senior authors provided mentorship and verified the analytical methods. The study was deemed exempt from full institutional review board review because of its retrospective design and minimal risk to participants.

The results, drawn from infants discharged between January 2021 and December 2022, show a statistically significant process change. The mean SAFER Discharge Score climbed from 3.0 before the intervention to 3.9 afterward, on a scale that tops out at 5. That near-point improvement means the typical BPD discharge moved from covering roughly three of the five essential elements to covering nearly all of them. In practical terms, far more families now left the hospital with a written action plan and emergency contacts in hand, a scheduled pulmonology appointment on the calendar, documented training on their child’s oxygen equipment, and an up-to-date chest radiograph in the medical record.

Perhaps the most clinically meaningful finding concerns timing. Before the guidelines were implemented, infants with BPD waited an average of 42.7 days after neonatal intensive care unit discharge before their first outpatient pulmonology appointment. After the intervention, that interval fell to 25.1 days, a reduction of more than two weeks. For infants whose lungs remain fragile and whose families must watch for respiratory infections that can rapidly escalate into emergencies, closing that gap matters. Earlier specialist contact means earlier medication adjustments, faster troubleshooting of home oxygen needs, and a safety net that catches deterioration before it becomes a readmission.

The study also tracked when pulmonology consultation occurred relative to discharge, another key driver of coordination. Consulting the pulmonology team while the infant is still in the unit, rather than after discharge, allows the receiving specialist to know the patient before the first clinic visit and gives families a chance to meet the team who will follow their child long term. The key driver diagram published with the study maps these interlocking elements, showing how consultation timing, caregiver education, written action plans, follow-up scheduling, and radiographic assessment feed into the shared goal of a safe and reliable transition home.

The findings align with a growing body of guidance on post-prematurity respiratory disease. The American Thoracic Society’s clinical practice guideline on outpatient respiratory management of infants, children, and adolescents with post-prematurity respiratory disease, published in 2021, emphasized structured, interdisciplinary care for these patients. Other work has documented institutional variation in home oxygen use among preterm infants and surveyed national experts about discharge practices, revealing widespread inconsistency. Prior research on children with severe bronchopulmonary dysplasia who went home dependent on ventilators has underscored how much these families depend on careful planning and rapid access to specialist expertise. The North Carolina project translates those national recommendations into a concrete, auditable bedside process.

The broader significance of the study lies in its demonstration that even complex, high-stakes care transitions can be engineered for reliability. Quality improvement science has transformed outcomes in many corners of pediatrics, and the SAFER framework offers other neonatal units a replicable template: a short, memorable checklist tied to measurable discharge criteria, tracked over time and refined through iterative testing. The authors note that the data supporting their findings are available upon reasonable request from the corresponding author, and they declare no competing interests. As more centers adopt similar structured discharge frameworks, the hope is that the weeks of vulnerability between the neonatal intensive care unit and the first pulmonology appointment will shrink for every infant with bronchopulmonary dysplasia, giving these medically fragile babies and their families a safer passage from hospital to home.

Subject of Research: Discharge guidelines and quality improvement for preterm infants with bronchopulmonary dysplasia

Article Title: Creation & implementation of discharge guidelines for preterm infants with bronchopulmonary dysplasia

Article References: Stephenson, N., Lynch, S. K., Donnelly, L. F., & Stoudemire, W. (2026). Creation & implementation of discharge guidelines for preterm infants with bronchopulmonary dysplasia. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02725-7

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02725-7

Keywords: bronchopulmonary dysplasia, preterm infants, neonatal intensive care, discharge planning, SAFER Discharge Score, quality improvement, pediatric pulmonology, care transitions, home oxygen therapy, neonatology, Journal of Perinatology, patient safety