Shared learning database

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Published date:
November 2012

An audit was conducted at our hospital looking at NICE jaundice guidelines and whether our trust was investigating and managing these affected babies according to the 'gold standard'.

We found the use of the transcutaneous bilirubinometer to be excellent in decreasing the number of painful blood tests needed and also in reducing our workload.

The main downfall noted and subsequently addressed was the lack of information provided to parents about the condition and management strategies.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

-To undertake an audit to check if the local neonatal team was adhering to recent NICE guidelines on neonatal jaundice (NICE CG98, May 2010)

-To make recommendations to improve compliance and quality of care towards patients.

Reasons for implementing your project

Before the project was started it was noted at monthly doctors meetings that:
1. Checking serum bilirubin samples on multiple babies daily (often more than once per day) was time consuming and made parents unhappy due to the number of blood tests required.
2. A recommendation for the department to invest in a transcutaneous bilirubinometer was recognised and after this was purchased the entire team of neonatal doctors underwent training on how to use this piece of equipment.
3. General feedback from many parents during ward rounds and reviews showed that many did not understand what jaundice was and why it was important for us to monitor this and what treatment was available.

There were many benefits identified from the audit:
1. We recognised some shortcomings such as not providing parents with enough information about jaundice and not providing patient information leaflets. We also noted that midwives were not flagging up higher risk babies. We observed that many doctors did not enquire about siblings who suffered with jaundice thus flagging up increased risk in subsequent babies.
2. We identified that a large amount of current practice was upto date and efficient which boosted the team morale.
3. We identified that the use of the transcutaneous bilirubinometer had cut down the workload on postnatal and neonatal ward doctors and received feedback that parents were very happy with this method as a screening tool.

How did you implement the project

We conducted a prospective audit between January 2011 to August 2011 involving a random selection of 48 babies with jaundice on the postnatal wards.

Data was collected using maternal and baby notes, biochemistry and haematology blood results and the information was gathered using a proforma. This proforma was filled out by doctors working on the postnatal wards who had received guidance and information about the audit via emails and local departmental meetings and teaching sessions.

Our project did not incur any costs.

Key findings

RESULTS: There was 90% compliance with NICE guidance with regards to serum bilirubin measurement in infants with jaundice at less than 24 hours of age. 83% of infants with jaundice at more than 24 hours of age were able to have transcutaneous bilirubin measurements which reduced the number of painful blood tests in these patients, alleviated parental anxiety around blood tests and significantly reduced the workload on postnatal doctors. Poor performance was demonstrated in assessing whether previous siblings had been affected with jaundice - thus failing to identify an important risk factor. We found this was only done in 15% of audited patients. Only 75% of parents received information about jaundice or patient information leaflets. EVALUATION: Auditing against NICE guidance raised awareness amongst doctors, nurses and midwives caring for infants with this condition. We were unable to quantify the exact savings made from using the transcutaneous bilirubinometer (TCB) but the cost reduction from using less lancets, blood collection tubes, plasters and so on is evident. The use of the TCB significantly reduced workload on doctors who were frequently bleeding infants to monitor their jaundice levels and feedback from parents was that they appreciated this method as it was less painful for their baby and generally a much faster test. Training midwives to measure bilirubin using the TCB had commenced after our audit was completed to further reduce workload on busy doctors. Our audit was presented in a departmental meeting so that all members of the team could appreciate the key learning points and acknowledge the good things we were doing but also improve on the downfalls. One of the main recommendations that was made was to involve the parents more in discussion about the condition- the pathophysiology, management options and what to do when they take their child home. We have provided patient information leaflets to ease this discussion and information-giving to parents.

Key learning points

I would recommend all neonatal units undertake a similar audit as jaundice is a significant problem on neonatal and postnatal units. The NICE guidelines help clarify any confusion and unify the practice of different doctors within the workplace.

I would recommend that a questionnaire is done prior to the audit from parents of infants affected with jaundice and medical professionals involved in assessing and treating the condition to primarily identify what they feel are problem areas. I would then conduct the audit to see if the results are similar to those concerns earlier identified and then of course implement changes and re-audit and see if anything else can be improved upon.

Contact details

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Primary care
Is the example industry-sponsored in any way?