P2.266: A Quality Improvement Initiative on Implementing and Guiding Hyperbilirubinemia Management Using EMR Integration with a Unit Focus

Purpose/Objectives: Our goal was to decrease subthreshold phototherapy use and readmission by 50% for hyperbilirubinemia in newborns by implementing the 2022 AAP hyperbilirubinemia guidelines over 2 years across our health network using EMR integrated tools and unit performance directed instruction.

Design/Methods: Data was collected through chart review of infants 35-42 weeks gestational age who needed phototherapy within the first 14 days of life, either during birth admission or readmission at St. Luke’s, a multihospital health network with 3 delivery units (~5000 births per year), including 3 newborn nurseries, 3 NICUs and an inpatient pediatric unit. The study spanned five periods: one six-month period before the guidelines were published and four six-month periods after.

Several interventions were instituted to limit subthreshold therapy initiation and address variation in treatment rates between units. First, education and supplementary online tools were provided to both primary care pediatricians and pediatric hospitalists consistent with the updated thresholds, risk factor integration, follow-up testing, and phototherapy recommendations. Also, the pediatric team worked with Epic to integrate bilirubin screening results for each patient (Figure 1) allowing for ease of interpretation and help guide further management. Finally, we provided nursing education to allow for better collaboration between our providers and staff.

Results: Overall, there has been a 65.8% decrease in newborns requiring phototherapy and a 70% decrease in readmission for jaundice. In our pre-study cohort, the overall rate of infants requiring phototherapy at our institution was 11.1%. In the final 6-month cohort, this rate dropped to 3.8%, which is consistent with national rates. Nurseries across our network saw a 71.8% decrease (7.8% to 2.2%) in phototherapy use while our NICU’s decreased initiation by 18.1% (15.8% to 13.7%) (Figure 2).

Conclusion/Discussion: Through a combination of education, integrated tools, and performance-directed instruction, we aimed to standardize care and improve outcomes across our health network. While these results support our goal achievement, they lend compelling evidence that a more conservative approach to managing hyperbilirubinemia is effective as it does not result in an increase in readmission, missed cases, or kernicterus.

A designated place within the EMR interface for plotting bilirubin levels along age-specific threshold curves facilitated the management of infants with hyperbilirubinemia by the care team with limited uncertainty. We also found this tool helpful in providing education on hyperbilirubinemia to families of all backgrounds and including them in the discussion of management.

Despite our interventions, our analysis still showed significant differences in phototherapy initiation between the NICU and newborn nursery settings. This could be due to the fact that NICU patients are critically admitted for concerns besides neonatal jaundice requiring closer attention and earlier therapies to avoid risk. Our next aim will be on enhanced unit specific focus, primarily the NICU setting.