450 - Assessing Barriers to Implementation of 2022 Clinical Practice Guideline (CPG) Concordant Care for Hyperbilirubinemia Management in Neonates

Publication Number: 450.3825

Preeta A. Kamat, Northwestern University The Feinberg School of Medicine, Chicago, IL, United States; Joy Koopmans, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Malika D. Shah, Northwestern University The Feinberg School of Medicine, Chicago, IL, United States

Background: Hyperbilirubinemia is a common cause of hospitalization in neonates. While treatment by phototherapy (PT) is standard, it is not without risk. In 2022 the American Academy of Pediatrics published updated clinical practice guidelines (CPG) surrounding the management of neonatal hyperbilirubinemia, which included higher PT thresholds stratified by gestational age and neurotoxicity risk status, escalation of care criteria, and discussion of rate of rise (ROR) levels suggestive of hemolysis.

Objective: This study assesses potential barriers to CPG concordant care for neonatal hyperbilirubinemia, focusing on the ROR and access to care on weekends. We hypothesized that infants receiving subthreshold PT would be more likely to 1) have a high rate of rise (>0.2 mg/dL/hr after 24 hours of life) and 2) require weekend follow-up.

Design/Methods: A retrospective chart review was completed of all infants at > 35 weeks of gestational age who received inpatient PT between 0-14 days of age from 02/01/2022 – 1/24/2024 in an urban hospital (n=601). ROR was calculated after 24 hours of life. Weekend follow-up was defined as infants who need bilirubin reassessment on a Saturday or Sunday. Chi-square analysis was completed to identify the association between subthreshold PT and (1) ROR and (2) weekend follow-up.

Results: Infants were stratified into pre-CPG (6 months before 2022 CPG), washout (6 months following 2022 CPG publication), and post-CPG (from 6 through 18 months following 2022 CPG publication). Positive DAT was slightly higher during the washout period (43% versus 34% pre-CPG and 35% post-CPG, p < 0.001). There were no other statistically significant differences in demographic factors among time periods. Subthreshold PT increased during the washout period compared to pre- and post-CPG periods (61% vs. 42% and 46%, respectively, p < 0.001). Post-CPG there was a significant association with subthreshold PT in those with high ROR (p = 0.005). Subthreshold PT and weekend follow-up were significantly associated (weekday 46% vs. weekend 58%, Chi square p = 0.010); this was unchanged when stratified by pre/post-CPG.

Conclusion(s): Following CPG implementation, infants with high ROR were more likely to have subthreshold PT, suggesting clinicians are factoring ROR into the decision to start subthreshold. More guidance regarding clinical decision making based on ROR is necessary. Clinicians are more likely to prescribe subthreshold PT when neonatal follow-up falls on a weekend, irrespective of CPG implementation.

Table 1: Demographics
*Percentages not equal to 100% due to rounding. CPG = Clinical Practice Guideline

Figure 1: Subthreshold Phototherapy By Bilirubin Rate of Rise Category After First 24 Hours of Life Pre- & Post-CPG


Figure 2: Subthreshold Phototherapy By Bilirubin Drawn Follow-up Category