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Audit of babies Admitted in SCBU with Neonatal Jaundice. Dr Paramita Dasgupta Ghosh SHO - Paediatrics. Facilitated by the Clinical Audit & Effectiveness Department James Paget Healthcare . Jaundice is the most common condition requiring medical attention in neonates

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Audit of babies Admitted in SCBU with Neonatal Jaundice

Dr Paramita Dasgupta Ghosh

SHO - Paediatrics

Facilitated by the Clinical Audit & Effectiveness Department

James Paget Healthcare

introduction
Jaundice is the most common condition requiring medical attention in neonates

Yellow discolouration of skin and mucous membrane in neonates is due to unconjugated bilirubin

Unconjugated bilirubin can pass BBB and is neurotoxic

Introduction

James Paget Hospital

introduction3
Jaundice might be the first presentation of numerous diseases

Investigations are needed to find underlying causes

Treatment should be instituted early to prevent permanent damages

Neonates are at high risk of getting jaundiced as they have high erythrocytic mass and turnover & immature liver

Introduction

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introduction4
Physiological Jaundice

Usually harmless in healthy term neonate

Never appears on first day

Peaks on 3rd & 4th day ,resolves by 2nd – 4th week.

Breast milk jaundice

peaks at 4th – 6th day

May persist up to 2 – 3 months

Not an indication to stop breast feeding

Introduction

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introduction5
Premature, LBW & unwell babies need treatment at lower levels

Conjugated hyperbilirubinaemia needs investigations

Introduction

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causes
< 24 hours

Rh haemolytic disease

ABO incompatibilities

G6PD & other enzyme deficiencies

Congenital Spherocytosis

Congenital infections (eg. TORCH)

Galactosaemia

Causes

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causes7
2nd – 5th day

Physiological ( Commonest)

Bruising/Cephahaematoma

Polycythaemia

Infections

Haemolysis

Galactosaemia

Familial Non-haemolytic jaundice

Metabolic (Amino acidopathies, organic acidaemias)

Causes

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causes8
Prolonged

Same as above

Breast milk jaundice( commonest)

Hypothyroidism

Neonatal hepatitis

Biliary tract problems

CF

Αlpha 1 AT deficiency

TPN hepatitis

Dubin Johnson/Rotor Syndrome

Causes

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the audit aim
Are we following trust guidelines for investigation Neonatal jaundice ?

Does the guideline need any revision ?

How can we improve our practice ?

The Audit: Aim

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methodolgy
Retrospective descriptive study

Period of study : 1st Jan to 30th June 2005

All admissions to SCBU scanned for jaundice

Doctor’s & nursing notes taken into account

Total number of notes scanned :85

Total no. of neonates with jaundice : 46

Methodolgy

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indications for investigating neonatal jaundice
Onset < 24 hrs

Premature

SBR>310 at 48hrs

SBR>360 thereafter

Prolonged >14 days –term

>21 days-preterm

Pale stools & dark urine

Unwell/Septic

Indications for investigating Neonatal Jaundice

James Paget Hospital

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Criteria 1

Neonates with jaundice (n=46)

All neonates with jaundice will have the following

A. Serum Bilirubin

B .Full Blood Count s

C. Blood grouping and direct Coombs test

D. Urea and Electrolytes

James Paget Hospital

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Criteria 2

Neonatal jaundice <24hrs n=3

  • Jaundice onset <24hrs should also have the following investigations performed :-
  • Reticulocytes
  • Blood Glucose
  • TORCH Screen
  • Coomb’s test
  • Rate of SBR rise monitoring

James Paget Hospital

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Criteria 3

Prolonged Jaundice Patients

  • All pt’s with Prolonged Jaundice will have the following investigations for Urine & Blood :-
  • Urine
  • Urine reducing substances (If fed)
  • Glucose
  • Urine amino and organic acids
  • MSU
  • Blood
  • Liver function tests
  • Thyroid function tests
  • TORCH screen
  • Immunoreactive Trypsin
  • Coagulation screen
  • Alpha -1
  • Galactose

No neonate had prolonged jaundice, therefore nobody fell into the criteria for this information

James Paget Hospital

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Additional information

  • For neonates who’s condition persists after first line investigations, the following second line investigations should be considered:
  • Immunoglobulins
  • G6PD in appropriate ethnic groups
  • Galactose – 1 – phosphate – uridyl transferase
  • Alpha – 1 antitrypsin (phenotype)
  • Check IRT screen. Consider sweat test / DNA for Cystic Fibrosis
  • Chromosomes
  • Abdominal ultrasound
  • Liver biopsy
  • Rate of rise monitored

No neonate had prolonged jaundice, therefore nobody fell into the criteria for this information

James Paget Hospital

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Criteria 4

Unwell and/or Premature Patients (n=42)

  • All neonates who are unwell will have the septic screen performed :
  • Septic Screen
  • MSU
  • Blood cultures
  • LP
  • CRP

James Paget Hospital

unwell n 20
Unwell ( n=20)
  • All unwell neonates should have the septic screen performed :
  • Septic Screen
  • MSU
  • Blood cultures
  • LP
  • CRP

James Paget Hospital

premature neonates n 22
Premature Neonates ( n=22)
  • All premature neonates with jaundice should have the septic screen performed :
  • MSU
  • Blood cultures
  • LP
  • CRP

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how was the neonate managed
How Was The Neonate Managed?

Observed = 22

Phototherapy = 24

Exchange Transfusion = 0

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some misses
One unwell,prem had jaundice <24 hrs, 1st SBR was above treatment line, not acted upon.

One had SBR in Exchange Transfusion Range , phototherapy was continued.

4 neonates,all prems had SBR above treatment line but no documentation & not acted upon

Some misses !!

James Paget Hospital

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How Was The Neonate Managed ?

Observed = 22 ( 5 needed Phototx)

Phototherapy = 24

Exchange Transfusion = 0 ( 1 needed transfusion)

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slide22

Duration of Phototherapy

N= 24

Unable to assess duration = 5

Maximum = 62 hours

Minimum = 2 hours

Average = 28 hours

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Number Of SBR Readings In First 48hrs For Jaundice <24hrs

n=3

2 Pt’s had 2 SBR readings in first 48hrs

1 Pt had 5 SBR readings in first 48hrs

James Paget Hospital

summary
SBRs done in all jaundiced babies

85% of all babies with neonatal jaundice had FBC with differentials

100% of all unwell babies with jaundice had FBC with differentials

100% of all babies with jaundice <24 hrs had FBC with Retics and BMs

Summary

James Paget Hospital

summary25
Only 4/46 (30%) of all neonates with jaundice had DCT and blood group

1/3 (33%) of neonatal jaundice <24 hrs didn’t have DAT& grouping.

Only 1/3 (33%) of neonatal jaundice <24 hrs had rate of rise monitored

None of the neonates with jaundice <24 hrs had TORCH screen

Summary

James Paget Hospital

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2/20 (10%) Unwell/Septic neonate had no Septic Screen

None of 42 (100%) unwell+/- premature babies had MSU

Only 2/20(10%) of unwell neonates had LP

5/46 (11%) of jaundiced neonates not picked up, all were premature (32 to 34 weeks), one of them, unwell prem.

James Paget Hospital

recommendations
Better documentation

Chasing SBR results

Revision of guideline to make it clearer

Re-audit in a year

Recommendations

James Paget Hospital

slide29

A big Thanks to……

Ben Young, Audit Facilitator

Nursing Stuff of SCBU

James Paget Hospital

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