Lehigh Valley Health NetworkLVHN Scholarly Works

USF-LVHN SELECT

Inpatient Pediatrics Hyperbilirubinemia Pathway:Initial Pilot DataLora BojilovaUSF MCOM- LVHN Campus, Lora.Bojilova@lvhn.org

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Published In/Presented AtBojilova, L. (2018, March). Inpatient Pediatrics Hyperbilirubinemia Pathway: Initial Pilot Data. Poster Presented at: 2018 SELECTCapstone Posters and Presentations Day. Kasych Family Pavilon, Lehigh Valley Health Network, Allentown, PA.

© 2018 Lehigh Valley Health Network

Background

Methodology Conclusions

Results

The product of this project is a clinical pathway for the evaluation and management of hyperbilirubinemia in the inpatient pediatrics unit at LVHN (Figure 2). This pathway consists of a change in the method of phototherapy delivery to maximize body surface area exposure, standardized nursing and physician protocols, and an accompanying EMR order set (Figure 3). Within the first two months, it was utilized in the care of twelve infants. Data was collected via chart review, with results shown in Figure 4.

Problem Statement

The goal of instituting a standardized approach to the identification and management of hyperbilirubinemia in term and near-term newborns is to reduce the incidence of severe hyperbilirubinemia, reduce variability in practice, optimize the delivery of phototherapy, improve safety and clinical outcomes, and decrease cost pertaining to hospital length-of-stay, laboratory testing, and other hospital resources.

Phas

e 1:

Def

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Phas

e 2:

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reat

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ase

3:

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4:

Sust

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Map current process for

management of diagnosis/episode

of care

Identify baseline data for current management

processPreliminary Chart Review

Stakeholders determine

Priority

Identify clinical opportunity for improvement

Develop Pathway Team

Peds Hospitalist, 1 medical student, 3 Peds

Residents, 3 Nursing Staff Representatives

Complete Capstone Project

Proposal and Clinical Pathway

Charter

Tollgate #1: CH PQIC07.23.17

Review Literatureand Best Practices

Identify EntryCriteria and

Scope

Create PathwayAlgorithm

09/13/17 – Meeting with Pediatric Hospitalists

Identify Metrics and Develop

Evaluation Plan

Tollgate #2: CH PQIC09.22.17

Identify Tools to Enable Pathway

Creation of Accompanying Order

Set

INCLUSION CRITERIA:1) GA >/= 35 wks2) Previously healthy3) Age </= 14 days4) TSB at or above threshold

for initiation of phototherapy

EXCLUSION CRITERIA:1) Direct byperbili2) Rectal temp >/= 100.4 or

signs of infection3) Meeting NICU criteria

Staff Training and

Implementation Plan

Tollgate #3: CH PQIC12.06.17

Multidisciplinary meetings with:• Products Committee for approval of new supplies (e.g. multi-use curtains)

• Mother infant Care Committee (week prior to 10.03/17) to present changes to be made to phototherapy policy (to cover inpatient wards, newborn nursery, and mother/baby unit)

• Clinical Consensus Committee Work Group (10.18.17) to address findings of preliminary chart review

Develop plan for monitoring

metrics and data collection

Enterprise Analytics

METRICS:1) Dec length of stay2) Dec percentage readmitted

within 48 hours3) Dec percentage

inappropriately receiving phototherapy

4) Inc provider compliance with pathway

Developed Nursing Education (didactic session, TLC education for RN review,

hands-on training for phototherapy set-up) & Pediatrics Resident Education (01.03.18

– didactic presentation with Q&A)

Quarterly Updates

presented at CH PQIC

Add Pathway to Policy Tech

11.08.17 – Care Pathway Form

Submitted

Phototherapy Pilot and Pathway

Go-Live01.01.18

Operationalize Metric Evaluation

Plan

4 Phases to Implementing Clinical Pathways

• Hyperbilirubinemia is a common cause of hospital admission in neonates.

• Severe hyperbilirubinemia can lead to acute bilirubin encephalopathy and kernicterus, a form of irreversible neurological damage.

• The current AAP Clinical Practice Guideline emphasizes the importance of a universal, systematic assessment of hyperbilirubinemia and the provision of prompt intervention, when needed.

• Several large children’s hospitals including CHOP and Seattle Children’s have established clinical pathways using the AAP guideline.

• Seattle Children’s Hospital found that a standard care pathway for neonatal jaundice can reduce cost and length of stay.

• LVHN has nearly 4,500 deliveries annually and the Children’s Hospital has 30 pediatric-specific subspecialties and a level IV NICU.

• A hyperbilirubinemia pathway does not currently exist at LVHN. • A retrospective chart review indicated that 52% of infants admitted

to the inpatient pediatric unit were inappropriately admitted for phototherapy and, of those, 52% lacked another outstanding reason for admission.

The completion of the project involved closely working with CH PQIC to create the clinical pathway. Figure 1 illustrates the steps in this process, from conception to approval. The pathway was available for use on 01/01/18 and was made live on the hospital network on 02/01/18. Finally, a post-pathway retrospective chart review was conducted on two months of pilot data.

Data and feedback from January and February 2018 suggest that:• The pathway seems practical for use and feasible to follow,• Triple phototherapy delivered in a way to maximize body surface area exposure appears to be

effective in lowering bilirubin and does not appear to adversely affect temperature stability,• There is an increase in documentation of neurotoxicity risk level in the EMR,• There is an increase in appropriate stratification of neurotoxicity risk, and• There is an increase in treatment of babies who met criteria for phototherapy and a decrease in

treatment of babies who did not meet criteria.Reduction in inappropriate treatment initiation suggests that the pathway may decrease unnecessary admissions, which may decrease exposure to HAIs in a vulnerable population, improve overall patient outcomes, and decrease healthcare costs.

Next Steps

• Further data collection and analysis• Development of a process for data collection and tracking of outcome metrics with Enterprise

Analytics • Creation of EMR note templates and dot phrases to be shared with the network’s providers• Creation of an educational outreach component to be distributed to the network’s providers• Completion of newborn nursery unit hyperbilirubinemia pathway (currently in the development stage)

Lehigh Valley Health Network, Allentown, PA

Inpatient Pediatrics Hyperbilirubinemia Pathway:Initial Pilot Data

Lora Bojilova, Mentor: Kristen Prendergast, MD

Pathway Creation Process

Figure 2.

Figure 1. Flowchart depicting steps taken in the creation of hyperbilirubinemia pathway. Included in this process are multidisciplinary meetings, Children’s Performance and Quality Improvement Committee (CH PQIC) meetings, and the creation of inclusion and exclusion criteria and metrics. Flowchart was adapted from LVHN’s CH PQIC “Summary Process of Pathway Creation” form.

Figure 3.

Figure 4. Comparison of babies admitted before and after 01/01/18. 2017 data has N = 68. 2018 data has N = 12.

Appropriate Initiation of PhototherapyPost-Pathway

Appropriate Initiation of PhototherapyPre-Pathway

Neurotoxicity Risk StratificationPost-Pathway

Neurotoxicity Risk StratificationPre-Pathway