A National Quality Improvement Collaborative to Reduce Subthreshold Phototherapy for Jaundice

Subthreshold phototherapy use is common in infants with hyperbilirubinemia but leads to overtreatment of safe bilirubin levels. Coincident with publication of the 2022 American Academy of Pediatrics neonatal hyperbilirubinemia guidelines, we formed a quality improvement (QI) collaborative with the aim to reduce inpatient subthreshold phototherapy use to 10% of all phototherapy encounters over 12 months.

Our QI collaborative included 146 hospitals across North America. Sites submitted data from inpatient phototherapy encounters of newborns born at 35 weeks' gestation or more between February 2022-January 2023 (baseline period; 6-month preguideline period, 6-month washout period) and February 2023-January 2024 (intervention period). Interventions included QI coaching, educational webinars, electronic health record tools, clinical algorithms, and communication resources. We analyzed the primary outcome with interrupted time series and balancing measures by statistical process control.

Final analysis included 33 384 phototherapy encounters (20 018 baseline, 13 366 intervention) from 119 sites. The percentage of encounters initiated at subthreshold bilirubin levels decreased from 48.2% in the preguideline baseline period to 41.1% at the end of intervention. Overall phototherapy encounters demonstrated a relative decrease of 33.3%, with median encounters per site per month declining from 12 during the baseline period to 8 at the end of intervention. Modest increases were seen in percentage of encounters that met escalation-of-care threshold (5.73%-6.32%) and peak bilirubin greater than 25 mg/dL (0.87%-2.12%).

Although subthreshold phototherapy decreased, the chosen goal of reducing subthreshold encounters to 10% or less of all phototherapy encounters was not reached after 12 months. Future work is needed to determine barriers to reducing unnecessary treatment for neonatal jaundice.