768 - Quality improvement reduces unnecessary serum bilirubin lab draws in a community hospital newborn nursery

Over 80% of newborns are affected by jaundice. Careful monitoring and treatment of high bilirubin levels prevents acute bilirubin encephalopathy and kernicterus. Transcutaneous bilirubin screening is safe, noninvasive, and correlates well with total serum bilirubin levels (TsB). The 2022 American Academy of Pediatrics’ (AAP) hyperbilirubinemia guidelines were updated to reflect recent evidence that neurotoxicity does not occur until TsB are well above exchange transfusion threshold, incorporating higher phototherapy thresholds, as well as evidence-based guidance on when to obtain TsB. Minimizing unnecessary TsB draws has many potential benefits, including decreased blood loss, fewer painful procedures, avoiding discharge delays, less costs, and fewer clinic visits.

 

Objective:

We sought to reduce the percentage of newborns requiring TsB draws from 30% to 15% at our community hospital nursery over 12 months.

 

Design/Methods:

We set our baseline period as 7/2021-6/2022. In 6/2022, we defined our project aim and began root cause analysis for excess newborn TsB. Our top root cause was lack of consensus for when TsB is needed. We initiated 4 interventions: (1) dissemination of 2022 AAP hyperbilirubinemia guidelines (8/2022), (2) physician journal club discussing AAP guidelines (8/2022), (3) circulation of BiliTool calculator incorporating AAP guidelines (9/2022), and (4) monthly discussion of project goals and troubleshooting (8/2022-12/2022). The primary outcome is percentage of newborns who received any TsB. Secondary outcomes include average TsB draws per newborn, percentage of newborns requiring phototherapy, and length of stay. Our balancing measure is 7-day readmission rate. Outcome measures are analyzed using statistical process control (SPC).

Results:

The project resulted in a Hawthorne effect, with an immediate decrease in our primary outcome while still in the planning phase (6/2022). In the first 5 months of interventions, the average percentage of newborns receiving a TsB declined from 30% to 19%, although this does not yet meet SPC criteria for significance due to lack of data points (Fig 1). We saw no change in average TsB draws per patient, percentage of newborns requiring phototherapy, length of stay, or readmissions.

Conclusion(s):

We conclude that an iterative process involving implementation of educational interventions and an online tool is effective in decreasing unnecessary newborn TsB without impacting readmissions. Interventions are ongoing with future changes to include nursing education and a bilirubin management tool integrated into our electronic medical record.