A Newborn Bilirubin of 30 or Greater as a "Never Event": A Multi-Hospital System's Approach

A Newborn Bilirubin of 30 or Greater as a “Never Event”:
A Multi-Hospital System’s Approach
Background:
At the 2003 Annual Perinatal Conference of a large hospital system, physicians, nurses and other health care team members representing one-hundred-twenty-seven hospitals heard Sue Sheridan tell her son’s story of life with kernicterus.  Health care providers listened intently.  As the presentation ended, a physician stood and apologized to Sue on behalf of the medical community for the failure of the medical community to properly diagnosis and treats her son’s condition.  One hospital administrator stated his hospital would begin universal screening for hyperbilirubinemia of all newborns by the end of the month and challenged other hospital administrators to do the same.  Physicians, nurses, and administrators left the conference committed to manage hyperbilirubinemia for the prevention of kernciterus.
Method: 
Clinicians began literature searches and methods for baseline data collection were explored by the corporate Perinatal Safety Initiative.  The hospital system’s Perinatal Clinical Work Group hosted a Rapid Design Team made up of multidisciplinary team members as well as national experts to address the problem of management of newborn hyperbilirubinemia and the prevention of kernicterus.  The recommendations of this team included five recommendations.  All newborns should have a bilirubin level objectively measured with the value plotted on the Bhutani nomogram by hour of life to predict risk value for the newborn.  All health care providers responsible for the care of newborns, regardless of hospital department, should have education regarding the management of hyperbilirubinemia and the prevention of kernicterus.  Furthermore, health care providers should have lactation education and families should have lactation education and support.  Hospitals should have sufficient bilimeters for newborn assessment and equipment to treat newborn hyperbilirubinemia.  And, newborns should have follow up assessments in the week after discharge.  Additionally, other departments such as medical records, ethics and compliance, and billing were identified as stake-holders critical to implementation of this initiative.
Multidisciplinary teams created tool-boxes of resources such as assessment templates and educational programs so that a standard program for “A Newborn Bilirubin of 30 or Greater as a Never Event” could be implemented system wide.   Information systems developed an enterprise report so that data can be routinely collected from all hospitals within the system.
Results:
The Clinical Work Group of the Perinatal Safety Initiative endorsed the recommendations of the design team and the work product of the clinicians.  By January 2005, all hospitals with in the system had implemented universal screening of newborns for the management of hyperbilirubinemia and the prevention of kernicterus.  Since implementation of the program, bilirubin values of neonates born in the system’s hospitals with values greater than 30 and greater than 24.5 have continued to decrease.
Conclusion:    
Implementation of the program has decreased newborn bilirubin values. Continuous monitoring and follow up of high values have assisted clinicians to determine reasons why values reach unacceptable levels.  This information is shared with other clinicians as lessons learned.  “A newborn bilirubin value of 30 or greater as a never event” has improved newborn outcomes.