Dr. JoAnn Harrold, Site Chief, Neonatology, Children s Hospital of Eastern Ontario Charlotte Etue, Clinical Nurse Specialist Childbirth/NICU, Grand

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1 Dr. JoAnn Harrold, Site Chief, Neonatology, Children s Hospital of Eastern Ontario Charlotte Etue, Clinical Nurse Specialist Childbirth/NICU, Grand River Hospital 1

2 1) Goals of Quality-Based Procedures 2) Why Hyperbilirubinemia? 3) QBP Development 4) Hyperbilirubinemia Clinical Pathway and Tools 5) Case Study 6) Recommendations 7) Evaluation 8) Resources 2

3 Quality-Based Procedures Goals: 1. Align incentives to facilitate adoption of best clinical evidenceinformed practices 2. Appropriately reduce variation in costs and practice across the province while improving outcomes 3. Ensure we are advancing right care, at the right place, at the right time 3

Hip replacement Knee replacement Cataract surgery Chronic kidney disease GI endoscopy Chemotherapy systemic treatment Stroke Congestive heart failure

4 Hip replacement Knee replacement Cataract surgery Chronic kidney disease GI endoscopy Chemotherapy systemic treatment Stroke Congestive heart failure Chronic obstructive pulmonary disease Vascular (non-cardiac) Two QBPs were selected to focus on the paediatric population: Tonsillectomy Hyperbilirubinemia 4

5 Common condition affecting approximately 60% of term and 80% of pre-term babies in the first week of life Often resolves without any need for intervention Risk of developing severe hyperbilirubinemia and acute bilirubin encephalopathy (kernicterus) Severe hyperbilirubinemia is on the rise in North America and Europe According to HIROC, Failure to identify/monitor hyperbilirubinemia is the 14 th highest risk in terms of cost Represents 1.5% of all claims costs, some of which have gone as high as $8Million 5

6 2011/12 Average Hyperbilirubinemia LOS (Days) by LHIN Data from the CIHI Portal Hyperbilirubinemia as defined in the QBP Clinical Handbook 6

7 2011/12 Hyperbilirubinemia Readmissions and Readmit LOS (Days) by LHIN Data from the CIHI Portal Hyperbilirubinemia as defined in the QBP Clinical Handbook 7

8 LHIN no Cases In HIG 594 Newborn/Neonate grams, Jaundice # Cases Weighted Cases Total Mean Est. Average Cost A C D E F $1, $2, $1, $1, $2, $1, $2, $1, $1, $1, $2, $1, $1, $1,855 8 Data provided MOHLTC, Health Analytics Branch Estimates using HBAM Acute Inpatient Unit Costs, 2011/12

9 Clinical Expert Advisory Group formed QBP population defined Clinical Pathway Development : Process mapping exercise Review of currently available clinical guidelines Review of evidence for components not covered by clinical guidelines (i.e. home phototherapy, transcutaneous bilirubin screening) CEAG consensus where no evidence existed Creation of tools/resources for implementation Development of performance evaluation metrics 9

10 Name Title Organization LHIN Pervez Z. Faruqi Paediatrician Chatham-Kent Health Alliance 1 Paul Dick Paediatrician, Chief of Paediatrics Grey Bruce Health Services 2 Charlotte Etue CNS, Childbirth Program, NICU Grand River Hospital 3 Co-Chair Tamar Packer Family Physician, Medical Director, St. Joseph s Healthcare 4 Newborn Care Hamilton Andrea Temple RN, Manager, Paediatrics/NICU William Osler health System 5 Jane Healey Paediatrician Trillium Health Partners 6 Luca Simonetto Senior Analyst, Strategy Management Trillium Health Partners 6 Office Michael Sgro Paediatrician St. Michael s Hospital 7 Vibhuti Shah Neonatologist Mount Sinai Hospital 7 Charmaine van Schaik Paediatrician, Chief of Paediatrics Southlake Regional Health Centre Robert Connelly Neonatologist Kingston General Hospital/ Hotel Dieu Hospital

11 Name Title Organization LHIN JoAnn Harrold Neonatologist Children s Hospital of Eastern 11 Co-Chair Ontario Liz Darling Midwife Ottawa 11 Andrea Mills Midwife Royal Victoria Hospital, Barrie 12 Angie Wiwczor Nurse Practitioner, Family Child Program Health Sciences North 13 Linsey Mutch Paediatrician North Bay Regional Health 13 Sandy Dunn Julian Little Riffaat Mamdani RN, PhD Knowledge Translation Specialist Professor and Chair, Dept. of Epidemiology & Community Medicine (Canada Research Chair in Human Genome Epidemiology) Program Consultant, Child Development Unit BORN Ontario Maternal-Child Screening Committee Ministry of Children and Youth Services 11

12 All Births 35+weeks gestation Age 0-14 days Diagnosis of Hyperbilirubinemia Treatment 12

13 Evidence-based clinical practice guidelines for the management of hyperbilirubinemia in term and late preterm infants have been developed by: American Academy of Pediatrics, 2004 Canadian Paediatric Society, 2007 NHS National Institute for Health and Clinical Evidence,

14 1) Universal Screening 2) Treatment 3) Screening/ Observation 14

15 15 Universal Screening

16 16 Treatment

17 17 Screening/ Observation

18 Phototherapy Treatment Graph Updated 18 Adapted with permission from the Champlain Maternal Newborn Regional Program (Champlain Maternal Newborn Regional Program, 2012)

19 Hour-Specific Nomogram Updated Based on data from Stevenson et al. (Stevenson DK, 2001) 19

20 Follow-Up Algorithm Created Modeled on Maisels Algorithm (Maisels MJ, 2009), reflecting the findings of the Clinical Expert Advisory 20

21 21 Modeled on Maisels Algorithm (Maisels MJ, 2009), reflecting the findings of the Clinical Expert Advisory

22 22 Modeled on Maisels Algorithm (Maisels MJ, 2009), reflecting the findings of the Clinical Expert Advisory

23 Universal Screening Male infant BW g weeks 24 year old G2P1 with an uncomplicated pregnancy Maternal Blood type A Rh-positive Breastfeeding exclusively, well established Jaundice was noted at 34 hours of age and TSB sent R i s k F a c t o r s f o r B i l i r u b i n E n c e p h a l o p a t h y ( R F # 1 ) : 1. I s o i m m u n e h a e m o l y t i c d i s e a s e 2. G 6 P D d e f i c i e n c y 3. A s y p h y x i a 4. S i g n i f i c a n t l e t h a r g y 5. T e m p e r a t u r e i n s t a b i l i t y 6. S e p s i s 7. A c i d o s i s 8. A l b u m i n < 3 0 g / L Total serum bilirubin = 128 mol/l No risk factors for Bilirubin Encephalopathy identified 23

24 Phototherapy Required? Phototherapy not required 24

25 Screening/Observation R i s k F a c t o r s f o r S e v e r e H y p e r b i l i r u b i n e m i a ( R F # 2 ) : 1. G e s t a t i o n a l A g e 2. P o s i t i v e D A T o r o t h e r k n o w n h a e m o l y t i c d i s e a s e ( G 6 P D d e f i c i e n c y, s p h e r o c y t o s i s ) 3. P r e v i o u s s i b l i n g w i t h n e o n a t a l j a u n d i c e r e q u i r i n g p h o t o t h e r a p y 4. C e p h a l o h a e m a t o m a o r s i g n i f i c a n t b r u i s i n g 5. E x c l u s i v e l y b r e a s t f e e d i n g, n o t w e l l e s t a b l i s h e d 6. E a s t A s i a n R a c e 25

Screening/Observation GA is > 35 +0 < 37 +6, no risk factors for Severe Hyperbilirubinemia identified = Choose Path B Bilirubin plots

26 Screening/Observation GA is > < 37 +6, no risk factors for Severe Hyperbilirubinemia identified = Choose Path B Bilirubin plots in the low-intermediate zone Follow-up will be within 2 days Infant is ready for discharge so D/C home with follow up within 2 days 26

27 Total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) are both acceptable methods of bilirubin screening (generally good correlation) TcB is relatively easy to perform, time saving, pain free for the infant and spares blood Can be less expensive than TSB depending on the model of machine used Accuracy of the TcB machine is dependent on regular maintenance and upkeep - quality assurance and compliance with Laboratory standards needs to be ensured 27

28 28 CEAG recommends: Initial screening TcB should be done PRIOR to the time of the Newborn Screen If the TcB result is within 50 µmol/l of the phototherapy treatment line, a TSB should be performed immediately A quality assurance program be implemented TcB not be used during or following phototherapy treatment, TSB is required Use of TcB does not replace lab availability and it cannot be used without available laboratory backup

29 Post-discharge follow-up can take place via primary care provider, a follow-up clinic, or a community health care provider Routine follow-ups do not usually require the consultation of a paediatiric specialist and should not generally take place in an Emergency Department CEAG recommends, where possible, the use of community health care resources to follow-up infants once discharged 29

30 Access to weekend lab services in the community is a major impediment to timely screening and monitoring of bilirubin Most labs have limited experience taking blood samples from newborns In communities where a blended model of hospital and communitybased services are available, CEAG recommends community-based services meet the following criteria: Skilled in obtaining blood from infants Use appropriate pain management Have the ability to deliver lab results within two hours of the blood draw 30

31 Potential to save costs and address gaps in some communities If blood sampling cannot be offered in the home, benefits are negated CEAG recommends a planned evaluation in any community implementing home phototherapy 31

Health care providers undertaking follow-up care must be aware of their patient s bilirubin journey and any actions taken while in hospital CEAG

32 Health care providers undertaking follow-up care must be aware of their patient s bilirubin journey and any actions taken while in hospital CEAG recommends the infant s parents or guardian be provided with materials that document their child s screening and treatment history upon discharge 32

33 Evaluation metrics have been proposed to the MOHLTC. They include: LOS Rate of readmission Rate of bilirubin screening Incidence of severe/critical hyperbilirubinemia Incidence of exchange transfusions Rate of phototherapy Rate of supplementation of BF infants receiving phototherapy Next Steps: Each QBP Clinical Handbook will be accompanied by an Indicator Handbook, detailing performance evaluation metrics Work Group to be struck to detail evaluation metrics and determine feasibility 33

34 Clinical Handbook soon to be available on MOHLTC website Implementation Toolkit available at: OHA Toolkit to Support the Implementation of QBPs: 34

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35 You can either press the star *1 on your touch tone phone, the operator will open your line when it is your turn to ask a question OR Enter your question on the right hand side in the chat box to Q&A group. If there are any questions not being answered during this session, please send your question(s) to: doreen.day@pcmch.on.ca 35

Clinical Pathway Handbook for Hyperbilirubinemia in Term and Late Pre-Term Infants ( 35 weeks)

Clinical Pathway Handbook for Hyperbilirubinemia in Term and Late Pre-Term Infants ( 35 weeks) Provincial Council for Maternal & Child Health & Ministry of Health and Long-Term Care December 12, 2017 Table