442 - Let there be light: Decreasing time to phototherapy for jaundiced neonates in the emergency department

Publication Number: 4433.442

Raechel L. Warchock, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Hannah Elizabeth. Smith, Inova Children's Hospital, Rockville, MD, United States; Margaret Rinaldi, Medical University of South Carolina, Charleston, SC, United States; Emily Morris, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Sara Lin, University of Michigan, Ann Arbor, MI, United States; Donald H. Arnold, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States

Background: Neonatal hyperbilirubinemia may cause bilirubin induced neurologic dysfunction (BIND) and kernicterus. Phototherapy decreases the risk for BIND and need for exchange transfusion but must be started expeditiously.

Objective: To decrease time to phototherapy (TTP) from time of arrival at an urban, academic pediatric emergency department (ED) among neonates presenting with hyperbilirubinemia to < 60 minutes.

Design/Methods: In February 2021 our pediatric ED implemented a multidisciplinary clinical practice guideline (CPG) using the Model for Improvement for evaluation and management of neonatal hyperbilirubinemia. The CPG directs nursing staff to immediately initiate phototherapy pending lab results. We performed a retrospective chart review for the 24-month period preceding CPG implementation and a prospective chart review (3/2021 - 3/2022) to examine pre- and post-CPG rates of TTP within 1-hour of arrival. We used the Wilcoxon rank-sum and Chi-sq tests to examine bivariate associations and logistic regression to examine TTP within 1-hour and a Cox proportional hazards model to examine adjusted times to TTP. Kaplan-Meier curves are presented to visualize pre- and post-CPG TTP.

Results: Demographic and clinical characteristics of included patients are displayed in the Table. There were significant improvements in pre- and post-CPG TTP within 1 hour (19% v. 54%) and TTP (95 [65, 142] v. 53 [IQR 639, 97] minutes,). Logistic regression demonstrated meaningful improvement in TTP within 1 hour (aOR 4.74, 95% CI 2.45, 9.20) after adjustment for total bilirubin. In the Cox proportional hazards model, neonates were twice as likely to have phototherapy initiated at any specific time (HR 2.0, 95% CI 1.5, 2.7) after adjustment for total bilirubin level. Improvement in TTP is displayed in the Kaplan-Meier plot (Figure).

Conclusion(s): Implementing a neonatal hyperbilirubinemia CPG was associated with clinically meaningful reduction in time to phototherapy and increased frequency of infants receiving phototherapy within one hour. Implementation of such a CPG might reduce the risk of BIND.

Kaplan-Meier time to phototherapy estimates
Kaplan-Meier time to phototherapy estimates

Characteristics of neonates treated with phototherapy for hyperbilirubinemia, bivariate analyses
Characteristics of neonates treated with phototherapy for hyperbilirubinemia, bivariate analyses 1

XMR chart for time to phototherapy (minutes) over time
XMR chart for time to phototherapy (minutes) over time