Hyperbilirubinemia Algorithm to Decrease Painful Procedures in the Neonatal Intensive Care Unit

Abstract

Problem & Purpose: Neonates aged 35 0/7 weeks post-menstrual age (PMA) and greater admitted to a level III neonatal intensive care unit (NICU) suffer from repeated painful procedures daily for the evaluation of hyperbilirubinemia in the first week of life. Transcutaneous bilirubin (TcB) monitoring is a safe and noninvasive alternative that can decrease painful heel lances and provide accurate bilirubin measurements. According to a retrospective chart review conducted for a period from September to December 2020, 66% of eligible neonates cared for in the target NICU experienced painful heel lances for hyperbilirubinemia monitoring despite the availability of TcB monitoring. The purpose of this quality improvement project was to implement and evaluate the use of a hyperbilirubinemia algorithm for infants ≥ 35 0/7 weeks PMA to decrease the number of painful procedures in the NICU. Methods: Project implementation took place over a 15-week period in the Fall of 2021 in a 26-bed level III NICU in a Mid-Atlantic Metropolitan hospital. An interdisciplinary team was created to compose an algorithm and review the use of the bilimeter tool. Data collected pre- and post-implementation included the active ordersets, the use of TcB monitoring and the number of heel lances. Data was collected using electronically run data sets as well as manual chart audits on a weekly basis from the electronic health record. Results: A total of 52 neonates were included in this project. With use of the algorithm, 64% of neonates received TcB monitoring within the first 12-24 hours of life indicating a 55% decrease in the number of heel lances. Conclusions: The use of a hyperbilirubinemia algorithm with TcB monitoring resulted in a reduction of heel lances by more than half, leading to an overall decreased number of painful procedures.