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Audit of babies Admitted in SCBU with Neonatal Jaundice

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

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  1. 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

  2. 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

  3. 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 James Paget Hospital

  4. 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 James Paget Hospital

  5. Premature, LBW & unwell babies need treatment at lower levels Conjugated hyperbilirubinaemia needs investigations Introduction James Paget Hospital

  6. < 24 hours Rh haemolytic disease ABO incompatibilities G6PD & other enzyme deficiencies Congenital Spherocytosis Congenital infections (eg. TORCH) Galactosaemia Causes James Paget Hospital

  7. 2nd – 5th day Physiological ( Commonest) Bruising/Cephahaematoma Polycythaemia Infections Haemolysis Galactosaemia Familial Non-haemolytic jaundice Metabolic (Amino acidopathies, organic acidaemias) Causes James Paget Hospital

  8. 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 James Paget Hospital

  9. Are we following trust guidelines for investigation Neonatal jaundice ? Does the guideline need any revision ? How can we improve our practice ? The Audit: Aim James Paget Hospital

  10. 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 James Paget Hospital

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

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

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

  19. How Was The Neonate Managed? Observed = 22 Phototherapy = 24 Exchange Transfusion = 0 James Paget Hospital

  20. 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

  21. How Was The Neonate Managed ? Observed = 22 ( 5 needed Phototx) Phototherapy = 24 Exchange Transfusion = 0 ( 1 needed transfusion) James Paget Hospital

  22. Duration of Phototherapy N= 24 Unable to assess duration = 5 Maximum = 62 hours Minimum = 2 hours Average = 28 hours James Paget Hospital

  23. 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

  24. 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

  25. 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

  26. 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

  27. Nursing notes were more explanatory than doctor’s notes….. as usual !! Special notes James Paget Hospital

  28. Better documentation Chasing SBR results Revision of guideline to make it clearer Re-audit in a year Recommendations James Paget Hospital

  29. A big Thanks to…… Ben Young, Audit Facilitator Nursing Stuff of SCBU James Paget Hospital

  30. Thank You !

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