P2D133: Updating the Hyperbilirubinemia Clinical Pathway and Lab Capabilities to Reduce Emergency Room Visits and Inpatient Hospital Days

Purpose/Objectives: Monitoring infants with hyperbilirubinemia accounts for a significant number of primary care visits, ED visits, and inpatient hospital days each year. Within CHOP, the ED sees approximately 400-500 visits annually, with over 40% of these visits resulting in an admission. The AAP recently published new clinical practice guidelines for management of hyperbilirubinemia, which updated and replaced the 2004 AAP clinical practice guidelines. The changes recommend raising thresholds for phototherapy, among other recommendations for screening and monitoring TSB/TcB. As the thresholds have been raised, the criteria for hospitalizing an infant is changed, resulting in a different treatment path for some newborns (hospitalization vs. outpatient management). As such, we are interested in the effects the new guidelines have on healthcare utilization.

Aims
1. Replace the existing CHOP clinical pathways with a single updated pathway that incorporates the 2022 AAP recommendations across Primary Care/ED/Inpatient settings
2. Reduce ED Visits for neonatal hyperbilirubinemia by 25% by February 2023
3. Reduce total hospital days for inpatient management of neonatal hyperbilirubinemia by 25% by February 2023
4. Develop an accessible dashboard that meaningfully communicates data to providers in near real-time by February 2023

Intervention: We deployed multiple interventions including updating the CHOP clinical pathway and expanding outpatient lab testing access.

Design/Methods: We compiled and reviewed ED visits for hyperbilirubinemia pulled from Epic from 1/01/2019 – 1/19/2023 and compared outcomes pre and post our interventions. The primary outcomes were # of ED visits, # of admissions, and total hospital days, with balancing measures of length of stay, readmissions, and ED revisits. We also performed a complete chart review of a subset of our cohort defined as all infants who were admitted between September 2021 – December 2021, before any of the interventions were implemented to serve as the control group.

Results: Comparing our cohort from Sept-Dec 2021 (pre-intervention) to Sept-Dec 2022 (post-intervention), there was a 32% reduction in ED visits, a 31% reduction in admissions, and a 21% reduction in hospital days. Of patients previously admitted between Sept-Dec 2021, 53% would not be admitted today. There was no increased incidence of kernicterus. There was a 3% increase in inpatient length of stay, a 4% reduction in ED revisits, and a 28% reduction in readmissions.

Conclusion/Discussion: Our results show that the interventions used to incorporate the new AAP recommendations likely led to a reduction in ED visits and inpatient hospital days, while maintaining quality in a relatively short period of time, narrowing the knowledge to action gap. Research suggests it can take up to 17 years to adopt new clinical practices/treatments. Our review also revealed variation in provider decision making and identified areas for refinement of the pathway.