O2050: Decreasing Unnecessary Bilirubin Serum Tests in Healthy Newborns on Mother Baby Unit at Holtz Children’s Hospital

Purpose/Objectives: Neonatal jaundice occurs in up to 84% of newborns. Our institution was obtaining total serum bilirubin (TSB) testing more frequently and at lower thresholds than currently recommended nationally. The overuse of unnecessary TSB can lead to parental anxiety, increased health care cost, pain for the newborn, and delayed discharges. The purpose of this study was to minimize unnecessary TSB testing for newborns in our Mother-Baby Unit (MBU) and promote high-value care. We aimed to decrease the monthly rate of unnecessary total bilirubin serum testing per 100 patient-days among healthy newborns in the Mother-Baby Unit by 30% by June 2022.

Design/Methods: A multi-disciplinary team was formed on October 2020 to review the current practice for ordering blood work among house staff in MBU. Root cause analysis was performed to identify factors contributing to TSBs, including variation in clinical practice, fear of hyperbilirubinemia, low level of evidence in 2004 AAP guideline, lack of standardization and suboptimal communication between physicians and nurses. Key driver was developed to plan our interventions (Figure 1). The interventions included: faculty buy-in, revising the hyperbilirubinemia clinical practice pathway, educating medical staff in high value care, and including a standardized hyperbilirubinemia assessment and plan in the daily progress note. Interventions were implemented using iterative Plan-Do-Study-Act (PDSA) cycles. Primary outcome was the monthly rate of TSB testing per 100 patient-days. The length of stay and rate of phototherapy treatment were chosen as balancing measures. Statistical process control chart (SPC) was used to display data overtime (Figure 2).

Results: From July 2020 to January 2022, 3152 newborns were admitted to our Mother-Baby units. 57% of newborns from the baseline period had at least one TSB drawn, compared with only 33% of newborns from the intervention period (P < .001). For those newborns who were tested, the median number of TSB testing per patient decreased during the intervention period to 1(IQR, 1-3) compared to 2 (IQR, 1-4) for the baseline period (P < .001). The mean center line at baseline was 54.1 TSBs per 100 patient-days. Post-implementation, special cause variation in testing rates shifted the mean center line to 24.3 TSB per 100 patient-days, a 55% reduction (Figure 2). There were no unintended adverse consequences from our interventions. Conversely, the rate of phototherapy treatment decreased during the intervention period to 4%, compared to 10% from baseline period (P < .001).

Conclusion/Discussion: Our quality improvement initiative was able to implement value improvement interventions leading to a reduction in the monthly total serum bilirubin (TSB) testing per 100 patient-days in healthy newborns without adversely affecting our patient’s length of stay or phototherapy rates. The most successful interventions were the implementation of the revised hyperbilirubinemia clinical pathway and high value of care coaching.