Total Serum Bilirubin Testing Research Articles

Decreasing Bilirubin Serum Tests in Healthy Newborns During Birth Hospitalization.

Substantial variability exists in hyperbilirubinemia screening and monitoring leading to unnecessary total serum bilirubin (TSB) testing in healthy newborns. We aimed to assess the impact of value-care interventions to decrease the monthly TSB testing rate per 100 patient-days among healthy newborns in our Mother-Baby Unit by 30% by June 2022. We formed a multidisciplinary team to review the current practice for ordering TSB among housestaff in our Mother-Baby Unit. We identified several themes: variation in clinical practice, fear of hyperbilirubinemia, and desire to act for high-intermediate risk bilirubin levels. The interventions consisted of obtaining faculty buy-in, redesigning the hyperbilirubinemia pathway, educating staff on high value-care, producing an instructional video, and prompting staff to incorporate a bilirubin risk assessment via smart phrases in our electronic health record. The primary outcome was the monthly TSB testing rate per 100 patient-days. Universal predischarge bilirubin screening, length of stay, phototherapy rates, and readmission rates were chosen as balancing measures. The monthly rate of TSB testing was reduced from 51 to 26.3 TSB per 100 patient-days, representing a 48% reduction. This improvement was sustained for 12 months. The percentage of infants with at least 1 TSB measurement during birth hospitalization decreased from 48% to 30%. Predischarge bilirubin screening, length of stay, and readmission rates were unchanged. Our quality improvement initiative led to a significant reduction in the monthly TSB testing per 100 patient-days in healthy newborns without evidence of harm.

KRAMERS RULE AS A SCREENING TEST TO ASSESS NEONATAL HYPERBILIRUBINEMIA

Background: neonatal jaundice is a frequently encountered condition in the postnatal ward. If not treated properly, it can lead to permanent neurological sequelae. The gold standard investigation for diagnosis is total serum bilirubin (TSB)level. Transcutaneous bilirubinometers and visual assessment of cephalo-caudal progression of yellowish discoloration of neonatal skin by Kramers rule are commonly used non-invasive methods to predict jaundice. If correctly applied, these methods can help in minimising the number of blood samples to be drawn for TSB testing. Aims/Objectives:1. To assess the reliability of Kramers rule in predicting TSB in healthy neonates admitted in postnatal ward. 2. To assess theusefulness of Kramers rule in deciding which neonates require testing of TSB levels. Methods: This is a cross sectional study conducted on 100 healthy neonates admitted in the post-natal ward of a tertiary care hospital. Data was collected in pre-designed case record sheets. Sensitivity and specificity of Kramers rule in correct prediction of serum bilirubin was identified by using true and false outcomes. Results:The mean age at which neonates were examined was at 72 hours of life. 41% of the neonates were male and 59% were female.79% of the total babies were born via normal vaginal delivery and 21% via caesarean section.The sensitivity of Kramers rule in predicting serum bilirubin levels was 83.33% with a specificity of 54.55% (P value 0.015). Conclusion: Kramers rule is a fairly reliable method for predicting serum bilirubin levels and can help in avoiding unnecessary blood testing in neonates, especially in resource limited settings where such facilities might not be available.

Implementation of a neonatal transcutaneous bilirubin screening programme in rural India

Background: Universal pre-discharge assessment of risk for neonatal hyperbilirubinaemia is recommended by the American Academy of Pediatrics. A common algorithm is universal transcutaneous bilirubin (TcB) screening, followed by confirmatory total serum bilirubin (TSB) testing for results which cause concern. There is a paucity of data on the feasibility of TcB screening in low-income settings. Objectives: To evaluate the acceptability and feasibility of implementing universal TcB screening at a resource-limited hospital in rural India, and to determine if it was associated with increased recognition of high-risk hyperbilirubinaemia. Methods: In December 2012 at Vivekananda Memorial Hospital, Karnataka, India, universal TcB screening at 24–48 hours of life was implemented, with TSB estimated if TcB was >75th percentile for age. The proportion of families that provided consent and the proportion of infants who underwent TcB and TSB testing were calculated. The rates of phototherapy pre- and post-implementation and the rate of high-risk hyperbilirubinaemia (TSB >95th percentile for age) post-implementation among infants ≥ 35 weeks gestation were determined. Results: Parents of 568 of 660 (86%) eligible infants consented to participation. All of these infants were screened with TcB. The proportion who had TSB testing was similar in the pre- (6%) and post-implementation (7%) periods. The rate of phototherapy was not significantly different after implementation (2% vs 3%). Five cases of high-risk hyperbilirubinaemia were identified post-implementation. Conclusions: The study demonstrates the acceptability and feasibility of universal TcB screening at a resource-limited hospital in rural India. In settings in which early post-discharge follow-up cannot be assured, TcB can play a valuable role in identifying infants who need evaluation.

‘Halving the heel pricks’: Evaluation of a neonatal jaundice protocol incorporating the use of a transcutaneous bilirubinometer

This study aimed to assess the impact of implementing a new jaundice protocol incorporating the use of the Konica Minolta/Air Shields JM 103 Jaundice Meter (JM103) (Konica Minolta Sensing Inc., Osaka, Japan) in the setting of an Australian post-natal ward. A before-and-after study was completed following the introduction of a protocol integrating the use of the JM103 monitor on to the post-natal ward. Eligible infants were ≥ 36 weeks gestation, > 24 h and < 8 days of age. The number of Total Serum Bilirubin tests (TSBRs) were compared for the 12 months prior (T1) with a 6-month period and 6 months after protocol introduction (T2). Transcutaneous bilirubin (TcBR) results were also collected in T2. Rates of phototherapy and peak TSBRs at commencement were also compared as measures of safety. Four hundred and twenty-six of the 2197 live births in T1 required one or more TSBRs compared with 119 of the 1169 live births in T2. This represents an odds ratio of 0.47 (95% confidence interval 0.38-0.58) for infants in T2 having ≥ 1 TSBR compared with T1. There was no difference between the groups for rates of phototherapy (3.8% vs. 3.0%; P= 0.2) nor any difference between the groups for peak SBR during phototherapy (301.9 µmol/L (standard deviation, SD 58) for T1 vs. 303.2 µmol/L (SD 54) for T2; P= 0.45). The estimated cost saving per year is $6966.00. TcBR measurement in conjunction with our protocol significantly reduces painful procedures and costs without increasing the risk of delaying treatment with phototherapy.

Normal distribution of pre-discharge total serum bilirubin in a culturally diverse cohort of healthy term newborn infants

Objective: To determine the percentile distribution of the pre-discharge total serum bilirubin (TSB) in a culturally diverse cohort of healthy term newborns. Study Design: Pre-discharge TSB values obtained during the first 96 hours of life in term newborn infants with birth weight 2,500 grams and no evidence of isoimmunization and hyperbilirubinemia (prior to and after discharge) were studied with respect to race/ethnic background and gender. The population's mean pre-discharge TSB levels and TSB percentile distribution (40th, 75th, and 95th) of the TSB values at 12-hour intervals were identified and compared with the American Academy of Pediatrics (AAP) recommended TSB nomogram. Descriptive, factorial ANOVA and multivariate regression statistics were used to analyze the results. Results: The study included 751 healthy newborns of which 215 (28.6%) were white, 91 (12.1%) were black, 303 (40.3%) were Hispanic, and 142 (18.9%) were Asian. We found that the pre-discharge TSB values in these term healthy newborns were significantly associated with the age at TSB testing, weight loss and exclusive breastfeeding but not race/ethnicity and gender. The TSB values were mainly in the 40th percentile zone. The numbers of TSBs in the 95th percentile zone varied from 3.2% to 6.4% at the different time points of measurement. After 48 hours of age, there was a discrepancy of 1 to 2 mg/dL as compared to the AAP recommended TSB nomogram. Conclusion: There is race/ethnicity and gender uniformity in the pre-discharge TSB levels of term healthy newborns. The observed discrepancy with the reference data suggests the need for determination of population-specific normal pre-discharge TSB values in each hospital setting for the effective post-discharge surveillance of all eligible infants.

Reduction in Hospital Readmission Rates for Hyperbilirubinemia Is Associated with Use of Transcutaneous Bilirubin Measurements

The use of transcutaneous bilirubin (TcB) measurements would seem to represent an opportunity to decrease the use of laboratory total serum bilirubin (TSB) testing because the former would serve as a surrogate for the latter. Many authors of previous studies have concluded that TcB measurements are useful and can serve as a reliable index for estimating TSB concentrations (1)(2)(3)(4), even in darkly pigmented neonates (5). Although the use of TcB measurements might represent, correspondingly, an opportunity to decrease expenses by decreasing laboratory TSB measurements, such a consequence would be dependent on several factors, including the cost of personnel and reagents for performing the TcB measurements and the number of TcB measurements performed. In addition, the TcB results might impact other caretaker practice behaviors, such as the ordering of TSB measurements and compliance with guidelines for the application of phototherapy, whether used in or outside the hospital, as governed by local practice routines. The newly revised American Academy of Pediatrics (AAP) Clinical Practice Guideline on management of hyperbilirubinemia in the newborn (6) would not necessarily affect or predict the interaction of these factors. In this issue of Clinical Chemistry , Petersen et al. (7) demonstrate that the introduction of TcB measurements for the identification of infants with hyperbilirubinemia was followed by a decrease in the number of hospital readmissions of infants with hyperbilirubinemia per 1000 births/month. However, they found that the interaction of various factors did not contribute to changes in the length of stay for normal newborns and that new costs, in addition to those for TcB measurements, arose from an increased use of laboratory TSB testing and increases in the number …

Indicators nurses employ in deciding to test for hyperbilirubinemia.

To identify the indicators nurses employ in deciding to test healthy full-term newborns for total serum bilirubin in the absence of a written protocol. Secondary analysis of data available on 130 mother-newborn pairs and informal interviews of 30 postpartum unit nurses. Two university teaching hospitals. All tested newborns and a 33% random sample of remaining newborns from a control group data set created during a previous study and a convenience sample of postpartum nurses from all shifts. Outcome data were obtained from a review of records. Background data were obtained from a review of records and questionnaires. Nurse data were obtained through a modified form of participant observation. Ninety-one percent of newborns tested for bilirubin were tested unnecessarily. In logistic regression analyses, variables predictive of nurse-driven total serum bilirubin testing were presence of jaundice, odds ratio (OR) = 31.95 (95% confidence interval, 6.71, 152.03), and feeding frequency, OR = 0.28 (0.11, 0.72). Identifying both presence and location of jaundice simultaneously did not significantly predict testing, OR = 1.82 (0.66, 5.04). Fifty-three percent of nurses who were interviewed identified both the presence of jaundice and feeding as indicators to consider for testing. Newborns are overtested for bilirubin. Indicators used by nurses in deciding to test a healthy newborn for total serum bilirubin are the presence of jaundice and feeding frequency. Nurses who assess feeding frequency are less likely to order bilirubin testing.

Home Health Nurse Clinical Assessment of Neonatal Jaundice

To compare 3 methods of clinical assessment of jaundice in newborns by home health nurses. Prospective clinical trial. Homes of newborns living within 10 miles of a 340-bed community hospital where they were delivered. Home health nurses and newborn patients (< or =2 weeks old). The nurses examined the newborns and documented whether they detected jaundice. In newborns thought to have jaundice, the nurses estimated bilirubin levels, documented the extent of caudal progression of the jaundice, and determined the Ingram (Cascade Health Care Products, Salem, Ore) icterometer readings from the newborns' noses. Total serum bilirubin tests were obtained from all newborns studied. Nurse assessment of the presence of jaundice and its caudal progression, nurse estimates of bilirubin levels, icterometer readings, and bilirubin levels. The nurses determined that 82 (50%) of the 164 newborns had jaundice. Their estimates of bilirubin levels were most highly correlated with serum bilirubin levels (Pearson correlation, 0.61). All 3 newborns with bilirubin levels greater than or equal to 291 micromol/L (> or =17 mg/dL) were recognized by the nurses as having jaundice. These newborns had icterometer readings greater than or equal to 3.5 and had estimated bilirubin levels of greater than or equal to 274 micromol/L (> or =16 mg/dL). The method of evaluation that each nurse was accustomed to using was the most accurate in determining the severity of newborn jaundice. These results suggest that postpartum home health nurses can effectively evaluate newborns for the presence and severity of jaundice.

An Evaluation of Factors Influencing the Discriminative Effectiveness of a Group of Liver Function Tests

Summary An evaluation has been made of the relative effectiveness of nine representative liver function tests in differentiating between a group of patients with cirrhosis and a group of normal subjects. The Bromsulfalein test was the most effective single test. The intravenous galactose tolerance and hippuric acid tests were approximately three-fourths as effective as the Bromsulfalein test; the zinc sulfate turbidity, 24-hour urine coproporphyrin, and per cent cholesterol ester tests were approximately three-fifths as effective; and the 24-hour urine urobilinogen, thymol turbidity, and total serum bilirubin tests were approximately two-fifths as effective. After allowing for interdependence among the tests, only four tests—the Bromsulfalein, zinc turbidity, hippuric acid, and urine coproporphyrin—were found to contribute independently to the discrimination between the normal and cirrhotic groups. The other five tests made little contribution beyond that already represented in the four independently significant tests. A weighted linear combination of these four tests, called the cirrhosis abnormality score, was significantly, though not greatly, more effective than the Bromsulfalein test alone for purposes of group distinction. It also misclassified fewer abnormal individuals. The independent contribution of the Bromsulfalein test to the optimal combination was one and one-half times that of the coproporphyrin test and two and one-half times that of the zinc turbidity and hippuric acid tests.