Decreasing Newborn Readmissions for Hyperbilirubinemia

Abstract

Purpose for the Program Hyperbilirubinemia is the most common indication for hospital readmission of term and late preterm infants. In reviewing our performance, we identified a 12‐month rolling readmission rate of 2.43%, which was greater than the 1.50% benchmark of other large teaching hospitals. Analysis of our data revealed that 25% of newborn readmissions were for hyperbilirubinemia. In an effort to reduce readmission rates, we identified opportunities to update and standardize assessment and management of hyperbilirubinemia. Proposed Change Our previous practice was to perform a transcutaneous bilirubin test at age 30 hours and to notify the infant care provider only if the infant fell into the high‐risk zone (95th percentile per the Bhutani nomogram). Subsequent testing and treatment was determined by the individual care provider, and there were no standard nursing interventions. A multidisciplinary task force was established to develop and implement an algorithm based on current evidence that focused on assessment, early identification of at‐risk infants, early implementation of interventions, and consistent outpatient management. Simultaneously with this work our facility was implementing the 10 Steps to Successful Breastfeeding in preparation for achieving Baby Friendly Hospital designation. The task force hoped to take advantage of the work in progress to support breastfeeding because a major risk factor for hyperbilirubinemia is inadequate breastfeeding. Implementation, Outcomes, and Evaluation We utilized the plan, do, study, act (PDSA) model to develop and implement the new algorithm. After four cycles with draft algorithms, we agreed on the final version. Nurses and physicians were educated on the algorithm, and it was implemented throughout the newborn service. Physician task force members also educated their peers on criteria for readmission and use of the online BiliTool to standardize treatment. The rolling 12‐month readmission rate in July 2014 was 1.89% which represents a 23% decrease. In evaluating our successful practice changes, we anticipate a continued decrease in the rolling 12‐month rate. The task force continues to review monthly data and analyze the effectiveness of interventions. Implications for Nursing Practice Nurses manage the care of hospitalized newborns and are responsible for assessing newborns, collaborating with health care providers, and implementing interventions, especially those that facilitate successful breastfeeding. The use of this algorithm standardizes practice to ensure that every infant receives appropriate evaluation of risk and intervention to avoid significant hyperbilirubinemia. Hyperbilirubinemia is the most common indication for hospital readmission of term and late preterm infants. In reviewing our performance, we identified a 12‐month rolling readmission rate of 2.43%, which was greater than the 1.50% benchmark of other large teaching hospitals. Analysis of our data revealed that 25% of newborn readmissions were for hyperbilirubinemia. In an effort to reduce readmission rates, we identified opportunities to update and standardize assessment and management of hyperbilirubinemia. Our previous practice was to perform a transcutaneous bilirubin test at age 30 hours and to notify the infant care provider only if the infant fell into the high‐risk zone (95th percentile per the Bhutani nomogram). Subsequent testing and treatment was determined by the individual care provider, and there were no standard nursing interventions. A multidisciplinary task force was established to develop and implement an algorithm based on current evidence that focused on assessment, early identification of at‐risk infants, early implementation of interventions, and consistent outpatient management. Simultaneously with this work our facility was implementing the 10 Steps to Successful Breastfeeding in preparation for achieving Baby Friendly Hospital designation. The task force hoped to take advantage of the work in progress to support breastfeeding because a major risk factor for hyperbilirubinemia is inadequate breastfeeding. We utilized the plan, do, study, act (PDSA) model to develop and implement the new algorithm. After four cycles with draft algorithms, we agreed on the final version. Nurses and physicians were educated on the algorithm, and it was implemented throughout the newborn service. Physician task force members also educated their peers on criteria for readmission and use of the online BiliTool to standardize treatment. The rolling 12‐month readmission rate in July 2014 was 1.89% which represents a 23% decrease. In evaluating our successful practice changes, we anticipate a continued decrease in the rolling 12‐month rate. The task force continues to review monthly data and analyze the effectiveness of interventions. Nurses manage the care of hospitalized newborns and are responsible for assessing newborns, collaborating with health care providers, and implementing interventions, especially those that facilitate successful breastfeeding. The use of this algorithm standardizes practice to ensure that every infant receives appropriate evaluation of risk and intervention to avoid significant hyperbilirubinemia.