Neonatal nurses reduce diagnosis times for jaundice in newborns

Newborn babies who need care on our special care baby unit at Yeovil Hospital are now able to get a diagnosis and treatment for jaundice within minutes.

It’s all thanks to a service evaluation project run by two colleagues on the unit – senior sister Beth Hawken and staff nurse Eleanora Forbes – who set about investigating re-admissions to hospital of small babies with the jaundice – a condition where the skin and whites of the eyes turn yellow.

The project was part of our trust’s chief nurse research fellowship that ran last year, and the findings resulted in a major change to the way test results are processed.

Beth explains: “At first, we wanted to find out exactly what the clinical journey of a newborn readmitted into YDH with jaundice looked like.

“To do this, Eleanora and I reviewed five different case studies of babies who had come back into hospital onto our postnatal ward.

“We studied every aspect of their care pathway in great detail, from the moment they were re-admitted to hospital and the time they were reviewed by a doctor, to when their bloods were taken.

“We also looked at the time it took for their bloods to get to the lab, how long the processing took, and the timeframe that a clinician reacted to the result…all the way through to the baby’s discharge from hospital.

“We wanted to find out whether any part of this process seemed to cause a delay for every baby we care for, and if there was a way that we could improve it.

“This involved checking whether there was any opportunity to speed things up, so everything could work as efficiently as possible, resulting in a possible reduction in the overall length of stay in hospital for both the baby and their family.”

Eleanora adds: “After we captured the results of five case study babies, we began a literature review, which also involved speaking to other people and groups interested in this type of work.

“For each baby we looked at whether there was a delay and what caused it, and alongside this we checked our literature review to see how jaundice was being managed in other areas of the country and even worldwide.

“By doing this, we found out that one of the major reasons for a delay in treatment for jaundice was that the blood sample journey took up to seven hours, from when it was first taken, to its transportation to the laboratory, analysing process, checking of the result, and the beginning of phototherapy treatment – it felt a bit too long and we were sure that it could be reduced.”

Once Beth and Eleanora had analysed the case study babies and recognised the emerging themes that were coming out, they felt that they were beginning to understand the current process, and then set about looking at what they could do to improve it.

“In the second part of our project we wanted to focus our efforts on why those delays were happening, and how we could improve them,” Beth continues.

“So we could understand things a little better, we sent out a questionnaire to the main people involved in the care pathway – the postgraduate doctors in training who carry out the reviews, midwives who look after the baby, and of course, the parents.

“We asked for their views on the current management of babies’ neonatal care, and from this we were able to unpick several common themes that came up.

“One thing that everybody reported was a recognition that education for colleagues needed to be improved. The second most common theme was the delay in getting the blood test results.

“Parents also said they’d have ideally been told more information about the equipment, and would have preferred more support around regular infant feeding, which helps to flush out jaundice from the baby.

“Once we understood what was currently happening and why, we were able to start looking at how we could improve things.”

Eleanora explains how their findings led to the diagnosis time for jaundice reducing from seven hours to just two to three minutes.

“One of the main areas of delay that found was the process of analysing bloods,” she adds. “From there, we found out we were actually already using this type of blood gas analysing equipment on our maternity unit, and one of the results shows the level of bilirubin in the blood – which is the main cause of jaundice.

“The machine wasn’t calibrated for analysing the bilirubin level in small neonatal babies though.

“From our earlier literature search, we found that some units did use this type of machine in neonatal care, so we contacted our biochemist consultant and asked whether we could do this with our machine.

“They took away our idea for a couple of months to go through all the safety checks and procedures, and then gave us the green light to start the machine to analyse bilirubin levels, meaning babies can get those test results within minutes.

“This is a real game changer in the care of neonatal babies as their treatment is not only much more efficient, but they’re not jaundice for so long, meaning they’re less likely to experience any complications.

“Sometimes if the jaundice gets so high, we aren’t able to treat it at YDH so the baby has to be transferred to Musgrove Park Hospital, or even Bristol Children’s Hospital, so starting it early can only be a good thing for everyone.

“We reviewed the care of two different babies with the same level of jaundice and found that the baby who had their tests done on the blood gas analyser stayed in hospital for 16 hours less.”

Beth and Eleanora have now started a trial on the special care baby unit to see how it’ll work in practice. The project is then expected to be extended to our midwifery teams and units across the trust, so colleagues can become more familiar with using this point of care blood gas machine instead of sending samples to the lab.

The second part of Beth and Eleanora’s quality improvement project will be to develop a colleague education programme that raises awareness of the most up to date guidelines around the management of jaundice, as well as how to use the equipment.

“The less time that a baby has to stay in hospital, the better for everyone, both psychologically and allowing them to get on with their life,” Beth continues.

“We feel that this project has made a significant difference to the care of babies already so we’re really proud of being given this opportunity through the chief nurse research fellowship.”

If you’re interested in finding out more about Beth and Eleanora’s study, feel free to contact them on Beth.Hawken@SomersetFT.nhs.uk and Eleanora.Forbes@SomersetFT.nhs.uk.