You’ve probably been there—a three-day-old neonate with clinical evidence of jaundice on examination, an accompanying unconjugated hyperbilirubinemia, and nervous caregivers struggling to process that their well-appearing newborn needs to be admitted for phototherapy. Upon arrival to the hospital, light emitted at the correct wavelength and intensity allows for isomers of bilirubin to be excreted by the neonate. While the 2009 American Academy of Pediatrics clinical practice guideline on hyperbilirubinemia provides a standard by which to initiate therapy, it does not address what to do for the child once admitted. When should the bilirubin level be re-checked? Should the neonate receive intravenous fluids? For how long should this otherwise healthy, term infant remain in the hospital? And what value of care are you providing with your answers to these clinical choices?
In this month’s Pediatrics, Romero et. al. (10.1542/peds.2016-1472) share their experience with a quality improvement initiative aimed to reduce unnecessary testing, standardize phototherapy interventions, and reduce the length-of-stay (LOS) for jaundiced neonates. The multidisciplinary team developed an institutional best-practices algorithm based on a literature review that was subsequently distributed to emergency and inpatient medical teams. Included in this algorithm were new phototherapy protocols and recommendations on intravenous fluid administration and laboratory testing. Over the course of 18 months, the mean LOS was reduced by nearly 12 hours (p<0.001) without any significant change in readmission rates over the same time period. Study authors were also successful in reducing the number of patients receiving IV fluids by nearly 50%. The overall result of these outcomes: the cost of a hospitalization for neonatal jaundice was reduced by $778 per discharge over the study period, with statistically significant reductions specifically noted for intravenous fluids, laboratory studies, and emergency department charges. Taken together, these findings suggest that focused efforts to standardize the evaluation and therapy for neonatal jaundice may be beneficial for providing more valuable care. Check out the algorithm proposed by Romero et. al. and see for yourself how you might improve the value of care you provide for jaundiced newborns.
