P1.206: Assessing Barriers to Implementation of 2022 Clinical Practice Guideline (CPG) Concordant Care for Hyperbilirubinemia Management in Neonates

Background: Over 80% of infants will experience jaundice. Careful monitoring of all newborn infants and the application of appropriate treatments for hyperbilirubinemia are essential because high bilirubin concentrations can cause significant morbidity and mortality. While treatment by phototherapy (PT) is effective, it is not without risk. In 2022 the American Academy of Pediatrics published updated clinical practice guidelines (CPG) surrounding the management of neonatal hyperbilirubinemia, which included higher PT thresholds stratified by gestational age and neurotoxicity risk status, escalation of care criteria, and discussion of rate of rise levels suggestive of hemolysis.

Methods: This study assesses potential barriers to CPG concordant care for neonatal hyperbilirubinemia, focusing on the ROR and access to care on weekends. We hypothesized that infants receiving subthreshold PT would be more likely to 1) have a high rate of rise (>0.2 mg/dL/hr after 24 hours of life) and 2) require weekend follow-up.

A retrospective chart review was completed of all infants at > 35 weeks of gestational age who received inpatient PT between 0-14 days of age from 02/01/2022 – 1/24/2024 in an urban hospital (n=601). ROR was calculated after 24 hours of life. Weekend follow-up was defined as infants who need bilirubin reassessment on a Saturday or Sunday. Chi-square analysis was completed to identify the association between subthreshold PT and (1) ROR and (2) weekend follow-up.

Results: Infants were stratified into pre-CPG (6 months before 2022 CPG), washout (6 months following 2022 CPG publication), and post-CPG (from 6 through 18 months following 2022 CPG publication). Positive DAT was slightly higher during the washout period (43% versus 34% pre-CPG and 35% post-CPG, p < 0.001). There were no other statistically significant differences in demographic factors among time periods. Subthreshold PT increased during the washout period compared to pre- and post-CPG periods (61% vs. 42% and 46%, respectively, p < 0.001). Post-CPG there was a significant association with subthreshold PT in those with high ROR (p = 0.005). Subthreshold PT and weekend follow-up were significantly associated (weekday 46% vs. weekend 58%, Chi square p = 0.010); this was unchanged when stratified by pre/post-CPG.

Conclusion: Clinicians are more likely to prescribe subthreshold PT when neonatal follow-up falls on a weekend, irrespective of 2022 CPG implementation. Following 2022 CPG implementation, infants with high ROR were also more likely to have subthreshold PT, indicating that clinicians began factoring ROR into the decision to start PT. Our study supports that both weekend follow-up and high ROR contribute to discordant CPG care for newborn hyperbilirubinemia. Future guidelines should address management of high ROR and access to weekend care for this population.