P3.F108: Local Perspectives of Project LIGHT: Learning and Implementing Guidelines in Hyperbilirubinemia Treatment

Purpose/Objectives: Neonatal hyperbilirubinemia is among the most common newborn conditions requiring intervention. However, recent evidence demonstrates overtreatment with phototherapy, with subsequent increased seizure risk in males, prolonged hospitalizations, and increased healthcare costs. Therefore, in 2022 the AAP updated its clinical practice guidelines for management of neonatal hyperbilirubinemia. This project is adapted from AAP Project LIGHT, a quality improvement project established through the AAP value in pediatrics (VIP) initiative with the global aim to improve evidence-based management of infants receiving inpatient phototherapy. Among the national project’s multiple aims, this adaptation presents the specific aims to decrease subthreshold phototherapy to less than 10% in 1 year and to decrease unnecessary rebound testing to less than 10% in 1 year.

Design/Methods: This project was set in a tertiary, academic children’s hospital caring for over 2000 well infants annually. Interventions included education, updated hospital clinical pathways, and updated electronic medical record (EMR) resources. Live and virtual educational sessions, adapted from webinars through the AAP VIP initiative and iteratively changed with each PDSA cycle, were conducted for providers and staff throughout the Department of Pediatrics. Clinical pathways were updated with site-specific protocols for bilirubin screening, phototherapy, newborn feeding, and escalation of care (EOC). EMR updates included new bilirubin nomograms, order sets, and documentation templates.

Outcome measures highlighted in this adaptation include, among all infants receiving inpatient phototherapy, the proportion of infants treated with subthreshold phototherapy and the proportion of low-risk infants receiving early rebound testing. Balancing measures include the incidence of reaching EOC threshold, incidence of TSB >25 mg/dL, duration of phototherapy and hospitalization, and incidence of readmission or phototherapy reinitiation. Data was derived from EMR query and confirmed with manual chart review of all infants who received inpatient phototherapy. Raw data was used where discrepancies existed. Only local data was analyzed, utilizing the AAP Quality Improvement Data Aggregator (QIDA), with results presented as P-charts.

Results: Our goal was met for both primary measures. Subthreshold therapy decreased from baseline median of 73.3% to post-intervention median of 0% (Figure 1). Similarly, low-risk infants receiving early rebound testing decreased from baseline median of 25% to post-intervention median of 0% (Figure 2). The shift in median for both primary measures met criteria for special cause variation. No significant increase or special cause variation existed for any balancing measures.

Conclusion/Discussion: Educational, EMR, and hospital system interventions were together associated with success in improving neonatal hyperbilirubinemia management, as evidenced by decreased proportions of infants receiving subthreshold phototherapy and low-risk infants receiving early rebound testing. These changes most likely relate to risk stratification, with subsequent reduction in total number of infants receiving phototherapy, and low-risk infants primarily excluded. Future interventions include disseminating the improvements throughout the larger healthcare system and evaluating outpatient management of hyperbilirubinemia.