In a recently released study in Pediatrics entitled, “Decreasing Bilirubin Serum Tests in Healthy Newborns,” Dr. Sarah Sukkar and colleagues from the Holtz Children’s Hospital at Jackson Memorial Hospital, Miami, FL embarked on a quality improvement (QI) initiative to revise their institutional clinical pathway in the Mother-Baby Unit of their associated Women’s Hospital (10.1542/peds.2022-059474). They aimed to decrease the monthly total serum bilirubin (TSB) testing rate per 100 patient-days among healthy newborns by 30% while not negatively affecting key indicators, including hospital readmission rates, phototherapy rates, length of stay, and universal pre-discharge bilirubin screening. Although their hospital had an institutional algorithm based on the 2004 and 2009 AAP Clinical Guidelines, the authors realized it included guidance to verify transcutaneous bilirubin at levels much lower than recommended and utilized a “rapid rate of rise” pathway as an additional indication for phototherapy (one not in the AAP guideline), and that clinicians each practiced differently, leading to variability in the frequency of TSB levels.
Kudos to the authors for identifying this issue and tackling it! I believe it’s easier to think, “hey, we’re on the safe side,” than to realize, as they did, that their current care practices resulted in unneeded blood draws, unnecessary medical care, and likely overdiagnosis and overtreatment. The authors lay out their PDSA cycles (Plan, Do, Study, Act cycles), which are easy to follow and pretty inspirational, serving as clear models for QI teams to replicate at their own institutions. They began with a fishbone analysis, which is a visual way to look for the many causes of a problem. Then they used the identified themes, which included “fear of hyperbilirubinemia,” to build their interventions with a stakeholder team. Interventions included:
- Getting faculty buy-in for changes to a revised institutional algorithm (that fully aligned with the AAP Clinical Guideline) via biweekly meetings
- An electronic medical record “smart phrase” that includes a step-by-step approach to bilirubin levels
- An 8 minute “Hyperbilirubinemia Screening Pathway Instructional Video” for trainees that lays out the new institutional algorithm, again step-by-step (I want to view this!)
You may be new to QI, but this excellent article makes it understandable. Balancing measures make it possible to monitor for any unexpected and unintended consequences of the improvement process – these included those mentioned above: readmissions, length of stay, phototherapy rates, and universal bilirubin screening. The project results are displayed as annotated control charts, which each graphically present the changes month to month in the main measure of interest (TSB per 100 patient days) and the balancing measures just described, and each graph is “annotated” with the timing of the start of PDSA cycle interventions. The project was very successful, with a 48% reduction in TSB measures (from 51 to 26.3) per 100 patient days. This article certainly got me thinking about what we currently do at my institution about bilirubin screening, and whether we can do it better. I hope my blog got you in this mindset too! Need details on the interventions? Just click to the article and learn more!
