Intermountain Healthcare - Salt Lake City, Utah
Universal Bilirubin Screening in Term/Near-Term Well Newborns
Overview: Intermountain Healthcare is a nonprofit health system of 22 hospitals, surgery centers, doctors, and clinics serving Utah and southeastern Idaho. The system's hospitals include 18 birthing facilities and a pediatric subspecialty hospital that does not deliver babies but has a 50-bed neonatal intensive care unit (NICU). More than 32,000 births per year take place at the system's hospitals, constituting about 55 percent of births in Utah; approximately 12 to 14 percent of these babies are admitted to the NICU.
Clinical jaundice is one of the most common problems encountered in pediatrics: 50 to 60 percent of all newborns have jaundice, which most often is benign. However, neurotoxic levels of bilirubin in the bloodstream during the first week of life can progress to hyperbilirubinemia, and, in rare cases, bilirubin encephalopathy (brain disease) and ultimately, kernicterus (brain damage). Newborn bilirubin levels typically do not peak until sometime between the third and fifth day of life. But over the past decade, the hospital stay for most newborn babies and their mothers has diminished to between 24 and 48 hours of childbirth. In early 2002, Intermountain clinicians realized that several cases of hyperbilirubinemia in term/late-preterm newborns had occurred. They concluded that they needed to have a baseline bilirubin and for high-risk cases, a follow-up (the latter usually occurs after discharge) to optimally assess and identify newborns at risk for jaundice. With 75 percent of well newborns having at least one risk for hyperbilirubinemia, it made sense to screen all babies prior to discharge and as appropriate per guidelines set forth by the American Academy of Pediatrics. By summer 2002, Intermountain implemented its Universal Bilirubin Screening in Term/Near-Term Well Newborns program in several urban sites, and in all sites by February 2003. The goal was to reduce hyperbilirubinemia cases in healthy-term infants by 50 percent through a universal newborn bilirubin screening guideline by December 2003.
Impact: Intermountain has drastically reduced the number of babies that develop a bilirubin level greater than 20 or 25. These levels were targeted based on input from the system's neonatologists and pediatricians. While bilirubin levels greater than 20 dropped initially and then rose somewhat again over time, bilirubin levels greater than 25 decreased markedly and the decrease has been sustained. No inborn babies have reached a bilirubin level of 30 or had documented kernicterus. This represents a significant reduction in risk/morbidity, so the program has been well worth the effort. Intermountain started this program prior to the Joint Commission listing bilirubin levels of 30 or greater as a sentinel event.
Challenges/success factors: It was incredibly difficult to get patients to bring babies back for the follow-up screening after discharge, and difficult to convince pediatric providers that this made a difference. Many physicians thought they could tell by looking at babies if they were jaundiced, and this doesn't work-especially with non-Caucasian babies. The fact that some babies develop jaundice and have no risk factors makes it even more difficult. The outpatient follow-up piece continues to be the most challenging, specifically, getting follow-up bilirubin levels done and plotted, and communicating results to the correct pediatric provider.
Future direction/sustainability: The system has a bilirubin Web tool for tracking, and most pediatric providers in Intermountain's system have access to the tool. They are expanding IS support so all providers will be able to access the tool. Ultimately, they need an electronic medical record so that any emergency department provider or pediatric provider can access the neonatal history and baseline bilirubin levels performed in the hospital, no matter where a baby is taken for the follow-up bilirubin screening. They also would like to have an alert to remind physicians about the second bilirubin check. Currently, they are developing one multipurpose form that would include the bilirubin result from the first test and would be used as a referral for the second lab without needing a physician's referral.
Advice to others: Clearly define how follow-up is to be done and with whom it is to be communicated. Many families name a pediatric provider in the hospital and then see a different provider post-discharge, making it difficult to ensure that at-risk babies get adequate follow-up care. Intermountain addresses this challenge by making the pediatric provider in the hospital responsible for post-discharge follow-up. In addition, assess how lab volumes will be affected and coordinate carefully. Intermountain's volume of outpatient labs increased, so they expanded their outpatient lab hours. Finally, the AAP's recommended follow-up schedule for babies discharged from hospital at 72 hours of age or less has been hard for many physicians to implement in their offices. The standard clearly defines that those babies should be evaluated within 48 to 72 hours of discharge. Making that culture change has been hard and requires buy-in from the physicians.
Contact: Janie Wilson, MS, RN
Operations Director, Women & Newborns Clinical Program
Telephone: (801) 442-2964
Contact: Larry D. Eggert, MD, FAAP, FACN
System Medical Director, Neonatology
Women & Newborns Clinical Program
Telephone: (435) 688-5447