Utilizing Risk Stratification to Optimize Outcomes for Neonates Admitted with Hyperbilirubinemia for Phototherapy.



Primary Author: Stranberg, Adam DO

Mentor: Gonzalez, Amy MD

Objective:

The aim of this quality improvement project was to implement a hyperbilirubinemia protocol on the UTMB Pediatric Inpatient floor based on a clinical calculator for determining risk of rebound hyperbilirubinemia in infants admitted for first time phototherapy to reduce phlebotomies while hospitalized and decrease need for bilirubin clinic follow-ups.

Abstract:

The American Academy of Pediatrics has standardized guidelines for initiation of phototherapy in infants, but no guidelines on discontinuation and risk stratification after phototherapy. Rebound hyperbilirubinemia is defined as the return of hyperbilirubinemia to phototherapy threshold within 72 hours of phototherapy discontinuation.  Current practice at UTMB is to assess the risk of rebound hyperbilirubinemia based on obtaining a rebound serum bilirubin result 6 hours after discontinuation of phototherapy. Chang et. al. developed a clinical calculator for determining the risk of rebound hyperbilirubinemia in infants, which utilizes gestational age, age when phototherapy was initiated and distance from phototherapy threshold at phototherapy discontinuation. 1 We instituted a hyperbilirubinemia protocol in our pediatric inpatient unit utilizing this clinical calculator to standardize discontinuation of phototherapy in order to reduce phlebotomies while hospitalized and decrease need for bilirubin clinic follow-ups.

After implementation of this protocol, we reviewed all 143 healthy infants admitted from April 2019 through March 2021, one year prior and one year after initiation of our protocol in March of 2020.

We utilized the following equation when bilirubin is < 14 mg/dl to determine when phototherapy can be discontinued.

50 + 15 (if gestational age <38 weeks) – 7 * (age in days at phototherapy initiation) – 4 * (AAP threshold at termination – bilirubin at termination) = X

Target score (X) is < 20, which correlates to less than a 4% risk of rebound hyperbilirubinemia.  In combination with clinical decision making, suggests phototherapy can be safely discontinued without a need for rebound serum bilirubin levels or follow-up for hyperbilirubinemia in clinic.

References:

1 Chang, P. W., Kuzniewicz, M. W., McCulloch, C. E., & Newman, T. B. (2017). A Clinical Prediction Rule for Rebound Hyperbilirubinemia Following Inpatient Phototherapy. Pediatrics, 139(3), e20162896.

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