Journal of Perinatology (2009) 29, S53–S57 r 2009 Nature Publishing Group All rights reserved. 0743-8346/09 $32 www.nature.com/jp
REVIEW
Systems changes to prevent severe hyperbilirubinemia and promote breastfeeding: pilot approaches AR Stark1 and CM Lannon2 1
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA and 2Center for Health Care Quality, Division of Health Policy and Clinical Effectiveness, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Providing safe and effective care requires coordination among the multiple levels of the health care system. These levels comprise the newborn (patient, family and community), nursery or primary care practice (microsystem), hospital or managed care organization (macro-organization) and policy, payment or regulatory issues (environmental context). Contemporary care practices associated with childbirth and early newborn care often reflect disruptions in coordination of these processes and place newborns at risk for poor outcomes. For example, with routine early postpartum discharge, often at less than 48 h after vaginal birth, the peak of serum bilirubin at 3 to 5 days of age typically occurs at home, rather than observed by clinicians in a newborn nursery. In addition, lactation is rarely well established by early discharge and support is often inadequate, increasing the risk of hyperbilirubinemia and discontinuation of breastfeeding. Also, late preterm infants are frequently cared for in the newborn nursery, although they often have difficulty establishing oral feeding and are at substantially higher risk for severe hyperbilirubinemia than infants born at term. Finally, pediatric follow-up is often delayed beyond the first week, after the optimal time for continued assessment of jaundice and lactation. The American Academy of Pediatrics Safe and Healthy Beginnings Initiative, a pilot quality improvement project, will target newborn nurseries, primary care practices and coordination between these sites using a systems-based approach to facilitate implementation of the 2004 guideline for management of hyperbilirubinemia. Journal of Perinatology (2009) 29, S53–S57; doi:10.1038/jp.2008.215
Keywords: hyperbilirubinemia; neonatal jaundice; clinical practice guideline; quality of health care
Commentary During the first week after birth, more than 60% of apparently healthy term and late preterm newborns experience jaundice due to hyperbilirubinemia. Of these, approximately 5% develop hyperbilirubinemia severe enough to require treatment with Correspondence: Dr AR Stark, Texas Children’s Hospital, 6621 Fannin/Neonatology/MC WT6-104, Houston, TX 77030, USA. E-mail:
[email protected]
phototherapy and approximately one in 15 000 develop serum bilirubin concentrations exceeding 30 mg per 100 ml.1,2 Lack of appropriate treatment places these infants at risk for kernicterus, the devastating, irreversible neurological condition that affects approximately one in 50 000 to 100 000 newborns in developed countries. An important challenge of the health care system is to maintain sufficient vigilance to reduce the incidence of these relatively rare but serious events while minimizing unintended consequences, such as increased parental anxiety, decreased breastfeeding or unnecessary treatment leading to excessive cost. A secondary challenge in the newborn period is to facilitate successful lactation. Frequent breastfeeding (8 to 12 times per day) decreases the incidence of severe hyperbilirubinemia.3–5 Conversely, dehydration and/or poor caloric intake associated with inadequate breastfeeding can contribute to the development of hyperbilirubinemia. However, despite the recognized benefits to both infants and mothers, and known interventions that promote continued lactation, only 70% of women in the United States initiate breastfeeding and only one-third continue exclusive breastfeeding past 6 months. Insufficient lactation counseling is known to interfere with successful breastfeeding and may result from disruptive hospital policies, early discharge, lack of timely follow-up care and lack of guidance from health care professionals. Lactation assessment during hospitalization can detect and help correct inadequate latch-on and milk transfer, which are associated with early cessation of breastfeeding.6,7 Furthermore, breastfeeding support from healthcare providers during routine primary care visits and from family members at home can improve breastfeeding outcomes.8 Providing safe and effective care requires coordination among the multiple levels of the health care system. These levels comprise the newborn (patient, family and community), nursery or primary care practice (microsystem), hospital or managed care organization (macro-organization) and policy, payment or regulatory issues (environmental context).9 Contemporary care practices associated with childbirth and early newborn care often reflect disruptions in coordination of these processes and place newborns at risk for poor outcomes. For example, with routine
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early postpartum discharge, often at less than 48 h after vaginal birth, the peak of serum bilirubin at 3 to 5 days of age typically occurs at home, rather than observed by clinicians in a newborn nursery. In addition, lactation is rarely well established by early discharge and support is often inadequate, increasing the risk of hyperbilirubinemia and discontinuation of breastfeeding. Also, late preterm infants are frequently cared for in the newborn nursery, although they often have difficulty establishing oral feeding and are at substantially higher risk for severe hyperbilirubinemia than infants born at term. Finally, pediatric follow-up is often delayed beyond the first week, after the optimal time for continued assessment of jaundice and lactation. Furthermore, health insurance policies do not always facilitate appropriate care for infants, and lack of appropriate compensation to the provider likely contributes to poor compliance with recommendations.10,11 Policies often do not support a prenatal visit with an infant health care provider, offer reimbursement for transcutaneous bilirubin measurement or provide routine coverage for early systematic follow-up by a clinician.
Aim
A seamless transition from the nursery team to the primary care practice, the infant’s medical home, is possible, but gaps in parent education, provider communication and continuity are frequent. A follow-up visit within 2 days of discharge is recommended by the American Academy of Pediatrics for infants discharged at 72 h of age have a documented plan that includes follow-up by a licensed health care provider
Parents counseled and provided written information about jaundice before nursery discharge; counseling documented in chart
Examples of potential changes nurseries can make 1. Review existing policy and update if necessary 2. Engage hospital leadership in adopting a policy 3. Provide training to staff regarding policy
1. Implement protocol requiring that all families be asked name of medical home and that medical home be documented in chart 2. Develop list of medical homes to help families identify a medical home 1. Incorporate reminder on risk assessment worksheets in chart 2. Initiate standard practice of documenting follow-up plan on chart 3. Monitor discharge plans for appropriateness and provide feedback to clinicians 4. Encourage family to make appointment 5. Make appointment for family 6. Provide name and no. for family to call 7. Send letter to PCPs re: appropriate f/u interval 1. Provide AAP FAQs to all parents
Figure 1b Continued.
Although guidelines provide recommendations on the basis of the best available evidence, they often fail to translate into standard practice and improved care for multiple reasons. One factor involves provider education. Studies of strategies used to change practice show that traditional didactic continuing medical education, in which information is acquired passively, is rarely successful.16 Although knowledge is essential to produce a change in provider behavior, additional strategies are needed. Interventions at the microsystem level that are more likely to change practice or improve health outcomes are: (1) multifaceted, (2) target multiple rather than single barriers to change, (3) utilize active learning in a sequenced manner over time and (4) provide tools and resources that facilitate implementation in the practice setting.16–18 Supplying practical strategies and simple tools can help clinicians make the transition from current processes to newer potentially better approaches. Changes in practice that are simplified and require limited adaptation are more likely to disseminate rapidly.19 The American Academy of Pediatrics Safe and Healthy Beginnings project has been established to facilitate implementation of the 2004 guideline for management of hyperbilirubinemia using a systems-based approach.20 This quality improvement project, focused at the microsystem
level, will target newborn nurseries, primary care practices and coordination between these sites. The objectives are to test strategies and tools that will enable clinical sites to ensure that: All infants are systematically assessed for risk of severe hyperbilirubinemia before discharge from the newborn nursery. All infants have appropriate follow-up based on age and risk for hyperbilirubinemia at discharge. All breastfeeding mothers receive appropriate and effective support and counseling. An example of an implementation framework in the nursery sites, known as a ‘key driver diagram, is shown in Figure 1. Additional diagrams for the key objectives in the primary care sites have been developed and will be tested in the Safe and Healthy Beginnings project. Safe and Healthy Beginnings is a pilot project of the Academy’s Quality Improvement Innovation Network through a partnership with the Center for Health Care Quality at Cincinnati Children’s Hospital Medical Center. The improvement project is designed to ensure a safe and healthy beginning for all newborns by testing measures, strategies and tools based on the following three key aspects of the AAP’s revised hyperbilirubinemia guidelines:20 (1) assessment of risk for severe hyperbilirubinemia before hospital discharge, (2) breastfeeding support and (3) care coordination between the nursery and primary care. Journal of Perinatology
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Aim
This key driver may or may not be in control of nursery
Increase to 100% the number of breastfeeding mothers who receive appropriate, effective support and counseling.
Examples of potential changes nurseries can make
Key drivers
Infant put to breast within first hour of life
Parents counseled about how to breastfeed and what to expect (with specific guidance that babies should breastfeed at least 8–12 times per day); counseling documented in chart
Two formal evaluations of breastfeeding documented in chart
1. Implement WHO/UNICEF ‘10 Steps’ 2. Establish multi-disciplinary working group to set policy and guide implementation 3. Delay clinical procedures that may interfere with early breastfeeding whenever possible
1. Provide training in effective counseling to staff responsible for counseling 2. Use ‘Clinical Care Path for Breastfeeding’ 3. Ensure physician support of effective counseling 4. Support rooming-in 5. Ensure rooming-in exclusion list is short 6. Support mother–baby nursing care 7. Use Jane Morton’s video to train staff 8. Provide parents simple instructions to get started (e.g. Breastfeeding Log, AAP’s ‘Breastfeeding your Baby’)
1. Provide training in appropriate charting to document breastfeeding assessment 2. Implement scoring tools (e.g. IBFAT, Latch) 3. Evaluate skill level of observer/ensure adequate training
Mother provided name and contact information of person qualified to answer breastfeeding questions and offer support
1. Provide resource guide (tailored for local community)
Figure 1c Continued.
Approximately 20 teams from the American Academy of Pediatrics’ Innovation Network will work together for 8 months in an adapted learning collaborative, based on the Institute for Healthcare Improvement Breakthrough Series model,21 to test whether identified tools and strategies improve care. This collaborative will involve monthly performance measurement and feedback, two face-to-face workshops and communication through monthly conference calls and email listserv. Teams will incorporate changes in the newborn nursery, such as systematic assessment of subsequent risk of hyperbilirubinemia, assurance of appropriate follow-up after discharge and assessment and counseling of breastfeeding mothers. Changes in the primary care setting include timing of the first visit and continued assessment of jaundice and breastfeeding, as well as lactation support. Teams will use the Model for Improvement22 to test the identified strategies and tools. For example, identifying a segment of high-risk families for whom the nursery team will document the medical home and schedule follow-up may improve compliance with initial follow-up visits, allowing clinicians to detect progression of hyperbilirubinemia, problems with breastfeeding and other neonatal conditions. A comprehensive toolkit will be developed and disseminated in fall of 2008 as a result of the AAP project. Broader implementation of the successful changes identified in this project could be further evaluated at the health system and payor level. The toolkit and Journal of Perinatology
associated implementation activities can provide a foundation to ensure safe and healthy beginnings for infants. Disclosure The authors have declared no financial interests. Drs Stark and Lannon are co-chairs of The American Academy of Pediatrics Safe and Healthy Beginnings Institute.
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