Management Clinical Pathway Hyperbilirubinemia

9
DOI: 10.1542/peds.2012-1156 ; originally published online November 12, 2012; 2012;130;e1688 Pediatrics John Zorc Margaret Wolff, Dana Aronson Schinasi, Jane Lavelle, Naomi Boorstein and Joseph Care Using a Clinical Pathway Management of Neonates With Hyperbilirubinemia: Improving Timeliness of http://pediatrics.aappublications.org/content/130/6/e1688.full.html located on the World Wide Web at: The online version of this article, along with updated information and services, is of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point publication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly at Indonesia:AAP Sponsored on April 6, 2014 pediatrics.aappublications.org Downloaded from at Indonesia:AAP Sponsored on April 6, 2014 pediatrics.aappublications.org Downloaded from

Transcript of Management Clinical Pathway Hyperbilirubinemia

Page 1: Management Clinical Pathway Hyperbilirubinemia

DOI: 10.1542/peds.2012-1156; originally published online November 12, 2012; 2012;130;e1688Pediatrics

John ZorcMargaret Wolff, Dana Aronson Schinasi, Jane Lavelle, Naomi Boorstein and Joseph

Care Using a Clinical PathwayManagement of Neonates With Hyperbilirubinemia: Improving Timeliness of

  

  http://pediatrics.aappublications.org/content/130/6/e1688.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 2: Management Clinical Pathway Hyperbilirubinemia

Management of Neonates With Hyperbilirubinemia:Improving Timeliness of Care Using a Clinical Pathway

abstractBACKGROUND: Neonatal hyperbilirubinemia is a common reason forneonates to present to the emergency department (ED). Althoughclinical practice guidelines provide recommendations for evaluationand therapy, few studies have evaluated ways to apply them effectivelyin the ED setting. The primary objective of this study was to comparetime to phototherapy in neonates presenting to the ED with jaundicebefore and after implementation of a nursing-initiated clinicalpathway. Secondary outcomes included time to bilirubin result andED length of stay in neonates.

METHODS: We performed a retrospective historical control study com-paring neonates presenting to the ED with jaundice during 9-monthperiods before and after initiation of the pathway. Charts were ab-stracted for times of assessment and treatment and final disposition.

RESULTS: Three hundred neonates were included in this study: 149before and 151 after pathway implementation. Median time to photo-therapy (historical control: 128 minutes vs postintervention group: 52minutes; P , .001), median time to bilirubin result (157 vs 99; P ,.001), and median ED length of stay (268 minutes vs 195 minutes; P ,.001) were shorter for neonates treated after the implementation ofthe clinical pathway. No complications were reported during the studyperiod.

CONCLUSIONS: After implementation of a clinical pathway for the man-agement of neonates with jaundice in the ED, we observed a reductionin time to phototherapy, time to bilirubin measurement, and overalllength of stay. Pediatrics 2012;130:e1688–e1694

AUTHORS: Margaret Wolff, MD,a Dana Aronson Schinasi,MD,b Jane Lavelle, MD,c Naomi Boorstein, RN,c and JosephJohn Zorc, MDc

aDepartment of Emergency Medicine, University of Michigan, AnnArbor, Michigan; bDivision of Emergency Medicine, FeinbergSchool of Medicine, Northwestern University, Chicago, Illinois;and cDivision of Emergency Medicine, Perelman School ofMedicine at the University of Pennsylvania, Philadelphia,Pennsylvania

KEY WORDShyperbilirubinemia, jaundice, infant, emergency department

ABBREVIATIONSAAP—American Academy of PediatricsED—emergency departmentIQR—interquartile rangeIV—intravenous lineLOS—length of stayRN—registered nurse

Dr Wolff designed the study, performed the initial analysis andinterpretation of data, drafted the initial manuscript, andapproved the final manuscript as submitted; Drs Schinasi andLavelle conceptualized and designed the study, interpreted thedata, revised the article for important intellectual content, andapproved the final manuscript as submitted; Ms Boorsteinperformed data collection, reviewed and revised themanuscript, and approved the final manuscript as submitted;and Dr Zorc analyzed and interpreted the data, reviewed andrevised the manuscript, and approved the final manuscript assubmitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-1156

doi:10.1542/peds.2012-1156

Accepted for publication Jul 16, 2012

Address correspondence to Margaret Wolff, MD, University ofMichigan Hospital and Health Systems, Department ofEmergency Medicine, 1500 E. Medical Center Drive, Ann Arbor,MI 48109. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: No external funding.

e1688 WOLFF et al at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 3: Management Clinical Pathway Hyperbilirubinemia

In 2009, 38 390 patients were evaluatedin emergency departments (ED) na-tionwide for neonatal jaundice andhyperbilirubinemia.1 Although the ma-jority of neonates presenting withjaundice have a benign, self-limitedcondition known as physiologic jaun-dice of the newborn, approximatelyone-third of neonates presenting to theED have levels of bilirubin that result inadmission. High levels of bilirubin areassociated with kernicterus, a chronicform of bilirubin encephalopathycharacterized by permanent neuro-logic damage. Although kernicterus israre, recent cases demonstrate theneed for adherence to recommen-dations to prevent complications.2–4

TheAmericanAcademyofPediatrics(AAP)Subcommittee on Hyperbilirubinemiapublished guidelines for the care ofneonates with hyperbilirubinemia thatemphasized standardized screening andtimely initiation of therapy when in-dicated.5 At our institution, we experi-enced 2 cases for whom treatment ofclinically significant hyperbilirubinemiawas delayed in the ED. Review of thesecases identified potential areas for im-provement in the processes of care tomeet the goals set by the AAP Guidelines.In response to this review, a multidisci-plinary team developed a clinical path-way that stresses rapid nursingassessment and initiation of photo-therapy, early serum bilirubin collectionby heel stick, and expedited transfer ofhigh-risk patients to the NICU to receivedefinitive therapy.

The primary objective of this study wasto compare time to phototherapy inneonates with jaundice or knownhyperbilirubinemia presenting to theED before and after implementation ofthe clinical pathway. The secondaryobjectives were to compare time fromarrival to bilirubin result and ED lengthof stay (LOS) before and after imple-mentation of the pathway.

METHODS

Setting

This study was performed in an urbanacademic pediatric ED with an annualcensus of 86 000 patients.

Study Population

Neonates presenting with the chiefcomplaint of jaundice or hyper-bilirubinemia to the EDwere eligible forthe hyperbilirubinemia clinical path-way if they were$24 hours of age and#21 days of age, born $35 weeks’gestation, and normothermic ($36°Cand ,38°C). Triage nurses identifiedthe patient chief complaint based onparental report or referral from theprimary care provider for jaundiceor documented hyperbilirubinemia. Ifjaundice was observed in a neonatepresenting for another concern, jaun-dice was also listed as a chief com-plaint. Patients were eligible for studyinclusion on their first ED visit; sub-sequent visits were not included in theanalysis.

Definitions and Data Collection

Neonates were identified through anelectronic tracking system of allpatients seen in the ED (Wellsoft,Somerset, NJ). Before pathway imple-mentation and periodically after path-way implementation, a query wasperformed to identify neonates #21days of age who presented with jaun-dice or hyperbilirubinemia as a chiefcomplaint. Data were provided to theED care team throughout the process.Patient ED arrival and discharge timeswere obtained from the ED trackingsystem. We abstracted temperature,gestational age, times of nursing eval-uation, laboratory results, and photo-therapy initiation from the patientmedical record.

Our primary outcome was time tophototherapy as defined by arrivaltime to documentation of phototherapy

initiation. Our secondary outcomemeasures were time to bilirubin result,defined by arrival time to bilirubin re-sult being reported by the laboratory,and LOS defined by arrival to ED dis-charge times. Process measures wererelated to pathway adherence: pro-portion of bilirubin tests performed byheel stick and proportion of infantsreceiving unnecessary intravenous (IV)placement. The balance measures ofthis project were parental satisfactionand complications of phototherapydefined as temperature instability afterinitiation of phototherapy or retinalexposure to phototherapy.

Intervention: Clinical PathwayDevelopment

Two patient safety events occurred atour institution that resulted in delay ofdefinitive therapy. The first neonatepresented with jaundice and de-hydration, and venipuncture by severalED providers was unsuccessful. Fivehours after presentation, a skilled IVnurse from the hospital-wide vascularaccess service obtained venous blood.Clinically significant hyperbilirubinemiawas diagnosed 6 hours after pre-sentation. The second patient was re-ferred from the primary care doctor forjaundice. After several attempts, thebedside registered nurse (RN) placedan IV line and obtained a small amountof venousblood.Given thesmall volume,the physician ordered an unconjugatedbilirubin level. This error was recog-nized after the sample was processed,necessitating an additional blood draw.This led to a delay in the recognition ofclinically significant hyperbilirubinemia,andphototherapywasnot initiateduntilNICU admission 6 hours after pre-sentation.

These events led to the formation ofa multidisciplinary team charged withdeveloping a strategy to improvetimeliness of therapy (phototherapy orexchange transfusion) for neonates

QUALITY REPORT

PEDIATRICS Volume 130, Number 6, December 2012 e1689 at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 4: Management Clinical Pathway Hyperbilirubinemia

presenting to the ED with the chief com-plaint of jaundice or hyperbilirubinemia.The multidisciplinary team consisted ofnurses, nurse practitioners, and physi-cians from the ED, NICU, and general pe-diatrics divisions. Given the importanceofprompt phototherapy initiation, the teamdecided the intervention should focus onthe initiation of phototherapy within 1hour of arrival to the ED for all neonatespresenting with the chief complaint ofjaundice or hyperbilirubinemia.

Afterestablishing theoverarchinggoal,the team reviewed these cases anddetermined that the major cause ofdelay was difficulty with neonatal ve-nipuncture. The next step was to es-tablish theusual careof theseneonatesto identify other potential areas forimprovement. This was accomplishedby interviewing nurses, attendingphysicians, and trainees in the ED. Welearned that laboratories were drawnafter physician evaluation and photo-therapy was initiated after bilirubinresults were available. IV lines wereplaced at the time of venous blooddraw, and many patients requiredmultiple attempts. Both nurses andphysicians expressed confusion re-garding the appropriate bilirubin testand indications for phototherapy. All ofthese factors were felt to contributeto delays in initiation of phototherapyand prolonged LOS. After consideringvarious strategies, the team came toa consensus that creating a clinicalpathway with accompanying order setandeducational interventionwould leadto prompt initiation of phototherapy.

TheAAPguidelinessuggestestablishingstanding nursing protocols for testingfor hyperbilirubinemia in jaundicedneonates.5 Therefore, we developeda clinical pathway (Fig 1) that is initi-ated by the ED triage RN. The ED triageRN serves as the first provider toevaluate each patient and assignsa triage level based on patient acuitythat determines priority level. To en-

sure that patients with clinically sig-nificant hyperbilirubinemia receivetimely room placement, the pathwayinstructs triage nurses to assign allpatients presenting with a complaint ofjaundice or hyperbilirubinemia to ei-ther a triage level 1 or 2 out of 5 levels,where 1 represents the most acutepatients. Triage level 1 was defined astotal serum bilirubin .20 before pre-sentation, ill appearance, clinical signsof severe dehydration, or alteredmental status. All other neonates withjaundice or hyperbilirubinemia weretriaged as a level 2. This triage assign-ment was reviewed with all nurses butwas consistent with the triage protocolbefore pathway implementation.

The bedside RN continues the clinicalpathway by beginning parent educationand requesting a physician order to ob-tain a serum bilirubin level via heel stickbefore physician evaluation. Immediatelyafter collection of the serum sample, theneonate is placed on phototherapy usinga bilirubin blanket. The protocol directsthe RN to place the neonate either supineon the bilirubin blanket or pronewith eyeshields to avoid retinal damage. The ne-onate and bilirubin blanket are thenwrapped with a blanket to prevent hy-pothermia. Temperature is taken withinitiation of phototherapy and every 2hours thereafter.

The educational component consistedof a didactic session at a departmental

FIGURE 1ED guideline for evaluation and treatment of neonates with hyperbilirubinemia/jaundice. BC, conjugatedbilirubin; BU, unconjugated bilirubin; H&P, history and physical; NG, nasogastric; OG, orogastric; TSB,total serum bilirubin. * The Bili Bed is a product of Natus Medical Inc., Seattle, WA.

e1690 WOLFF et al at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 5: Management Clinical Pathway Hyperbilirubinemia

meeting for physicians and nursingleadership and separate online edu-cation modules for physicians andnurses. The education reviewed theevidence behind the recommendationsand highlighted key changes in prac-tice. The nurses received training onobtaining blood via heel stick instead ofthe traditional method of venipuncture,and routine IV placement was dis-couraged. The clinical pathway wasposted on our institutional intranet andserved as an educational tool withhyperlinks to information such as thenomograms for phototherapy and ex-change transfusion, recommendedlaboratory studies, and standardizeddischarge instructions. An order setin our computerized physician orderentry system accompanied the path-way to increase consistency in order-ing.

Project Timeline

Thestudyperiodof21months included9months of baseline data collection(historical control), a 3-month in-tervention period during rollout andeducation, and 9 months of follow-up(postintervention). We performed a ret-rospective historical control studycomparing timeliness of care in neo-nates who were evaluated in our ED fora chief complaint of jaundice orhyperbilirubinemia, comparing thebaseline historical control period withthe postintervention period, whichwere both 9-month periods occurringat identical seasons to reduce otherpotential variation in ED volume.Compliance and performance dataweresharedwith the ED staff at regularintervals after pathway implementa-tion.

Data Analysis

We summarized study data usingmedian and interquartile ranges fornonnormal distributions and meansand standard deviations for normal

distributions. Continuous variableswere analyzed using an independentsamples t test, and categorical datawere analyzed by using Fisher’s exacttest or x2 analysis where appropriate.Nonparametric variables were ana-lyzed with the Mann-Whitney U test.Statistical significance was designatedat P # .05. Statistical analysis wasperformed by using Statistical Packagefor the Social Sciences (SPSS Version19.0, Chicago, IL).

The institutional review board waivedoversight for this quality improvementproject and analysis.

RESULTS

During the study period, there were 2414visitsmadebyneonates$24hoursof ageand#21 days of age to the ED. Of these,446 visits were for the chief complaint ofhyperbilirubinemia or jaundice; 81 visitswere excluded for presence of fever orhypothermia, and 65 visits were excludedas repeat visits. Therefore, 300 neonateswere included in the study: 149 neonateswere in the historical control group, and151 were in the postintervention group(Table 1). An additional 80 neonates weredischarged with a diagnosis of hyper-bilirubinemia or jaundice after present-ing for a different complaint.

Median time to phototherapy after theclinical pathway initiation was 52minutes (interquartile range [IQR]: 36–77; range: 10–250) compared with 128minites (IQR: 68–175; range: 18–374) inthe historical control (P , .001). Thiseffect was sustained throughout thestudy period (Fig 2). Median time tobilirubin result was also shorter in thepostintervention group (99 minutes,IQR: 79–136) compared with the his-torical control group (157 minutes, IQR:126–204; P , .001; Fig 3). LOS de-creased after the intervention from 268minutes (IQR: 212–331) in the historicalcontrol group to 195minutes (IQR: 144–281) in the postintervention group (P,.001; Fig 4).

Seventy-eight patientswere admitted tothe NICU during the study period: 51in the historical control group and 27 inthe postintervention group. Mediantime to phototherapy for patients beingadmitted to the NICU after the clinicalpathway initiation was 44 minutes (IQR:35–80; range: 11–169) compared with133 minutes (IQR 76–180; range 18–322) in the historical control (P ,.001). There was no significant differ-ence in LOS between the groups: his-torical control 272 minutes (IQR: 226–338) versus 240 minutes (IQR: 182–332)in the postintervention group.

There was strong adherence to thepathway after initiation: 95.3% ofpatients in the postintervention grouphad bilirubin testing completed bya heel stick compared with 16.7% in thehistorical control (P, .0001). After theintervention, IV placement decreasedto 3.9% compared with 87.9% in thehistorical control (P , .0001). Therewere no parental complaints re-garding unnecessary phototherapy,and there were no complications ob-served during the study period.

DISCUSSION

The results of our study indicate thatimplementation of a clinical pathwayfor neonates presenting with hyper-bilirubinemia or jaundice resulted intimely initiation of phototherapy. Weachieved our goal of initiating photo-therapy within an hour of presentationfor themajority of neonates. In addition,therewasa reduction in unnecessary IVplacement and LOS decreased. Theseresults are consistent with recentstudies that have used clinical path-ways in the ED to standardize care anddecrease LOS in patients with septicshock and cerebrospinal fluid shuntmalfunction.6,7

Implementation of this pathway re-quired a change in the culture of our EDaround the care of these patients. Thiswas accomplished by empowering the

QUALITY REPORT

PEDIATRICS Volume 130, Number 6, December 2012 e1691 at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 6: Management Clinical Pathway Hyperbilirubinemia

nursing staff to initiate the protocoland through sustained educationalefforts. There were formal educationsessions during project rollout andmonthly after project initiation at de-partmental meetings and through an

assigned online learning module fortrainees. This educational effort wasreinforced by enlisting the help ofseveral nurses and physicians to be-come informal peer champions of theproject, providing support and real-

time feedback to colleagues whenworking in theED. Additional reductionsin time to care may be achieved by in-stituting standing nursing orders forlaboratory testing in these patients.However, we were unable to overcomethe resistance to standing nursinglaboratory orders in our ED.

Another change in practice involvedobtaining blood for bilirubin testing byheel stick. When obtaining blood forlaboratory testing, the common prac-tice in our pediatric ED is to leave an IVline in place in the event that additionaldiagnostic or therapeutic interventionsare required. Because of the challengesin obtaining IV access in neonates, wefound that time to successful venousblood draw before pathway imple-mentation was extremely variable,ranging from 1 to 5 attempts and takingas long as 4 hours. Therefore, the teamconsidered options that would yieldearlier bilirubin results and decreaseunnecessary IV placement. Screening

TABLE 1 Patient Characteristics

Preintervention n = 149 (%) Postintervention n = 151 (%)

Mean age (d) 5.25 5.23Male 86 (58) 89 (59)RaceBlack 62 (42) 77 (51)White 48 (32) 39 (26)Hispanic 8 (5) 7 (5)Asian 17 (11) 16 (11)Other 14 (9) 12 (8)

Triage category1 8 (5) 8 (5)2 140 (94) 142 (94)3 1 (0.7) 0 (0)4 0 (0) 0 (0)5 0 (0) 1 (0.7)

Admitted 75 (50) 66 (44)Insurance status n = 137 n = 73Commercial 56 (41) 37 (51)Public* 76 (55) 35 (48)Self-pay 5 (3) 1 (1)

* P , .05.

FIGURE 2Monthly median time to phototherapy from arrival in the ED.

e1692 WOLFF et al at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 7: Management Clinical Pathway Hyperbilirubinemia

with transcutaneous bilirubin testingwas considered but ultimately wasdismissed given that such testing onlyprovides measurements within 2 to 3mg/dLof the total serumbilirubin level.5

The majority of published data re-garding the relationship between totalserum bilirubin levels and kernicterusor developmental outcomes are basedon capillary levels which can be

obtained with a simple heel stick.5,8

Therefore, capillary testing emerged asthe team’s preferred method. The disad-vantage of this method is that when theinitial heel stick sample reveals clinicallysignificant hyperbilirubinemia, additionallaboratories must be obtained by an ad-ditional blood draw. However, patientswith a reassuring bilirubin level only re-quire the initial heel stick.

The decision to initiate phototherapy onevery neonate with the chief complaint ofjaundice or hyperbilirubinemia was ini-tially questioned by members of theclinical team. The main value of photo-therapy is that it reducestherisk that totalserum bilirubin levels will reach the levelwhere exchange transfusion is recom-mended.5 Therefore, it is prudent to ini-tiate phototherapy quickly in neonates

FIGURE 3Monthly median length of stay in the ED.

FIGURE 4Monthly median time to bilirubin result.

QUALITY REPORT

PEDIATRICS Volume 130, Number 6, December 2012 e1693 at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 8: Management Clinical Pathway Hyperbilirubinemia

with clinically significant hyper-bilirubinemia. Our team felt thatto ensure that patients with clinicallysignificant hyperbilirubinemia re-ceived phototherapy expeditiously, itwas necessary to make phototherapythe standard of care for all patientspresenting with the chief complaintof jaundice or hyperbilirubinemia. EachED provider cares for only a fewpatients annually with clinically signif-icant hyperbilirubinemia, making itdifficult to maintain vigilance aboutprompt phototherapy initiation. In ad-dition, by making phototherapy thestandard of care for all of thesepatients, we were able to justify havingphototherapy equipment dedicated toED patients located in the ED for easieraccess. Some providers were con-cerned that initiation of phototherapywould make parents hesitant to holdand feed their child. After consideringthis, the team chose a blanket devicethat would still allow parents to holdand feed their child.

From an economic standpoint, there arecosts associated with initiating photo-therapyoneveryneonatepresentingwithjaundiceorhyperbilirubinemia.However,the estimated lifetime cost of caring fora child with kernicterus is at least$900 000.9 Therefore, it is possible thatthere could be savings in an approachthat aggressively treats neonates withphototherapy. Phototherapy is associ-ated with a potential risk of temperature

instability and retinal damage. However,these risks can be prevented with closeattention to body temperature and theuse of eye patches. After implementationof this clinical pathway, the majority ofneonates were on phototherapy for#40minutes before the result of the serumbilirubin was available. We believe theminimal risk associated with a brief pe-riod of phototherapy for patients whoultimately have bilirubin levels that donot require phototherapy is outweighedby the potential benefit of prompt initia-tion of phototherapy for patients withhyperbilirubinemia.

From a quality improvement standpoint,the success of this project hinged on thetimely feedback provided to the medicalproviders regarding their compliancewith the pathway and suggestions forimprovement. One barrier that we facedinitially was resistance on the part ofa few clinicians to following the pathway.However, after direct feedback and con-tinued reminders from peer championsof the project, the majority of the clini-cians began using the pathway. In addi-tion, aggregate data were presented tothe ED clinical staff on a regular basis toshow trends in care and to remind pro-vidersof theclinicalpathway.Anotherkeycomponent of the success of this projectwas making the clinical pathway easilyaccessible to all providers of the careteambyplacing itonthehospital intranet,which was accessible from any patientroom. An accompanying order set in the

computerized physician order entrysystem preselected the recommendedlaboratories, which provided real-timedecision support. The next cycle of ourquality improvementprojectwill focusondecreasing LOS for thepatients requiringNICU admission.

Ourstudyhasseveral limitations. Ideally,wewould have studied the effect of eachof the components of the pathway bystaggering the initiation of each com-ponent or by assessing the variouscomponents in different study groupsaspart of a randomized control trial.However, given the serious safety eventsthat prompted the change in care forthese patients, we felt it was necessaryto implement these changes immedi-ately for the entire patient population tomaximize the likelihood that all patientsreceived prompt therapy. In addition, theblunt measurement of our balancemeasures does not allow us to fullyassess parental satisfaction. Finally,this study was conducted at a singleinstitution and represents changesin practice that may vary in other set-tings.

CONCLUSIONS

Neonates with hyperbilirubinemia whowere treated after the implementationof a clinical pathway in our ED receivedinitiation of phototherapy earlier andhad reduced length of stay.

REFERENCES

1. US Department of Health and Human Serv-ices. 2009 national statistics. All ED visits forhemolytic jaundice and perinatal jaundice.Healthcare Cost and Utilization Project WebSite, HCUPnet. Available at: http://hcupnet.ahrq.gov/. Accessed April 11, 2012

2. Centers for Disease Control and Prevention.Kernicterus in full-term infants–United States,1994–1998. JAMA. 2001;286(3):299–300

3. Bhutani VK, Johnson L. Synopsis report fromthe pilot USA Kernicterus Registry. J Peri-natol. 2009;29(suppl 1):S4–S7

4. Mollen TJ, Scarfone R, Harris MC. Acute, se-vere bilirubin encephalopathy in a newborn.Pediatr Emerg Care. 2004;20(9):599–601

5. American Academy of Pediatrics Subcommittee onHyperbilirubinemia. Management of hyperbiliru-binemia in the newborn infant 35 or more weeksof gestation. Pediatrics. 2004;114(1):297–316

6. Chern JJ, Macias CG, Jea A, Curry DJ,Luerssen TG, Whitehead WE. Effectiveness ofa clinical pathway for patients with cere-brospinal fluid shunt malfunction. J Neuro-surg Pediatr. 2010;6(4):318–324

7. Larsen GY, Mecham N, Greenberg R. An emer-gency department septic shock protocol andcare guideline for children initiated at triage.Pediatrics. 2011;127(6). Available at: www.pe-diatrics.org/cgi/content/full/127/6/e1585

8. Leslie GI, Philips JB III, Cassady G. Capillary andvenous bilirubin values. Are they really differ-ent? Am J Dis Child. 1987;141(11):1199–1200

9. Suresh GK, Clark RE. Cost-effectiveness ofstrategies that are intended to preventkernicterus in newborn infants. Pediatrics.2004;114(4):917–924

e1694 WOLFF et al at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from

Page 9: Management Clinical Pathway Hyperbilirubinemia

DOI: 10.1542/peds.2012-1156; originally published online November 12, 2012; 2012;130;e1688Pediatrics

John ZorcMargaret Wolff, Dana Aronson Schinasi, Jane Lavelle, Naomi Boorstein and Joseph

Care Using a Clinical PathwayManagement of Neonates With Hyperbilirubinemia: Improving Timeliness of

  

ServicesUpdated Information &

htmlhttp://pediatrics.aappublications.org/content/130/6/e1688.full.including high resolution figures, can be found at:

References

html#ref-list-1http://pediatrics.aappublications.org/content/130/6/e1688.full.at:This article cites 7 articles, 2 of which can be accessed free

Subspecialty Collections

orn_infant_subhttp://pediatrics.aappublications.org/cgi/collection/fetus:newbFetus/Newborn Infant

_medicine_subhttp://pediatrics.aappublications.org/cgi/collection/emergencyEmergency Medicinethe following collection(s):This article, along with others on similar topics, appears in

Permissions & Licensing

tmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtables) or in its entirety can be found online at: Information about reproducing this article in parts (figures,

Reprints http://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on April 6, 2014pediatrics.aappublications.orgDownloaded from