Dr. JoAnn Harrold, Site Chief, Neonatology, Children’s Hospital of Eastern Ontario

Charlotte Etue, Clinical Nurse Specialist Childbirth/NICU, Grand River Hospital

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1) Goals of Quality-Based Procedures

2) Why Hyperbilirubinemia?

3) QBP Development

4) Hyperbilirubinemia Clinical Pathway and Tools

5) Case Study

6) Recommendations

7) Evaluation

8) Resources

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Quality-Based Procedures Goals:

1. Align incentives to facilitate adoption of best clinical evidence-

informed practices

2. Appropriately reduce variation in costs and practice across the

province while improving outcomes

3. Ensure we are advancing right care, at the right place, at the right

time

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• Hip replacement• Knee replacement• Cataract surgery• Chronic kidney disease• GI endoscopy• Chemotherapy – systemic treatment• Stroke• Congestive heart failure• Chronic obstructive pulmonary disease• Vascular (non-cardiac)

• Two QBPs were selected to focus on the paediatric population:• Tonsillectomy• Hyperbilirubinemia

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• Common condition affecting approximately 60% of term and 80% of pre-term babies in the first week of life• Often resolves without any need for intervention

• Risk of developing severe hyperbilirubinemia and acute bilirubin encephalopathy (kernicterus) – Severe hyperbilirubinemia is on the rise in North America and Europe

• According to HIROC, “Failure to identify/monitor hyperbilirubinemia” is the 14th highest risk in terms of cost• Represents 1.5% of all claims costs, some of which have gone

as high as $8Million

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Data from the CIHI PortalHyperbilirubinemia as defined in the QBP Clinical Handbook

2011/12 Average Hyperbilirubinemia LOS (Days) by LHIN

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Data from the CIHI PortalHyperbilirubinemia as defined in the QBP Clinical Handbook

2011/12 Hyperbilirubinemia Readmissions and Readmit LOS (Days) by LHIN

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Data provided MOHLTC, Health Analytics BranchEstimates using HBAM Acute Inpatient Unit Costs, 2011/12

Total Mean

A C D E F

1 118 36.96 0.31 $1,730

2 233 80.45 0.35 $2,046

3 420 135.4 0.32 $1,681

4 677 227.45 0.34 $1,914

5 385 134.65 0.35 $2,015

6 769 249.28 0.32 $1,808

7 791 278.44 0.35 $2,222

8 674 221.6 0.33 $1,648

9 735 239.41 0.33 $1,734

10 93 29.85 0.32 $1,863

11 819 297.38 0.36 $2,242

12 100 34.13 0.34 $1,688

13 256 84.4 0.33 $1,862

14 159 55.08 0.35 $1,855

LHIN no

Cases In HIG 594

Newborn/Neonate 2500+ grams, Jaundice

#

Cases

Weighted Cases Est. Average

Cost

• Clinical Expert Advisory Group formed

• QBP population defined

• Clinical Pathway Development :• Process mapping exercise• Review of currently available clinical guidelines• Review of evidence for components not covered by clinical guidelines (i.e. home

phototherapy, transcutaneous bilirubin screening)• CEAG consensus where no evidence existed

• Creation of tools/resources for implementation

• Development of performance evaluation metrics

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Name Title Organization LHIN

Pervez Z. Faruqi Paediatrician Chatham-Kent Health Alliance 1

Paul Dick Paediatrician, Chief of Paediatrics Grey Bruce Health Services 2

Charlotte Etue CNS, Childbirth Program, NICU

Co-Chair

Grand River Hospital 3

Tamar Packer Family Physician, Medical Director,

Newborn Care

St. Joseph’s Healthcare

Hamilton

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Andrea Temple RN, Manager, Paediatrics/NICU William Osler health System 5

Jane Healey Paediatrician Trillium Health Partners 6

Luca Simonetto Senior Analyst, Strategy Management

Office

Trillium Health Partners 6

Michael Sgro Paediatrician St. Michael’s Hospital 7

Vibhuti Shah Neonatologist Mount Sinai Hospital 7

Charmaine van Schaik Paediatrician, Chief of Paediatrics Southlake Regional Health

Centre

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Robert Connelly Neonatologist Kingston General Hospital/

Hotel Dieu Hospital

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Name Title Organization LHIN

JoAnn Harrold Neonatologist

Co-Chair

Children’s Hospital of Eastern

Ontario

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Liz Darling Midwife Ottawa 11

Andrea Mills Midwife Royal Victoria Hospital, Barrie 12

Angie Wiwczor Nurse Practitioner, Family Child Program Health Sciences North 13

Linsey Mutch Paediatrician North Bay Regional Health 13

Sandy Dunn RN, PhD

Knowledge Translation Specialist

BORN Ontario

Julian Little Professor and Chair, Dept. of

Epidemiology & Community Medicine

(Canada Research Chair in Human

Genome Epidemiology)

Maternal-Child Screening

Committee

Riffaat Mamdani Program Consultant, Child Development

Unit

Ministry of Children and Youth

Services

All Births35+weeks gestation

Age 0-14 days

Diagnosis of Hyperbilirubinemia

Treatment

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Evidence-based clinical practice guidelines for the

management of hyperbilirubinemia in term and late pre-

term infants have been developed by:

• American Academy of Pediatrics, 2004

• Canadian Paediatric Society, 2007

• NHS National Institute for Health and Clinical Evidence, 2010

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1) Universal

Screening

2) Treatment

3) Screening/

Observation

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Universal Screening

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Treatment

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Screening/

Observation

Phototherapy Treatment Graph Updated

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Adapted with permission from the Champlain Maternal Newborn Regional Program (Champlain Maternal Newborn Regional Program, 2012)

Hour-Specific Nomogram Updated

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Based on data from Stevenson et al. (Stevenson DK, 2001)

Follow-Up Algorithm Created

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Modeled on Maisels’ Algorithm (Maisels MJ, 2009), reflecting the findings of the Clinical Expert Advisory

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Modeled on Maisels’ Algorithm (Maisels MJ, 2009), reflecting the findings of the Clinical Expert Advisory

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Modeled on Maisels’ Algorithm (Maisels MJ, 2009), reflecting the findings of the Clinical Expert Advisory

Universal Screening

• Male infant BW - 3400g born @ 37+2 weeks

• 24 year old G2P1 with an uncomplicated pregnancy

• Maternal Blood type A Rh-positive

• Breastfeeding exclusively, well established

• Jaundice was noted at 34 hours of age and TSB sent

• Total serum bilirubin = 128 mol/l

• No risk factors for Bilirubin Encephalopathy identified

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Risk Factors for Bilirubin Encephalopathy (RF #1):1. Isoimmune haemolytic disease2. G6PD deficiency3. Asyphyxia4. Significant lethargy5. Temperature instability6. Sepsis7. Acidosis8. Albumin <30g/L

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• Phototherapy not required

Phototherapy Required?

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Risk Factors for Severe Hyperbilirubinemia (RF #2):1. Gestational Age2. Positive DAT or other known haemolytic disease (G6PD deficiency, spherocytosis)3. Previous sibling with neonatal jaundice requiring phototherapy4. Cephalohaematoma or significant bruising5. Exclusively breastfeeding, not well established6. East Asian Race

Screening/Observation

• GA is > 35+0 < 37+6, no risk factors for Severe Hyperbilirubinemia identified

= Choose Path B

• Bilirubin plots in the low-intermediate zone

• Follow-up will be within 2 days

• Infant is ready for discharge so D/C home with follow up within 2 days

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Screening/Observation

• Total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) are both acceptable methods of bilirubin screening (generally good correlation)

• TcB is relatively easy to perform, time saving, pain free for the infant and spares blood

• Can be less expensive than TSB depending on the model of machine used

• Accuracy of the TcB machine is dependent on regular maintenance and upkeep - quality assurance and compliance with Laboratory standards needs to be ensured

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CEAG recommends:

• Initial screening TcB should be done PRIOR to the time of the

Newborn Screen

• If the TcB result is within 50 µmol/L of the phototherapy

treatment line, a TSB should be performed immediately

• A quality assurance program be implemented

• TcB not be used during or following phototherapy treatment,

TSB is required

• Use of TcB does not replace lab availability and it cannot be

used without available laboratory backup

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• Post-discharge follow-up can take place via primary care

provider, a follow-up clinic, or a community health care

provider• Routine follow-ups do not usually require the consultation of a

paediatiric specialist and should not generally take place in an

Emergency Department

• CEAG recommends, where possible, the use of community

health care resources to follow-up infants once discharged

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• Access to weekend lab services in the community is a major impediment to timely screening and monitoring of bilirubin

• Most labs have limited experience taking blood samples from newborns

• In communities where a blended model of hospital and community-based services are available, CEAG recommends community-based services meet the following criteria: • Skilled in obtaining blood from infants• Use appropriate pain management• Have the ability to deliver lab results within two hours of the

blood draw

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• Potential to save costs and address gaps in some

communities

• If blood sampling cannot be offered in the home, benefits are

negated

• CEAG recommends a planned evaluation in any community

implementing home phototherapy

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• Health care providers undertaking follow-up care must be

aware of their patient’s “bilirubin journey” and any actions

taken while in hospital

• CEAG recommends the infant’s parents or guardian be

provided with materials that document their child’s screening

and treatment history upon discharge

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• Evaluation metrics have been proposed to the MOHLTC. They include:• LOS• Rate of readmission• Rate of bilirubin screening• Incidence of severe/critical hyperbilirubinemia• Incidence of exchange transfusions• Rate of phototherapy• Rate of supplementation of BF infants receiving phototherapy

Next Steps:• Each QBP Clinical Handbook will be accompanied by an Indicator Handbook,

detailing performance evaluation metrics• Work Group to be struck to detail evaluation metrics and

determine feasibility

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Clinical Handbook soon to be available on MOHLTC website

Implementation Toolkit available at:

www.pcmch.on.ca

OHA Toolkit to Support the Implementation of QBPs:

www.oha.com

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