1. Implementation of a Flowsheet to Better Manage Bilirubin Levels in Newborns Dr. Alia Chauhan, MD, FAAP Assistant Professor of Pediatrics & Family Medicine NSLIJ- Hofstra Medical School Dr. Vinod Kumar, PGY-2 Family Medicine Residency Program, Southside Hospital Dr. Leveille (PGY-3); Dr. Bushman (PGY-2) Dr. Sunil Sood, MD,FAAP, Kevin Masick, PhD

2. Objective To identify newborns with risk factors who might develop severe hyperbilirubinemia and, in some cases acute bilirubin encephalopathy / kernicterus. We speculate that the complexity of the existing American Academy of Pediatrics (AAP) guidelines decreases adherence. Our objective is to simplify standard management of hyperbilirubinemia on a single page in a check list form “Bilirubin Flow sheet”. It will help physicians to identify babies with risk factors readily & will help monitor these babies more efficiently which will prevent readmission for therapeutic intervention.

5. AAP Clinical Practice Guidelines 2004 Recommendations 5.1 Before discharge every newborn should be assessed, for the risk of developing severe hyperbilirubinemia, and all nurseries should establish protocols for assessing this risk.

6. Method: We conducted a retrospective review of 50 randomly selected charts using bilirubin flow sheet. Data recorded using bilirubin flow sheet was compared with physicians documentation in terms of risk factors and discharge follow up appointments. Inclusion criteria : Baby with initial bilirubin in Low intermediate risk zone/High intermediate risk zone/High risk zone. ( Regardless of phototherapy) Exclusion criteria : Babies with initial bilirubin normal or low risk zone bilirubin.

7. Findings: Additional risk factors were identified on chart review using bilirubin flow sheet VS documented by PMD. Total no of charts: 50 3/50: 3 additional risk factors : 6% 4/50: Same number of risk factors : 8% 21/50: 1 additional risk factor : 42% 22/50: 2 additional risk factors : 44%

10. AAP-Recommendation 6.1.2 Follow-up should be provided as follows:- Infant discharged should be seen by age in hours : Discharge before age 24 h: Follow up @ 72 hours of Age. Discharge between 24 and 47.9 h: Follow up @96 hours of Age. Discharge between 48 and 72 h: Follow up @120 hours of Age.

11. Findings : Total no of charts reviewed : 50 15 charts identified who didn’t received phototherapy but had risk factors. These charts were reviewed for appropriate follow-up appointment. 6% : No follow up appointment documented. 7% follow up given in hours. 87% follow up given in days.

13. Conclusion We conclude that there is a lack of adherence to AAP guidelines in the management of hyperbilirubinemia. In our study we looked at only two items risk factor identification, and timely followup,which can prevent readmission for therapeutic intervention. We identified two additional risk factors in 44% charts during chart review using bilirubin flow sheet, and one additional risk factor in 42% charts. In terms of follow up we found 87% follow-up given in days regardless of newborn age in hours.

14. AMERICAN ACADEMY OF PEDIATRICS Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant > 35 Weeks of Gestation Pediatrics 2004 (July); 114:297