P4A163: Reduction in Length of Stay and Duration of Phototherapy During Birth Hospitalization After Hyperbilirubinemia Management Guideline Implementation

Purpose/Objectives: Hyperbilirubinemia is a common problem in newborns. Despite widely accepted guidelines for management, there is significant variation in care, including thresholds and timing for initiation and discontinuation of phototherapy. In 2022, the American Academy of Pediatrics (AAP) published an updated guideline for the management of hyperbilirubinemia with new risk stratification recommendations and thresholds for treatment. Via implementation of the 2022 AAP guideline, we primarily aimed to decrease the proportion of infants requiring phototherapy during birth hospitalization by 5% and secondarily aimed to reduce the length of stay (LOS) and duration of phototherapy by 10% in a 12-month period.

Design/Methods: Using the Model for Improvement, we assembled a team of stakeholders and performed a gap analysis on baseline state to target interventions. We included infants cared for by pediatric hospitalists in the postpartum unit treated with phototherapy during birth hospitalization during our baseline period (February 2022-August 2022) and intervention period (September 2022-present). Our primary intervention was implementation of a bundle in September 2022 to standardize care consistent with the updated AAP guideline, including standard note templates and discharge guidance for primary care physicians. The primary outcome was the percent of infants requiring phototherapy. Secondary outcomes included LOS and duration of phototherapy. We monitored the proportion of infants receiving phototherapy at subthreshold bilirubin levels (≥ 0.3 mg/dL below the phototherapy threshold) and readmission rate for phototherapy within 7 days as process and balancing measures. Statistical process control charts were utilized for all measures.

Results: Analysis to date includes 3742 total newborns admitted to the postpartum unit, including 170 newborns (baseline n=113, intervention n=57) requiring phototherapy during the birth hospitalization. The percent of newborns receiving phototherapy minimally decreased from 6.3% at baseline to 4.9% after the guideline change. Average length of stay decreased from a baseline of 80.4 hours to 76.4 hours, and duration of phototherapy decreased from 25.3 to 20.1 hours (Figure 1). The percent of newborns receiving subthreshold phototherapy increased from 31% to 68%, while readmission rate decreased from 7.4% to 4.7%.

Conclusion/Discussion: Bundled implementation of the updated 2022 AAP hyperbilirubinemia management guideline decreased the average LOS by 5% and duration of phototherapy by 25% with a reduction in readmission. Interestingly, there was minimal change in the proportion of infants initiated on phototherapy and an increase in the percent of infants with treatment initiation at subthreshold bilirubin values. This is perhaps related to provider discomfort with higher initiation values and will be the target of a subsequent PDSA cycle.