Guideline-Based Educational Intervention to Decrease the Risk for Readmission of Newborns With Severe Hyperbilirubinemia

ARTICLE Guideline-Based Educational Intervention to Decrease the Risk for Readmission of Newborns With Severe Hyperbilirubinemia Julee B. Waldrop, DNP, FNP, PNP, Christina K. Anderson, MD, & Debra H. Brandon, PhD, RN, CCNS, FAAN ABSTRACT Introduction: The purpose of this study was to determine if educational intervention with medical providers in combination with a management tool to facilitate clinical guideline usage would (a) increase quality of care, (b) increase compliance with published guidelines, and (c) decrease hospital readmissions as a result of hyperbilirubinemia in the first week of life. Method: A quality improvement initiative was undertaken with a preintervention/postintervention design. Intervention: An educational intervention was offered to persons who provide medical care to newborns. The charts of newborns were reviewed before and after the intervention in three samples: a care quality sample (N = 244), a compliance sample (N = 240), and a readmission sample. Julee B. Waldrop, Associate Professor, College of Nursing, University of Central Florida, Orlando, FL. Christina K. Anderson, Jeffers, Mann and Artmann Pediatrics, Raliegh, NC Debra H. Brandon, Associate Professor, School of Nursing, Duke University, Durham, NC. Conflicts of interest: None to report. Correspondence: Julee B. Waldrop, DNP, FNP, PNP, College of Nursing, UCF, 12201 Research Pkwy, Orlando, FL 32814; e-mail: jwaldrop@ucf.edu. 0891-5245/$36.00 Copyright Q 2013 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online October 24, 2011. http://dx.doi.org/10.1016/j.pedhc.2011.09.002 Results: In the quality care sample, documentation of three quality care indicators improved significantly and one worsened significantly. In the compliance sample, the percentage of infants who were given appropriate follow-up appointments in primary care based on their hyperbilirubinemia risk at discharge improved (p =.03), and the readmission rate of newborns within the first week of life as a result of hyperbilirubinemia decreased by 50%. Discussion: An educational intervention with a clinical tool may help change provider practice. Longer follow-up is needed to determine if the impact is sustainable. J Pediatr Health Care. (2013) 27, 41-50. KEY WORDS Hyperbilirubinemia, infant, quality improvement, educational intervention, guidelines Jaundice of the newborn, which is a common problem seen in newborn nurseries and primary care practices, stems from a developmental imbalance between the production and conjugation of bilirubin (Kaplan & Hammerman, 2004; Maisels & McDonagh, 2008). Approximately 20% of newborns will exhibit hyperbilirubinemia (defined as a total serum bilirubin [TSB] level of 12 mg/dl or greater; Bhutani, Johnson, & Sivieri, 1999). Early treatment of these infants is necessary to prevent the development of severe hyperbilirubinemia (defined as a TSB level of 20 mg/dl or greater; Ip et al., 2004), which can lead to kernicterus (brain damage due to an accumulation of bilirubin in basal ganglia and various brainstem nuclei; American www.jpedhc.org January/February 2013 41

Academy of Pediatrics [AAP] Subcommittee on Hyperbilirubinemia, 2004). The incidence of severe hyperbilirubinemia is not tracked at the national level in the United States (Bhutani & Johnson, 2009), but it can be estimated from more limited samples. In a 1995-1996 birth cohort of 50,000 California infants, 2% had TSB levels above 20 mg/dl, 0.15% had TSB levels > 25 mg/dl, and 0.01% had TSB levels > 30 mg/dl (Escobar et al., 2005). Extrapolating these percentages to the current annual U.S. birth rate of 4,247,694 (Martin et al., 2010), a TSB level > 20 mg/dl would be expected in 84,954 infants, with 6372 having TSB levels > 25 mg/dl and 425 having TSB levels > 30 mg/dl. Although a voluntary kernicterus registry has been established, the true incidence of kernicterus in the United States is not known; the best available estimates suggest a range of 1.8 to 3.7 per 100,000 births (Bhutani & Johnson, 2009). Lower incidences have been reported in European epidemiological studies: 1.3 per 100,000 in Denmark (Maimburg, Bech, Bjerre, Olsen, & Moller-Madsen, 2009) and 0.9 per 100,000 in the United Kingdom and Ireland (Manning, Todd, Maxwell, & Platt, 2007). Several known risk factors for severe hyperbilirubinemia have increased in prevalence during the past several decades. Late preterm infants (those born between 35 weeks/0 days and 37 weeks/6 days gestation) are less able than full-term infants to conjugate bilirubin (Raju, Higgins, Stark & Leveno, 2006), and the rate of these late preterm births increased by 25% between 1990 and 2006 (Martin, Osterman, & Sutton, 2010). Breastfeeding also has been associated with an increased risk of hyperbilirubinemia (possibly because of the increased enterohepatic circulation of bilirubin; Maisels & McDonagh, 2008), and in the United States, breastfeeding initiation rates increased from 68% in 1999 to 75% in 2007 (Centers for Disease Control and Prevention, 2010). Furthermore, because serum bilirubin levels typically have not yet peaked in infants discharged within 48 hours of delivery (Maisels & Newman, 2006), early discharge of newborns with inadequate follow-up increases the risk of rehospitalization for severe hyperbilirubinemia (Farhat & Rajab, 2011) and also is linked to an increase in reported cases of kernicterus (Johnson, Bhutani, Karp, Silveira, & Shapiro, 2009). The length of postpartum hospital stays decreased in the late 1980s and early 1990s (DeFrances & Hall, 2007). This trend has been reinforced in recent years by structural changes in health care delivery that increase pressure on hospitals to promote early discharge, such as the closing of community hospital maternity beds (Burling, 2008) and the increasing numbers of uninsured patients needing hospital care (DeNavas-Walt, Proctor, & Smith, 2008). Severe hyperbilirubinemia can now be preempted by timely phototherapy, and although most phototherapy is provided in the hospital setting, fiber-optic technology has allowed effective treatment in the home setting as well (Mills & Tudehope, 2000). In this context, prompt in-hospital treatment of neonates with severe hyperbilirubinemia and identification and follow-up of infants at high risk for this condition after discharge are of critical importance. The AAP Subcommittee on Hyperbilirubinemia published revised guidelines for the management of hyperbilirubinemia in infants $ 35 weeks gestation in 2004. These guidelines, based on a review of the evidence (Ip, Glicken, Kulig, OÕBrien, & Sege, 2003; Ip et al., 2004) and informed by expert opinion, were developed for use in both hospital nursery and outpatient settings. In addition, the institution of mandatory testing of bilirubin levels in newborns before discharge (which is not explicitly recommended in the guidelines) has been shown in several studies to reduce readmissions for hyperbilirubinemia. Eggert, Wiedmeier, Wilson, and Christensen (2006) instituted prehospital discharge bilirubin screening in an 18-hospital system and decreased readmission rates from 0.55% to 0.43%. Alkalay, Bresee, and Simmons (2010) reported that institution of universal transcutaneous bilirubin (TCB) screening before discharge reduced readmission rates for severe hyperbilirubinemia in the first 30 days of life from 0.94% to 0.37% (p =.001). Reduction in the incidence of TSB levels of $ 30 mg/dl (from 9 to 3 per 100,000, p =.0051) and of TSB levels of 25.0 to 29.9 mg/dl (43 to 27 per 100,000, p =.0019) occurred in a large hospital sample after institution of predischarge bilirubin screening policies (Mah et al., 2010). PROBLEM As part of ongoing quality tracking, it was noted that the overall readmission rate in 2008 for infants born at a university medical center in the southeastern United States in the first 7 days of life averaged about 1.2% (range, 0.9% to 2.2%; N = 95). This rate exceeded the University Healthsystem Consortium (https://www.uhc.edu) benchmark of 0.75% for readmissions. A retrospective chart review of all readmissions by the first author identified that 34% of these infants (N = 36, about 1% of births) had been readmitted with the primary diagnosis of hyperbilirubinemia, and physiologic hyperbilirubinemia had contributed to 100% of those readmissions. (None of these infants had hemolytic disease.) These readmissions occurred despite the fact that universal predischarge bilirubin screening had been instituted in 2006. The readmission rate exceeded not only the rates reported by Eggert et al. (2006), Alkalay et al. (2010), and Mah et al. (2010) after institution of such screening, but also the 1.1% readmission rate reported by Burgos, Schmitt, Stevenson, and Phibbs (2008) before institution of screening. A multidisciplinary committee was formed to address this problem. The Model of Performance Improvement derived from the original work by W. Edwards Deming 42 Volume 27 Number 1 Journal of Pediatric Health Care

(Langley, Nolan, Norman, Provost, & Nolan, 1996) was used to identify the problem and conceptualize the implementation of this project. Members of the committee included the director of the Newborn Nursery (the first author), who also was the opinion leader and project champion (Greenhalgh, Robert, Bate, Macfarlane, & Kyriakidou, 2005); a pediatric nurse practitioner (PNP); pediatric faculty and residents; Newborn Nursery staff nurses; quality improvement professionals; and lactation consultants. The Newborn Nursery Chart Review Tool from the Safe and Healthy Beginnings Project developed by the Quality Improvement Innovation Network (QuIIN) of the AAP (Lannon & Stark, 2004; QuIIN, 2007) was used to identify quality improvement issues in the newborn nursery related to the prevention of severe hyperbilirubinemia. This tool provided baseline data that demonstrated that 100% of infants had been screened for hyperbilirubinemia before discharge but only 70% to 75% of newborns discharged before 72 hours of age had a documented plan for follow-up within 2 days of discharge. In addition, it was noted that follow-up appointments had been documented in the medical record for only 13 (36%) of the 36 rehospitalized infants. STUDY HYPOTHESIS The multidisciplinary team determined that delivering an educational intervention to the major medical providers of care to newborns would be a cost-effective method for addressing these quality improvement issues in the newborn nursery. This study hypothesized that use of educational interventions with medical providers, along with a tool to facilitate adherence to clinical guidelines, would (a) increase compliance with the guidelines for decreasing the risk of severe hyperbilirubinemia and (b) decrease hospital readmissions resulting from hyperbilirubinemia in the first week of life by 50%. METHODS In this quality improvement initiative, an educational intervention designed to reduce readmission of newborns with severe hyperbilirubinemia was delivered to the medical care providers who admitted infants to the newborn nursery of the hospital. A preintervention/postintervention design was used to evaluate quality indicators, compliance with nationally published hyperbilirubinemia guidelines (AAP, 2004), and newborn readmission rates during the first week of life. This study was approved by the Institutional Review Boards of the University of North Carolina and Duke University. Setting This project was implemented in the Newborn Nursery of the University of North Carolina Hospital, a major academic medical center in the southeastern United States. Approximately 3600 infants are delivered at this medical center each year. Target participants included four provider groups (N = 70 different providers) with admitting privileges for the Newborn Nursery. The Division of General Pediatrics and the Pediatric Residency Program provides the majority (67%) of the medical care in this nursery. Family Medicine and its Residency Program (12%), Piedmont Health Services (17%), a group of federally funded clinics for the underserved, and a local private pediatric practice (2%), along with a few additional outside providers (2%), provide the remainder of the care. Intervention Intervention design The Assessment of Risk for Severe Hyperbilirubinemia (ARSH) tool for clinicians (QuIIN, 2009) was adapted for use in the educational intervention after the principal investigator (a PNP and director of the Newborn Nursery) held discussions with pediatric residents, attending physicians, and another PNP who also provided care to newborns in the nursery. These discussions revealed that a step-by-step approach to risk assessment would be helpful in the clinical setting. The steps are: Step 1: Identify risk factors with use of the Risk Factors of Development of Severe Hyperbilirubinemia chart. Step 2: Assess for TCB by 24 hours of age. Step 3: Use the Risk of Subsequent Severe Hyperbilirubinemia nomogram provided in the ARSH tool to identify the infantõs risk zone for severe hyperbilirubinemia. A follow-up appointment with a primary care provider should be scheduled within 24 hours if the infant is in a high-risk zone and within 1 to 2 days if infant is not in the lowrisk zone. Step 4: Determine if this baby needs phototherapy. Use the Phototherapy Guidelines for Newborns 35 or More Weeks of Gestation nomogram to determine whether phototherapy (provided either in the hospital or at home) is needed. To make the ARSH tool easier to use, it was reformatted as a front-and-back one-page document that listed the aforementioned steps. In addition, before delivery of the educational intervention, the tool was retrospectively applied to all infants readmitted between January and September 2009 so that each provider group could be given an individualized assessment of its current contribution to readmissions for hyperbilirubinemia. Implementation In the fall of 2009, the first and second authors presented the educational intervention to each provider group. The information presented included: (a) www.jpedhc.org January/February 2013 43

TABLE 1. Provider group face-to-face attendance at training Provider group % Births Total medical care providers (N) Providers trained face to face (N) NP MD Total NP MD Total Face-to-face (% of all providers) PED 67 1 29 30 1 a 23 24 80 PHS 17 1 10 11 1 0 1 b 9 FM 12 1 9 10 1 9 10 100 CHCC 2 2 5 4 4 80 Other c 2 5 5 0 0 0 TOTAL 3 57 61 3 36 39 CHCC, Local childrenõs clinic; FM, Family Medicine attending physicians; MD, medical doctor; NP, nurse practitioner; PED, pediatric attending physicians and residents; PHS, Piedmont Health Services. a This pediatric nurse practitioner was the director of the Newborn Nursery and supervised 38% of all care given by pediatric attendings and residents. b One provider (a pediatric nurse practitioner who was trained) covers 57% of care in the Newborn Nursery for this group. c Three other private practices with few providers (did not include in educational training). a description of hyperbilirubinemia-related quality care issues identified in the newborn nursery; (b) an evaluation of each groupõs current hyperbilirubinemia management practices, based on the aforementioned chart review of infants readmitted for hyperbilirubinemia in 2009, including comparison with and discussion of the current AAP guidelines with particular emphasis on appropriate follow-up after discharge; and (c) an explanation of the purpose and use of the modified ARSH tool. Overall, 39 of the 61 medical providers (64%) were able to attend a face-to-face presentation and discussion (Table 1). Sixty-four percent is deceptively low, because one provider group had 11 members (10 physicians and one PNP), of whom only one (the PNP) received a one-on-one educational intervention; however, she provided 57% of the care for this group. The principle investigator was the PNP in the Division of General Pediatrics and Pediatric Residency Program group (consisting of 29 physicians and one PNP) and was responsible for 38% of the care provided by that group. All medical providers who were unable to attend a presentation received the content (in PowerPoint format with notes) and the ARSH tool via e-mail. Additional copies of the tool were laminated and made available as reminders in the Newborn Nursery at the computer charting area. It was hoped that when the providers realized there was room for improvement in their practice and that an easy-to-follow tool was available to help them improve compliance with the guidelines, their practice would actually improve. Method of Evaluation The effectiveness of the intervention was assessed by comparisons of care quality, compliance, and rehospitalization data before and after the intervention in three samples. 1. In the care quality sample, the QuIIN Newborn Nursery Chart Review tool (QuIIN, 2007) was used. Although this tool has not formally been tested for reliability, 10 newborn nurseries across the United States who participated in the AAP QuIIN Safe and Healthy Beginnings project have provided expert content validity. 2. In the compliance sample, the following items were extracted from a chart review based on the ARSH tool: (a) assessment of risk factors for severe hyperbilirubinemia; (b) evaluation of risk based on TCB or TSB; (c) appropriateness of followup; and (d) if phototherapy was indicated and given or not. 3. The infant readmission sample included the number of infants who were readmitted with the primary diagnosis of hyperbilirubinemia in the 6 months prior to the educational intervention and the 6 months after the intervention. The care quality sample (N = 240) was drawn over a 10-month period, and the compliance sample (N = 244) was drawn over a 4-month period. (Figure 1 provides a flow chart of the sample selection process.) The two samples were drawn during different time frames because of the authorsõ availability. The record of any newborn admitted to and discharged from the University of North Carolina Hospital Newborn Nursery during the time frame of a sample was eligible for review. For each sample, a table of random numbers from 0 to 9 was generated for 40 rows (weeks), and the last number of the infantõs medical record was used to identify five infants per week for the samples. For the infant readmission sample, the charts of all infants readmitted with the primary diagnosis of hyperbilirubinemia during the entire 12 months were reviewed. Care quality The Safe and Healthy Beginnings Project Newborn Nursery Chart Review Tool (QuIIN, 2007) was completed for each infant in the sample. This chart review 44 Volume 27 Number 1 Journal of Pediatric Health Care

FIGURE 1. Study flow diagram. tool includes 16 indicators of care quality: four indicators focused on the risk of severe hyperbilirubinemia, four items documenting the adequacy of care coordination, and eight indicators of breastfeeding support (QuIIN, 2007). An example of an indicator of assessment of risk for severe hyperbilirubinemia is: Is there documentation that risk for severe hyperbilirubinemia was assessed? For evaluation of coordination of care, an example is: For infants discharged at < 72 hours of age, is there documentation of a plan for follow-up that includes the infant being seen by a licensed health care provider within 2 days of discharge? Indicators supportive of breastfeeding include: Is there documentation that the infant is fed exclusively motherõs milk without supplement? and Is there documentation that two formal assessments of breastfeeding were done that includes descriptions of position, latch, and milk transfer? The 16 indicators are scored as yes or no. Compliance Data were extracted from chart review of the infants in the compliance sample to evaluate compliance with the AAP hyperbilirubinemia guidelines using the ARSH toolõs four-step process that had been presented in the educational intervention: (a and b) determination of the risk zone for the development of severe hyperbilirubinemia by assessing risk factors, the bilirubin level (defined as the last documented bilirubin level before discharge or treatment), and the infantõs hours of life when it was obtained, and categorization of the risk zone as low, low intermediate, high intermediate, or high risk; (c) documentation of appropriate follow-up care in the community based on the infantõs risk zone (for example 1, 2, or 3 days after discharge); and (d) use of appropriate phototherapy based on the infantõs gestational age, risk factors, and bilirubin level. Infants were assigned to gestational age categories defined as < 37 weeks and 6 days, 37 weeks and 0 days to 37 weeks and 6 days, and $ 38 weeks, based on identified decrease in risk with increasing weeks of gestation (AAP, 2004; Bhutani et al., 1999). The indicated management strategy was coded as no phototherapy needed, received phototherapy as indicated, or phototherapy indicated but not given. Readmissions The medical records of all infants readmitted with the diagnosis of hyperbilirubinemia in the first 7 days of life during the 12-month study period were reviewed and data were abstracted for descriptive information. Data Analysis Descriptive statistics were calculated for each study sample. Significant differences before and after the delivery of the intervention were determined using t tests for continuous variables and either v 2 or FisherÕs Exact tests for categorical variables. RESULTS Care Quality Indicators Three quality indicators in the area of breastfeeding support (counseled to breastfeed 8 to 10 times per day, contact information given for lactation consultant, and contact information given for health care provider) were near 100% before and after the intervention. www.jpedhc.org January/February 2013 45

FIGURE 2. Percentage of infants in compliance sample (N = 244) given appropriate follow-up appointments based on risk zone at discharge, before and after the intervention. (Percentages do not sum up to 100% because of missing data.) Documentation of the presence of jaundice on the discharge examination and a discussion of jaundice risk with parents in the medical providerõs note improved from 95.5% to 100% (p =.033). Documentation of written and oral counseling of parent(s) in the providerõs note also improved from 76.4% to 89.6% (p =.008). Nursing staff documentation of the infant being exclusively breastfed improved from 46.1% to 61.1% (p =.025). However, documentation of two observed breastfeedings by any provider decreased from 60.8% to 42.1% (p =.006). No statistically significant changes were found in any of the other 12 indicators. Compliance No significant difference was found before and after the intervention in the percentage of infants who were evaluated for risk of severe A 50% reduction in readmissions for hyperbilirubinemia occurred after the intervention.. hyperbilirubinemia with a bilirubin measurement (96% and 95%, respectively). The percentage of infants in the high-risk zone for development of severe hyperbilirubinemia at discharge decreased after the intervention from 18.1% to 5.7%; this finding was not statistically significant (p =.06) but could be considered clinically significant. The percentage of infants given appropriate follow-up appointments in primary care, based on their risk zone at discharge, increased significantly from 73% to 84.4% (p =.03; Figure 2). Phototherapy was indicated but not given in 18.2% of the cases before the intervention (N = 2/11) and 16.7% of the cases after the intervention (N = 1/6); this difference was not significant. Further description of this sample is presented in Table 2. Readmissions A 50% reduction in readmissions for hyperbilirubinemia occurred after the intervention (1.1% of births before the intervention; 0.59% afterward): 20 infants were readmitted in the 6 months before the intervention and 10 were readmitted in the 6 months after the intervention (p =.06, effect size 0.74; Figure 3). All of the infants who were readmitted had been delivered vaginally, and their average newborn hospital stay was 1.7 TABLE 2. Description and results of outcomes for compliance sample before and after the intervention Variable Before the intervention After the intervention N % N % Bilirubin assessed 117 95 116 95 Gestational age 35 weeks to 36 weeks and 6 days 2 1.6 1 0.8 37 weeks to 37 weeks and 6 days 12 10.7 12 9.8 > 38 weeks 108 87.7 109 89.3 Risk zone at discharge High 16 18.1 7 5.7 High intermediate 29 23.7 32 26.2 Low intermediate 41 33.6 33 27.1 Low 33 25.4 44 36.1 Not able to assess 5 4.1 6 4.9 Given appropriate follow-up 89 73 103 84.4* Phototherapy indicated and given 9 81.8 5 83.3 Phototherapy indicated but not given 2 18.2 1 16.7 *p <.05 (p =.03). 46 Volume 27 Number 1 Journal of Pediatric Health Care

FIGURE 3. Percentage of infants readmitted during the first week of life by birth month before and after the intervention for the total sample (N = 3519). days (with a day defined as staying past midnight). No significant differences in admission numbers based on ethnicity were found. Further description of this population is provided in Table 3. DISCUSSION In the years following the publication of the AAPÕs guidelines for prevention of severe hyperbilirubinemia in 2004, many hospitals implemented policies to evaluate bilirubin levels in all newborns before discharge. Two recent studies have demonstrated that this process improvement decreases readmission for severe hyperbilirubinemia (Alkalay et al., 2010; Mah et al., 2010). However, despite excellent compliance with such a policy, the readmission rate for the newborn nursery in which this initiative took place still exceeded benchmark levels for readmissions in the first week of life. Based on chart reviews, it was determined that adherence to the guidelines and arrangements for follow-up care after discharge both could be improved. In the care quality sample, four of the 16 quality indicators evaluated changed significantly. Documentation of the presence of jaundice or discussion of jaundice by the medical provider, documentation of written and oral counseling by the provider, and documentation of infants who were exclusively breastfed improved significantly, although documentation of two formal assessments of breastfeeding worsened. In the compliance sample, a statistically significant increase was found in the percentage of infants discharged with appropriate planned follow-up in the community. A reduction in the percentage of infants discharged while in the high-risk zone also occurred. Although the decrease was not statistically significant, it could be argued that this reduction may have had a clinical impact by decreasing readmissions. Lastly, delivery of the educational intervention was followed by a 50% reduction in readmissions during the first week of life with the diagnosis of hyperbilirubinemia. It is a coincidence that the reduction met the goal exactly; the first author originally wanted a goal of 75% reduction, but the team believed that goal was unrealistic, and thus it was modified to 50%. Realistic evaluation of clinical guideline compliance in clinical practice is difficult. Available evidence suggests that adherence to guidelines often is less than ideal. For example, a review of medical records of Medicaid patients in Washington state indicated that compliance with AAP guidelines for urinary tract infection in the first year of life was less than 50% (Cohen, Rivara, Davis, & Christakis, 2005). A survey of primary care physicians indicated that their adherence to AAP diagnostic guidelines for attention deficit hyperactivity was only 28% (Chan, Hopkins, Perrin, Herrerias, & Homer, 2005), and a Swiss study reported that adherence to asthma and chronic obstructive pulmonary disease guidelines in primary care ranged from 33% to 60% (Weidinger, Nilsson, & Lindblad, 2009) despite the availability of professional guidelines for asthma management since 1991 (National Asthma Education and Prevention Program Expert Panel, 2007). This intervention took place in a newborn nursery in which a number of processes to facilitate quality care already were in place. For example, the electronic charting template includes a default or assumption of no jaundice under skin assessment; therefore, documentation of physical assessment for jaundice will always www.jpedhc.org January/February 2013 47

TABLE 3. Description of infants readmitted in the first 7 days of life with the diagnosis of hyperbilirubinemia (N = 30) during a 12-month period Characteristic Mean SD n % Newborn Nursery stay Maternal age 27.8 6.4 Apgar score 1 min 7.4 2.0 5 min 8.7 0.6 Bilirubin at discharge 9.3 3.1 Ethnicity White 16 53 Black 2 6 Asian 0 0 Hispanic 11 36 Middle Eastern 5 16 Public insurance 21 70 Language English 18 60 Spanish 12 40 Baby No. First 16 53 Second 8 27 Third + 6 20 Weight loss > 10% 1 3 Feeding type Breast 26 86.6 Formula 2 6.7 Both 2 6.7 ABO/Rh 15 50 Direct Coombs + 3 10 Gestational age < 36 wk and 6 d 8 26 37 wk and 0 d to 4 14 37 wk and 6 d >38wk 18 60 Readmission stay Newborn length 1.7 0.5 of stay (d) Bilirubin on admission 21.4 3.3 Length of stay 2.0 1.3 Exclusive breastfeeding 26 86.7 on admission Breastfeeding on discharge 17 51.5 be at 100%. However, improvements in documentation of written and oral counseling cannot readily be entered into the template. Each patientõs family receives written information about jaundice upon admission of the infant to the unit, but providers must document the discussion of jaundice with parents, making this a more clinically significant behavioral change in documentation. Improvement in documentation of exclusive breastfeeding also is encouraging. Although improved documentation does not necessarily mean improved practices, it is a standard method of evaluating care. Conversely, a significant decrease was noted in one care quality indicator: documentation of two observed breastfeedings. A possible explanation for this unexpected finding is the change to a mother-baby nursing model of care approximately 6 weeks before the intervention took place. Relative inexperience with this model among many of the obstetrical nurses caring for and providing documentation on the infants may have affected this indicator. In addition, a serious illness in the lactation consultant director led to low staffing levels during this period. In some areas the compliance with quality indicators was already high and thus there was no room for improvement. These areas included assessment of bilirubin level, documentation of primary care practice/ provider, documentation that 8 to 12 breastfeedings per day were recommended, and documentation that parents received contact information for lactation consultants and licensed health care providers upon discharge. The number of infants discharged at > 72 hours of age was very small, and thus changes in this indicator are difficult to identify. Two quality care indicators were still in need of improvement at the end of the study: documentation of breastfeeding within the first hour of life and documentation that the mother was given contact information for peer or community support for breastfeeding. In addition to improvement in several quality indicators, a smaller percentage of infants were discharged in the high-risk zone (Table 2), despite the continued pressure to discharge infants before the recommended 72 hours of life. The average length of newborn stay for infants in the compliance sample was 1.7 days. The AAP Committee on Fetus and Newborn (2010) does not recommend early discharge (< 48 hours) unless the infant is full term (37-41 completed weeks), appropriate weight for gestation, and meets 16 additional criteria. It is worth noting that despite a 29.1% cesarean birth rate during the study period, no infant delivered by cesarean section was readmitted with a diagnosis of hyperbilirubinemia. The extra day of inpatient care provided to these infants may have prevented severe hyperbilirubinemia by allowing adequate time for breastfeeding initiation and support after birth. The implementation of this educational intervention was supported by published guidelines (AAP Subcommittee on Hyperbilirubinemia, 2004) and led by an opinion leader in the community. The most significant difficulty encountered in this process was scheduling face-to-face time with the multiple providers responsible for care. One 11-member provider group scheduled the intervention twice for its monthly meeting and then cancelled because their agenda was too full. However, 57% of newborn care for this group was provided by a single PNP who did receive the intervention, which lessened the impact of our inability to provide the intervention face-to-face for the 10 physicians in this group. The content of the educational intervention was provided to these physicians via email, but there was no follow-up to determine whether they had actually read it or discussed it in the group. 48 Volume 27 Number 1 Journal of Pediatric Health Care

The preintervention/postintervention design of this study limits the ability to establish cause and effect. This design was chosen because the goal was to improve the standard of care for all infants in the system, and including a control group of infants whose care providers received no intervention would have precluded that possibility. Data sampling was randomized to minimize differences between the sample groups before and after the intervention, although it is still possible that there were unexplored differences between the samples. During the study period it is possible that other initiatives with a potential impact on hyperbilirubinemia management could have been implemented in one or more medical provider groups; however, none is known to the authors. Ideally, future work would include This study demonstrates that educational interventions using guidelinebased clinical tools have the potential to change medical provider behavior and improve patient outcomes.. a control group over a longer period with prospective data collection to provide a greater numbers of readmissions. CONCLUSIONS The purpose of practice guidelines is to support the process of making patient care decisions, but guidelines must be used if they are to have a positive impact on outcomes. Too often, health care quality improvement analysts lament that it takes medical providers years to implement any guideline-based changes in their practices. Dissemination of guidelines alone may not be adequate to change practice behaviors (Kryworuchko, Stacey, Bai, & Graham, 2009). Therefore it is important to evaluate the effectiveness of professional guidelines in the real world to determine whether they can be practically employed and to identify barriers to their implementation. The multifaceted intervention strategies used in this study (including education about the guidelines, sharing current practice information, and training on the use of a clinical management tool by a local opinion leader) have been shown to be effective (Trowbridge & Weingarten, 2001). This study demonstrates that educational interventions using guideline-based clinical tools have the potential to change medical provider behavior and improve patient outcomes, as evidenced by the 50% decrease in readmissions for hyperbilirubinemia during the first week of life. REFERENCES Alkalay, A. L., Bresee, C. J., & Simmons, C. F. (2010). Decreased neonatal jaundice readmission rate after implementing hyperbilirubinemia guidelines and universal screening for bilirubin. 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