PC2159: A Standardized Protocol to Reduce Readmission for Hyperbilirubinemia in Infants ≥ 35 Weeks Estimated Gestational Age

Purpose/Objectives: Most newborns will experience jaundice. While jaundice is typically benign, all newborns must be monitored to identify those at risk for severe hyperbilirubinemia. Monitoring and treatment with phototherapy must outweigh the risk of harm from unnecessary testing, prolonged hospital stay, and decreased breastfeeding. At Brooke Army Medical Center (BAMC), infants who require phototherapy after discharge from the Newborn Nursery must be readmitted and treated on the Pediatric Ward.

Prior to May 2021, no standardized protocol existed for the identification and management of hyperbilirubinemia at BAMC. Further, the average rate of inborn readmission for all causes was 2.09%, which is above the National Perinatal Information Center (NPIC) average of 0.7%.

The aim of this project is to establish a standardized approach to the prevention and management of hyperbilirubinemia in infants greater than or equal to 35 weeks estimated gestational age (EGA) as recommended by the American Academy of Pediatrics (AAP) in order to decrease the rate of readmission for hyperbilirubinemia. Specifically, we aimed to decrease readmission rate for hyperbilirubinemia by 60% within 9 months of protocol implementation at BAMC.

Design/Methods: De-identified baseline data for infants ≥ 35 weeks EGA born at BAMC from January 2019 to April 2021 was collected. After protocol implementation, monthly readmission rate for hyperbilirubinemia was computed. Process measures included hour of life (HOL) for initial transcutaneous bilirubin (TcB). Balance measures included percentage of patients requiring serum bilirubin (TsB), number of TsBs obtained per 100 infants, and length of hospital stay. Statistical process control charts were used to measure changes in quality over time.

Using the LEAN system to identify root causes and countermeasures, 2 main interventions were identified. First, a standardized protocol for the prevention and management of hyperbilirubinemia was developed and implemented in the BAMC Nursery. Second, equipment on the newborn nursery was upgraded to optimize management for infants who required phototherapy.

Results: Baseline data showed a monthly readmission rate for hyperbilirubinemia of 1.76%. Following protocol implementation in April 2021 and equipment upgrade in October 2021, we saw a clinically significant downward shift in the monthly readmission rate to 0.74%, representing a 58% decrease from baseline.

Conclusion/Discussion: Protocol implementation and equipment upgrade was associated with a clinically significant decrease in readmissions for hyperbilirubinemia with no concurrent increase in phlebotomy, unnecessary laboratory testing, or length of hospital stay. No clinically significant changes were detected for balance measures. For military treatment facilities with readmission rates above the NPIC average, this protocol may offer a model for improvement. Limitations of this project include the inability to track multiple areas of protocol compliance, potential for overestimated TcB with increased skin pigmentation, and risk factors of hyperbilirubinemia such as birth trauma and race may have delayed clinical findings and is not well documented, respectively.