109 - Hyperbilirubinemia Guidelines for Premature Infants: A New and Improved Display Format

Publication Number: 2104.109

Robert L. Stavis, Grand Rounds Software, Bryn Mawr, PA, United States

Background: Based on the 2012 guidelines for the management of hyperbilirubinemia in premature infants of Maisels et al. (J Perinatol 2012;32:660), the Premie BiliRecs (PBR; Palma JP, Arain YH. Clin Perinatol 2016;43:375) has become widely used to provide decision support for infants with a corrected gestational age (GA) of 27 0/7 to 34 6/7 weeks and a chronologic age of ≥48 hours.

Objective: The current work describes an alternate format for the 2012 guidelines that was developed in the Crib Notes® EHR that is conceptually and graphically similar to the AAP guidelines for infants ≥35 weeks. This new format overcomes certain limitations of PBR and provides decision support for all infants < 35 weeks GA.

Design/Methods: The X-axis is formatted and auto-scaled to display the infant's chronologic age in hours/days. The Y-axis is scaled from 0 to GA-appropriate maximum TSB values with auto-scaling as needed. The threshold lines for low-risk/high-risk phototherapy and exchange transfusion are a series of contiguous line segments that represent the Maisels et al. guidelines and essentially duplicate the PBR thresholds. Each complete threshold line includes an initial segment defined by a quadratic equation that closely approximates the initial AAP 35 week high-risk thresholds and takes precedence in the first hours/days of life when the AAP guidelines are lower than the Maisels et al. guidelines. The quadratic equations and the parameters that control each line segment threshold are defined in a database table with a record for each GA week+day up to 34 6/7 weeks. Each record provides: (1) the coefficients for the quadratic equations; (2) the slopes and intercepts for each threshold line segment; and (3) the beginning and ending hour for each threshold line segment.

Results: For a 27 0/7 week infant with a corrected GA of 35 0/7 weeks, the new format is essentially identical to the PBR graphs (Figure 1). A typical phototherapy graph in Crib Notes for a 28 4/7 week infant is shown in Figure 2. For this infant, the initial AAP 35 week high-risk threshold is lower than the low-risk and high-risk thresholds of Maisels et al. until 16 and 5 hours of age respectively; the subsequent line segments follow the recommendations of Maisels et al.

Conclusion(s): This new format for the display of the guidelines Maisels et al. displays the premature infant bilirubin guidelines with an appearance consistent with the AAP guidelines for infants ≥35 weeks. The new format resolves important limitations of PBR and may reduce the cognitive burden involved in interpreting the guidelines across the entire gestational age spectrum in NICUs.

Premie BiliRecs overlaid by Crib Notes Thresholds
The display of the chronologic age in the X-axis of the new format provides the same information as the display of the corrected GA in the X-axis in PBR.

Phototherapy Guidelines in Crib Notes
The integration of the AAP 35 week high-risk thresholds with the guidelines of Maisels et al. provides decision support from the time of birth. At 34 weeks GA, the AAP threshold is less than the low risk Maisels et al. guidelines for nearly 3 days; at 24 weeks GA, the AAP threshold is less than the low risk Maisels et al. guidelines for only 6 hours.