Paediatrics & Child Health, 2017, 259–263

doi: 10.1093/pch/pxx056
Original Article
Advance Access publication 22 June 2017

Original Article

A nurse-initiated jaundice management protocol improves

quality of care in the paediatric emergency department
Michelle Long MD FRCPC1,2, Ken J. Farion MD FRCPC2,3, Roger Zemek MD FRCPC2,3, Debby
Voskamp RN BScN2, Nick Barrowman PhD1,4, Salwa Akiki MSc4, Sarah Reid MD FRCPC2,3

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1
Department of Pediatrics, University of Ottawa, Ottawa, Ontario; 2Emergency Department, Children’s Hospital
of Eastern Ontario, Ottawa, Ontario; 3Departments of Pediatrics and Emergency Medicine, University of Ottawa,
Ottawa, Ontario; 4Clinical Research Unit, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
Correspondence: Michelle Long, Emergency Department, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa,
Ontario K1H 8L1. Telephone 613-737-7600 ext. 3955, Fax 613-738-4892, e-mail: MLong@cheo.on.ca
Ethics Board Approval: Children’s Hospital of Eastern Ontario Research Ethics Board, Ottawa, ON

Abstract
Background:  Hyperbilirubinemia is a common neonatal condition requiring timely management to prevent acute bilirubin
encephalopathy. Management protocols allow nonphysicians to initiate designated actions prior to physician assessment.
Objective:  To assess the effectiveness of a nurse-initiated neonatal jaundice management protocol for serum bilirubin sam-
pling and phototherapy for neonates presenting with hyperbilirubinemia to the Paediatric Emergency Department (PED).
Methods:  A health records review was performed for jaundiced neonates 12 months prior to the introduction of the man-
agement protocol (control period) and 12 months after (intervention period). Randomly selected charts were evaluated for
time to serum bilirubin sampling, phototherapy initiation, ED length of stay, admission rate, completion of direct antiglobu-
lin test and nursing documentation.
Results:  Two hundred and sixty-six neonates (131 control and 135 intervention) were included. Median time to serum bil-
irubin sampling was reduced by 22% (36 min versus 28 min; P<0.001) with 34 min difference at the 90th percentile (94 min
[95% confidence interval (CI) 63.7 to 116.9] versus 60 min [95% CI 49.0 to 78.2]). Statistically significant improvements
were found in time to phototherapy initiation (127 min [95% CI 72.0 to 160.7] versus 65 min [95% CI 50.0 to 72.4] at 90th
percentile), ED length of stay (267 min [95% CI 180.9 to 292.9] versus 216 min [95% CI 171.1 to 247.4] at 90th percentile)
and hospital admissions (36% versus 17%; P<0.001). Improvements were also observed in direct antiglobulin test measure-
ment (P<0.001) and nursing documentation (P=0.017)
Conclusions:  Implementation of a PED neonatal jaundice management protocol was associated with improved timeliness
and standardization of care for this common and important condition.

Keywords:  Emergency department; Hyperbilirubinemia; Infant; Jaundice; Management protocol.

Many of the two-thirds of neonates who develop jaundice in the first weeks of the effectiveness of clinical pathways by delegating authority for nonphysician
life present to the Paediatric Emergency Department (PED) for management implementers to perform designated actions prior to physician assessment,
(1,2). Though the majority of jaundice cases are benign and self-limited, acute thus facilitating timely care (6). Studies evaluating PED nurse-initiated clinical
bilirubin encephalopathy still occurs in approximately 1 in 10,000 live births pathways and management protocols have demonstrated significant outcome
(1,3,4). improvements for acutely ill patients (5,7–9).
National and international neonatal hyperbilirubinemia practice guidelines A study evaluating a PED neonatal jaundice clinical pathway demon-
have emphasized timely interventions for prevention of neurological complica- strated improved times to phototherapy, bloodwork and decreased length
tions (1–3). PED overcrowding may contribute to delayed assessments, serum of stay (4). The median time from triage to serum bilirubin sampling and
bilirubin sampling and phototherapy initiation for neonates with severe hyper- phototherapy in this study was greater than 1 h. The authors noted that addi-
bilirubinemia (4). Clinical pathways operationalize best evidence guidelines tional improvements could be accomplished by implementing a manage-
into accessible bedside formats for health care provider teams (5). Management ment protocol to permit nurse-initiated bloodwork and phototherapy prior
protocols, also known as standing orders or medical directives, further improve to physician assessment (4).

©The Author 2017. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. 259
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260 Paediatrics & Child Health, 2017, Vol. 22, No. 5

The goal of our study was to assess the impact of a nurse-initiated man- Measures
agement protocol for jaundiced neonates in the PED. We hypothesized that The primary outcome was median and 90th percentile time from triage assess-
a protocol authorizing serum bilirubin sampling and phototherapy initia- ment to serum bilirubin sampling documented in the electronic health record.
tion prior to physician assessment would be associated with a 20% reduc- Secondary outcomes included median and 90th percentile times from triage
tion in time to serum bilirubin sampling. We further hypothesized that this assessment to phototherapy initiation, total ED LOS, admission rate, rate of
would be associated with decreased time to phototherapy and ED length of DAT sampling and completion of nursing documentation for time of bilirubin
stay (LOS). sampling and phototherapy initiation. If phototherapy initiation was not doc-
umented, we classified the patient as having not received phototherapy. DAT
sampling was included to identify patients with isoimmune hemolytic disease
METHODS in order to classify risk of kernicterus.
Study setting and population
This study was performed in the Children’s Hospital of Eastern Ontario Sample size estimation
(CHEO) ED, a tertiary care centre with 68,000 visits and approximately 400 The ideal time to bloodwork and phototherapy initiation for jaundiced neonates

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neonatal jaundice cases annually. Eligibility criteria included neonates of any is undefined in the literature; thus a 20% time reduction to these interventions
gestational age, 0 to 28 days, on first presentation with the chief complaint of was deemed to be clinically significant based on expert opinion. A prestudy chart
jaundice or hyperbilirubinemia identified by primary care provider, parental audit examining 100 randomly selected charts (50 control and 50 intervention)
report or triage assessment. Neonates were excluded if they required resuscita- was performed to inform our sample size calculation. Median time to serum bil-
tion (Pediatric Canadian Triage and Acuity Scale [PaedCTAS] 1) or had serum irubin sampling in the pilot intervention sample was 31 minutes compared to 39
bilirubin level measured by a primary care provider immediately prior to PED minutes in the control period, a 20.5% reduction. Since the time to serum biliru-
presentation (10). bin sampling was skewed, a log transformation was used, resulting in an approx-
imate Gaussian distribution with a standard deviation of 0.61. In order to have
Existing standard of care (control period) 80% power to detect this reduction, with probability of type-I error fixed at 5%,
a minimum of 119 charts from control and intervention periods were required.
Prior to the protocol, neonatal jaundice management was variable in our PED.
We randomly selected 140 charts from all eligible neonatal jaundice visits during
Verbal orders were commonly employed and phototherapy was initiated either
the control and intervention periods using a computer-generated random sample.
at the time of serum bilirubin sampling or after bilirubin results were known.
Medical trainees often performed initial assessments followed by staff physician
review, potentially leading to management delays. Data analysis
Patient characteristics were examined using descriptive statistics. For categorical
Development of neonatal jaundice management protocol variables, frequencies and percentages were computed. For continuous variables,
Our PED supports the expansion of the nursing role through nurse-initiated man- mean (standard deviation), median (interquartile range [IQR]) and range were
agement protocols (11,12). As a patient safety initiative to standardize quality of computed. To test for patient differences between the control and intervention
care for jaundiced neonates, a multidisciplinary team of ED nurses and physicians periods in categorical variables, the chi-square or Fisher’s exact test was used. The
developed the management protocol (available from the corresponding author by continuous variable of age was compared using the Student’s t test.
request). Previously published institutional guidelines for management protocol Times from triage to serum bilirubin sampling, phototherapy initiation and
implementation were followed (11). ED LOS were summarized using median and IQR. For the primary and sec-
The management protocol instructs the triage nurse to assign a triage level of ondary outcome analyses, times from triage to serum bilirubin sampling, pho-
‘PaedCTAS 2 – Emergent’ (10). Within 15 minutes of patient arrival, the bed- totherapy initiation and discharge were compared using the Mann–Whitney U
side nurse provides parental education, obtains consent and blood via heelstick test. Two-sided P values less than 0.05 were considered statistically significant.
for serum bilirubin and direct antiglobulin test (DAT) and initiates high-inten- Because time from triage to serum bilirubin sampling was skewed, the differ-
sity phototherapy (Olympic Bili-Bassinet; 30 to 35 µW/cm2/nm). Neonates ence in the 90th percentile in the control and intervention periods was further
remain under phototherapy with continuous temperature monitoring and eye used to describe group differences in times at the upper end of the distribution.
shielding until the serum bilirubin level is resulted and reviewed by the physi- Completeness of documentation was compared using Pearson’s chi-square test.
cian. For febrile, jaundiced neonates, the Jaundice Management Protocol was Serum bilirubin levels according to postnatal age in hours and kernicterus
used in conjunction with our institution’s Febrile Neonate/Rule Out Sepsis risk factors were used to determine qualification for exchange transfusion (ET)
Management Protocol. (2). Neonates were classified as low risk (>38 weeks and well), medium risk
(>38 weeks and risk factors or 35 to 37 6/7 weeks and well) or high risk (35
Study design to 37 6/7 weeks and risk factors). A Fisher’s exact test was used to determine
Health record reviews were performed for eligible neonates over a 25-month whether the number of neonates meeting ET criteria differed between control
period: 12 months prior to management protocol initiation (control period, and intervention periods. Postnatal age in hours was calculated by taking the
October 1, 2010 to September 30, 2011) and 12 months after (intervention difference between triage date/time and birth date/time, rounding to the near-
period, November 1, 2011 to October 31, 2012). The study periods were sepa- est 6 h. When birth time was not available, the baby was considered born at
rated by a ‘training period’ (October 2011). Twelve-month study periods were 12:00 in order to provide an estimate of age in hours.
chosen to minimize seasonal variation in PED volumes. All statistical analyses were performed using SPSS 22.0 (SPSS, Inc., Chicago, IL).
Relevant charts were identified using ICD-10-A coding for neonatal jaun-
dice and hyperbilirubinemia. One reviewer screened the charts for inclusion/
RESULTS
exclusion criteria and abstracted relevant data using a standardized data collec-
tion form. Ten per cent of the charts were reviewed by a second reviewer. Data Patient characteristics
were entered into a customized database created in REDCap, a secure, web- During the study periods, 820 jaundiced neonates were seen in the PED of
based application for data capture in research studies (13). Ethics approval was which 280 were randomly selected for review. Of these, 266 neonates were
obtained through the CHEO Research Ethics Board. included in the study (131 neonates in the control group and 135 in the
Paediatrics & Child Health, 2017, Vol. 22, No. 5 261

Table 1.  Demographic characteristics

Pre (N=131) Post (N=135) P value

N (%)

Age (days) (mean±SD) 6.07 ± 4.18 6.12 ± 4.28 0.92a

Gender
 Female 58 (44.3) 50 (37.0) 0.23b
 Male 73 (55.7) 85 (63.0)
Gestational age
 35–37 + 6 days 29 (26.1) 23 (20.5) 0.32b
  >38 weeks 82 (73.9) 89 (79.5)
PaedCTAS code

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 1 0 (0.0) 0 (0.0) 0.37b
 2 129 (98.5) 132 (97.8)
 3 1 (0.8) 3 (2.2)
 4 1 (0.8) 0 (0.0)
 5 0 (0.0) 0 (0.0)
Visit type
  Home initiated 53 (40.5) 67 (49.6) 0.25b
 Referred 77 (58.8) 66 (48.9)
  Not documented 1 (0.8) 2 (1.5)
Feeding type
  Breast fed 79 (60.3) 97 (71.9) 0.13b
  Formula fed 9 (6.9) 6 (4.4)
  Both breast fed and formula fed 28 (21.4) 16 (11.9)
  Not documented 15 (11.5) 16 (11.9)
Phototherapy initiation
 Yes 75 (58.1) 101 (74.8) 0.004*,b
 No 54 (41.9) 34 (25.2)
First physician assessment
Figure 1.  Flow diagram of participants recruited into the study.   Medical student 6 (4.6) 7 (5.2) 0.66b
 Resident 42 (32.1) 43 (31.9)
intervention group, Figure 1). Patient characteristics are described in Table  Fellow 12 (9.2) 9 (6.7)
1. There was a statistically significant difference in the serum bilirubin levels  Staff 39 (29.8) 50 (37.0)
in the control group (277 µmol/L, IQR: 231 to 309 µmol/L) compared to   Not documented 32 (24.4) 26 (19.3)
the intervention group (247 µmol/L, IQR: 206 to 288 µmol/L) (P<0.001). Kernicterus risk zone
After adjusting for ‘home-initiated’ versus ‘referred’ visit types in the control  Low-risk 83 (64.3) 89 (66.4) 0.92b
and intervention groups with a two-way Analysis of Variance (ANOVA), a  Medium-risk 41 (31.8) 36 (26.9)
statistically significant decreased serum bilirubin level was still present. There  High-risk 5 (3.9) 9 (6.7)
was 100% agreement between reviewers for gender, disposition, dates of visit,
triage assessment, documentation of phototherapy initiation and serum bil- T test. bChi-square test. *P<0.05
a

irubin sampling. Inter-rater reliability was almost perfect for time of triage
assessment (κ=0.85) and time of serum bilirubin sampling (κ=0.88) and sub-
42 minutes (IQR: 26 to 70) in the control group compared to 34 minutes
stantial for time of discharge (κ=0.67) and time of phototherapy initiation
(IQR: 26 to 45) in the intervention group (P=0.032) with a decrease of 62
(κ=0.75).
minutes at the 90th percentile (127 minutes [95% CI 72.0 to 160.7 minutes]
versus 65 minutes [95% CI 50.0 to 72.4 minutes]).
Primary outcome While there was no significant difference in ED LOS between control and
Clinical outcomes are described in Table 2. The intervention group had intervention periods (129  min [IQR: 99 to  179] versus 128  min [IQR: 94
improved median time from triage to serum bilirubin sampling (36 min- to  184]; P=0.669), there was a statistically significant decrease in ED LOS
utes [IQR: 25 to 59] versus 28 minutes [IQR: 22 to 38], a 22.2% reduction for discharged neonates in the intervention period, with a median difference
[P=0.001], Figure 2). The 90th percentile of time from triage to serum bilirubin of 17  min (135  min [IQR 108 to  176] versus 118  min [IQR: 91 to  155];
sampling was 94 minutes in the control group (95% confidence interval [CI] P=0.011). The difference in 90th percentile ED LOS for discharged patients
63.7 to 116.9 minutes) compared to 60 minutes in the intervention group (95% was 51 min (267 min [95% CI 180.9 to 292.9 min] versus 216 min [95% CI
CI 49.0 to 78.2 minutes). 171.1 to 247.4 min]). There were significantly fewer admissions to hospital in
the intervention group compared to the control group (17% versus 35.9%;
Secondary outcomes P<0.001). There was no significant difference between the number of neo-
Phototherapy initiation documentation was improved in the intervention group nates meeting ET criteria between the control and intervention periods (5.4%
(101 [74.8%] versus 75 [57.2%]; P=0.004). Median time to phototherapy was versus 2.2%; P=0.21).
262 Paediatrics & Child Health, 2017, Vol. 22, No. 5

Table 2.  Clinical outcomes

Pre (N=131) Post (N=135) P value

N (%) or median (IQR)

Serum bilirubin levels 277 (231–309) 247 (206–288) <0.001*,a

(µmol/L)
Disposition
 Admitted 47 (35.9) 23 (17.0)
 Discharged 84 (64.1) 112 (83.0) <0.001*,b
Serum bilirubin levels categorized by disposition (µmol/L)
 Admitted 314 (283–359) 306 (266–377) 0.68a
 Discharged 254 (223–289) 240 (2001–264) 0.014*,a

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DAT completed
 Yes 45 (34.4) 94 (69.6) <0.001*,b
 No 86 (65.6) 41 (30.4)
DAT result
 Positive 2 (4.8) 4 (4.4) 0.94b
 Negative 40 (95.2) 86 (95.6)
Number of patients admitted to:
 Ward 41 (87.2) 22 (95.7) 0.27b
  Neonatal Intensive 6 (12.8) 1 (4.3)
Care Unit
  Pediatric Intensive 0 (0.0) 0 (0.0)
Care Unit
Patients meeting exchange
transfusion criteria
 Yes 7 (5.4) 3 (2.2) 0.21c
 No 122 (94.6) 131 (97.8)

DAT direct antiglobulin test; IQR interquartile range.

a
Mann–Whitney U test. bChi-square test. cFisher’s exact test. *P<0.05

DAT measurement significantly increased after management protocol initia-

tion (34.4% versus 69.6%; P<0.001). Nursing documentation of therapies was Figure 2.  Time from triage to serum bilirubin sampling in control and intervention periods. The
significantly higher following management protocol implementation (54.6% vertical axis uses a log scaling. Individual times are represented by circles. For each period, the
versus 68.9%; P=0.017). There were no parental complaints, safety incidents median (dark horizontal line) and 25th and 75th percentiles (top and bottom of the box) have been
or adverse events in regards to the protocol identified through the institutional superimposed.

Safety Reporting System during the study period.

ED overcrowding may lead to delayed treatment and prolonged ED LOS
(6). Despite a 3.9% increase in patient census at our institution over the study
DISCUSSION period (with no concomitant increase in staffing), our time to serum bilirubin
A novel PED nurse-initiated neonatal jaundice management protocol was asso- sampling and phototherapy initiation improved with the use of the manage-
ciated with reduced time to bloodwork, phototherapy, ED LOS for discharged ment protocol. Admitted patients’ ED LOS may be impacted by bed availability
patients and improved nursing documentation. These results are consistent and staffing. Excluding admitted patients, discharged neonates in the interven-
with previous studies demonstrating the effectiveness of nurse-initiated treat- tion period had a statistically significant decreased ED LOS. Use of the protocol
ments (5,8,9,11). Standardization of care and improved adherence to practice was associated with a clinically significant reduction in ED LOS for patients at
guidelines with protocol implementation may account for the decreased time the 90th percentile by almost an hour.
to jaundice management. Despite randomization, the intervention group had a significantly lower
Although most patients received timely bilirubin sampling and photother- median serum bilirubin level and a lower admission rate. Since our manage-
apy prior to protocol implementation, there were a proportion of ‘outliers’ who ment protocol only impacts initial PED care and the decision to admit is pri-
experienced delays due to factors including physician availability, daily census marily based on the initial bilirubin level, this was an unexpected and interesting
and acuity in the PED. Protocol implementation was associated with a reduc- finding. Adjusting for visit type did not account for the difference in serum bil-
tion in the 90th percentile times to bilirubin sampling and phototherapy by irubin levels. To our knowledge, there is no literature on how quickly serum
more than half an hour and an hour, respectively. We found a smaller decrease in bilirubin levels rise in untreated neonates with hyperbilirubinemia. Future pro-
median time to bilirubin sampling and phototherapy than Wolff et al. did post- spective studies are required to investigate this association.
protocol implementation (4). Time to these interventions at our institution in The possibility of over-diagnosis and treatment was carefully considered
the control period was already substantially less than in Wolff ’s study intervention when creating the management protocol. Our intervention did not lead to
period, likely reflecting the use of verbal orders. more aggressive hyperbilirubinemia screening since only neonates presenting
Paediatrics & Child Health, 2017, Vol. 22, No. 5 263

with jaundice qualified for the protocol. Prompt phototherapy initiation Conflict of Interest
for every jaundiced neonate reduces the risk of severe h­ yperbilirubinemia.
The authors have no conflicts of interest to disclose. The authors have no financial relation-
The known minimal risks associated with a brief period of phototherapy for ships relevant to this article to disclose.
­neonates whose bilirubin levels do not require treatment is outweighed by
the potential benefit of rapid initiation of phototherapy for neonates who
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