A systems approach for neonatal hyperbilirubinemia in term and near-term newborns

Abstract

Objective: To propose and implement a family-centered systems approach to manage newborn jaundice for safer outcomes.

Design: Observational study for known adverse outcomes.

Setting: Semiprivate urban birthing hospital.

Patients/participants: 31,059 well babies discharged as healthy from a cohort of 41,961 live births (1990-2000).

Interventions: Incremental implementation of a systems approach that incorporated a hospital policy to (a) authorize nurses to obtain a bilirubin (total serum/transcutaneous) measurement for clinical jaundice, (b) universal predischarge total serum bilirubin (at routine metabolic screening), and (c) targeted follow-up, using the bilirubin nomogram (hour-specific, percentile-based total serum bilirubin/transcutaneous bilirubin).

Main outcome measures: Known adverse outcomes assessed for early- and late-onset severe hyperbilirubinemia before, during, and after systems approach implementation.

Results: Adverse outcomes decreased for well babies: exchange transfusion, intensive phototherapy, and readmission. During the study period, there were no "never events" (total serum bilirubin greater than or equal to 30 mg/dl), while "close calls" (total serum bilirubin greater than or equal to 25 mg/dl) were 1 in 15,000 as compared to a reported incidence of 1 in 625.

Conclusions: Reduced adverse events, significant reduction in close calls, and no never events met family expectations for safer experiences with this approach.