2/14/2017

1

Preventing Newborn Readmissions for Hyperbilirubinemia

Rainey Martin, MSN, RN, AGCNS-BC, RNC-OB Perinatal Clinical Nurse Specialist

March 2017

• 6 regions of care in Central Indiana: East, West, South, & North Indianapolis, Anderson, Kokomo

Community Health Network

Community Health Network – Maternity Services

• Tertiary Care Center • CHN: 3800 deliveries/year

• Level 2 hospitals • CHS: 1800 deliveries/year

• CHE: 1000 deliveries/year

• CHA: 900 deliveries/year

• CHRH: 500 deliveries/year

2/14/2017

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Objectives

• List 3 risk factors for newborn hyperbilirubinemia

• Describe 2 nursing interventions to decrease the risk of a newborn readmission for hyperbilirubinemia

• Describe the creation of one concise algorithm from multiple references and resources to guide clinical decision making

• Bilirubin is a by-product of RBC and hemoglobin breakdown

• Bilirubin binds to albumin and is carried to the liver

• Immature liver of a newborn can’t conjugate bilirubin—can’t make it water soluble so it is easily eliminated from the body

• Unconjugated bilirubin re-enters the bloodstream and can cross the blood-brain barrier, where it can cause minor to life-threatening CNS effects

• Kernicterus-permanent neurophysiologic outcome of bilirubin toxicity in newborns

(Wells, et al., 2013)

Patho Review of Hyperbilirubinemia

• Jaundice

• Shrill cry, inconsolable

• Lethargy

• Apnea

• Deafness

• Mental Disability

• Seizures

• Cerebral Palsy

• Death

Possible Effects of Hyperbilirubinemia

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• Complaints from parents and lactation staff • 57 newborn readmissions in 2014 at CHN (44 OBS) • 1.45% readmission rate is more than double the

benchmark rate of 0.75% (Waldrop, et al., 2013) • Estimated loss of $204,610 to the network due to

newborn jaundice readmissions • American Academy of Pediatrics (AAP) “Guidelines for

the management of hyperbilirubinemia in the newborn infant 35 or more weeks’ gestation” not fully implemented at CHNw

• Neonatal jaundice is a major cause of readmissions, accounting for up to 85% of newborns hospitalized in the first week of life (Goulet, et al., 2006)

Cause for Action

• 16 providers (pediatricians, neonatologists, pediatric hospitalists, family medicine) responded

• 100% of providers reported assessing for risk factors for jaundice, but only 43% reported that the presence of risk factors was used to help determine treatment and outpatient follow up

• 87.5% reported that the bili level at discharge was the primary and sometimes only criteria used to determine necessary follow up

Survey of Current Practice

• Literature Review

• Chart Reviews of jaundice readmissions in 2014

• Multi-disciplinary team assembled

• Nursing Director

• Nurse Manager/CNS Student

• Physician Chair of Pediatric Department

• Private Practice Pediatrician

• Pediatric Hospitalist

• CNS

Identification of Opportunities

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• Implement use of algorithm to guide nursing and medical decision making for the management and treatment of hyperbilirubinemia combining:

• AAP guidelines

• Hospital policy and procedures

• Identified best practices in the literature to guide nursing and medical decision making for the management and treatment of hyperbilirubinemia.

Recommendations of the Bili Team

• Laminated and placed in strategic places on the units

• Nurses’ stations

• MD Dictation rooms

• Nurseries

• Education and coaching of nursing and medical staff on algorithm and Bilitool.org link in Epic

Jaundice Algorithm

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• Incorporate the AAP risk assessment for severe hyperbilirubinemia into nursing documentation in the electronic medical record

• Require nursing to perform the risk assessment once per shift

Recommendations from Bili Team

• Institute in-room phototherapy for the treatment of hyperbilirubinemia to support breastfeeding, a major risk factor and a characteristic found in 100% of readmissions for hyperbilirubinemia at CHNw

Recommendations from Bili Team: Work in Progress

• Standardize discharge instructions for jaundice for all infants

• Encourage post-discharge outpatient lactation visits for at risk newborns

Recommendations from Bili Team: Work in Progress

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• Successful implementation has led to decreased newborn readmission rates at CHNw (Inpatient and OBS)

• 48% reduction in newborn readmissions for hyperbilirubinemia across 3 sites of care

• $71,391 in estimated direct cost savings on jaundice readmissions for CHNw in 2016, as compared to 2015

Results

Results: CHN

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

Newborn Readmission Rate Jaundice Readmission Rate (IP & OBS)

Linear (Jaundice Readmission Rate (IP & OBS))

Jaundice algorithm go live

5/1/2015

Results: CHE

-1.00%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Newborn Readmission Rate Jaundice Readmission Rate (IP & OBS)

Linear (Jaundice Readmission Rate (IP & OBS))

Jaundice algorithm go live 6/1/2015

2/14/2017

7

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Newborn Readmission Rate Jaundice Readmission Rate (IP & OBS)

Linear (Jaundice Readmission Rate (IP & OBS))

Results: CHS

Jaundice algorithm go live 12/1/15

Questions & Discussion

Alkalay, A.L., Bresee, C.J., & Simmons, C.F. (2010). Decreased neonatal jaundice readmission rate after implementing hyperbilirubinemia guidelines and universal screening for bilirubin. Clinical Pediatrics. 49(9), 830-833.

Alkalay, A.L. & Simmons, C.F. (2005). Hyperbilirubinemia guidelines in newborn infants (Letter to the editor). Pediatrics. 115(3), 824-825.

Allen, M., Strohecker, M.L., & Maurer, P. (2012). “Mom, I’m yellow”: An evidence-based initiative to reduce risks of newborn hyperbilirubinemia and hospital readmissions. Journal of Obstetric, Gynecologic, and Neonatal Nurses. 41(3), S146-S147.

Bhutani, V.K., Johnson, L. H., Schwoebel, A, & Gennaro, S. (2006). A systems approach for neonatal hyperbilirubinemia in term and near-term newborns. Journal of Obstetric, Gynecologic, and Neonatal Nurses. 35(4), 444-455.

Gennaro, S., Schwoebel, A., Hall, J.Y., & Bhutani, V.K. (2006). Hyperbilirubinemia: Identification and management in the healthy term and near-term newborn, 2nd edition. Washington, D.C.: Association of Women’s Health, Obstetric, and Neonatal Nurses.

Goodhue, C.J., and Wang, K.S. (2013). Persistent hyperbilirubinemia in a newborn. Journal of Pediatric Health. 28(2), 172-176.

Goulet, L., Fall, A., D’Amour, D., & Pineault, R. (2007). Preparation for discharge, maternal satisfaction, and newborn readmission for jaundice: Comparing postpartum models of care. Birth. 34(2), 131-139.

Madden, J.M., Soumerai, S.B., Lieu, T.A., Mandl, K.D., Zhang, F., & Ross-Degnan, D. (2004). Length of stay policies and ascertainment of postdischarge problems in newborns. Pediatrics. 113(1), 42-49.

Management Of Hyperbilirubinemia In The Newborn Infant 35 Or More Weeks Of Gestation. (2004). Pediatrics, 114(1), 297-316.

Moerschel, S.K., Cianciaruso, L.B., and Tracy, L.R. (2008). A practical approach to neonatal jaundice. American Family Physician. 77(9), 1255-1262.

Montes, M. & Notario, L. (2012). Two phase innovative approach to newborns at risk of hyperbilirubinemia. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 41(3), S44.

Nelson, L., Doering, J.J., Anderson, M., and Kelly, L. (2012). Outcome of clinical nurse specialist-led hyperbilirubinemia screening of late preterm newborns.

Clinical Nurse Specialist. 26(3), 164-168.

Rodriguez, M., Backus, A., Watson, C. Mannel, R., & Frye, D. (2006). Kernicterus as a never event: a hospital system approach and the role of the childbirth educator. International Journal of Childbirth Education. 21(1), 4-10.

Seagraves, K., Brulte, A., McNeely, K., &Prithman, U. (2014). Supporting breastfeeding to reduce newborn readmissions for hyperbilirubinemia. Nursing for Women’s Health. 17(6), 498-507.

Schwarts, H.P., Haberman, B.E., & Ruddy, R.M. (2011). Hyperbilirubinemia: Current guidelines and emerging therapies. Pediatric Emergency Care. 27(9), 884-889.

Simmons, S. (2011). Hyperbilirubinemia in neonates: prevention, early identification, and treatment. Advances in Neonatal Care. 11(5S), S22-S27.

Szucs, K.A., and Rosenman, M.B. (2013). Family-centered, evidenced-based phototherapy delivery. Pediatrics. 131(6), e1982-e1985.

Universal Screening for Hyperbilirubinemia (2010). Journal of Obstetric, Gynecologic, and Neonatal Nurses. 39(1), 83-84.

Waldrop, J.B., Anderson, C.K., & Brandon, D.H. (2013). Guideline-based educational intervention to decrease the risk for readmission of newborns with severe hyperbilirubinemia. Journal of Pediatric Health Care. 27(1), 41-50.

Wells, C., Ahmed, A., and Musser, A. (2013). Strategies for neonatal hyperbilirubinemia: a literature review. Maternal Child Nursing. 38(6), 377-382.

References