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Less Stress, More Nursing Care for Infants

Monday September 25, 2006
Susan Spinner, RN, MSN, APN, uses Draeger Medical's Minolta JM103 to measure a newborn's bilirubin levels at Virtua Health, Voorhees, N.J. Photo courtesy of Virtua Health.
Susan Spinner, RN, MSN, APN, uses Draeger Medical's Minolta JM103 to measure a newborn's bilirubin levels at Virtua Health, Voorhees, N.J. Photo courtesy of Virtua Health.
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Virtua Health uses transcutaneous method for testing newborn bilirubin levels.

Spurred by a recommendation by the American Academy of Pediatrics (AAP), nurses at Virtua Health in South Jersey are implementing a new method for testing bilirubin levels in newborns. A transcutaneous test is more efficient for nurses and less painful for infants than the traditional serum test.
Neonatal jaundice, or hyperbilirubinemia, has long been recognized as a significant disorder among newborns. Increased bilirubin - a byproduct of red blood cells - causes jaundice, which can result in permanent brain damage. The extent of the brain damage is dependent on the concentration of bilirubin that reaches the brain and the duration of the exposure.
Infants with hyperbilirubinemia present with yellow staining of the skin and sclera, which spreads across the body and extremities to the palms of the hands and soles of the feet. Infants are usually not jaundiced at birth because bilirubin is cleared from the fetal circulation by the placenta. But it is estimated that 60% of newborns - and up to 80% of preterm infants - develop jaundice within the first week of life.1
Due to the increasing incidence of hyperbilirubinemia, the AAP recommends that bilirubin levels in all newborns be tested prior to discharge from the hospital.2
The Joint Commission for Accreditation of Hospitals (JCAHO) issued a sentinel event alert on this same subject in 2001 and again in 2004.3,4 Virtua Health, a multihospital health care organization in South Jersey, responded to the AAP's recommendation by organizing a Bilirubin Task Force at Virtua Memorial Hospital Burlington County and Virtua West Jersey Hospital Voorhees.
Reexamining protocols
The task force - composed of physicians, nursing administration, nurse managers from each unit, and the pediatric/neonatal clinical nurse specialist - decided to change the protocols for bilirubin testing at all Virtua facilities. Until that point, pediatricians had determined whether to draw a serum bilirubin based on an infant's clinical presentation.
Task force members undertook a review of all current literature of bilirubin testing methods. They studied the standard of care at other hospitals and health systems in the region. Consideration was given to the volume of babies cared for annually - 7,700 infants are born at Virtua hospitals each year. The result was a unanimous decision to standardize practice: All newborns would undergo a bilirubin test prior to discharge from the hospital.
But serum bilirubin testing causes a significant amount of stress for the infant and adds to a nurse's task list. Nurses perform the screening by drawing blood from a newborn's heel. Results are not available from the lab for about an hour. The Bilirubin Task Force decided to study whether infant stress levels and nursing efficiency could be improved with new technology available - specifically, Draeger Medical's Minolta JM103, a transcutaneous bilimeter.
Testing the technology
The literature review showed that the correlation between the JM103 skin test and serum bilirubin levels were statistically significant.5 The task force wanted to study the transcutaneous test vs. serum in infants greater than 36 weeks gestational age at Virtua and created several projects to do so.
As part of the initiative, a comprehensive educational program was created for all nurses in maternal child health at Burlington County Memorial Hospital and Virtua Voorhees. Lisa Marshall, RN, BSN, CCRN, the pediatric staff development specialist, taught about causes, signs, and symptoms of hyperbilirubinemia; discharge planning; and parent education. Marshall also explained to nurses how to use the equipment. All nurses completed competencies for the education before the projects began, and now the education is part of Virtua's annual mandatory competencies for maternal child health nurses.
During the test period, data was collected and reported by the clinical nurse specialist. The variables studied included accuracy of the equipment, infant heart rate (as an indicator of stress), and nursing time to perform each test (as a measure of efficiency). Over several months, 50 infants were studied.
The research results showed that the accuracy of the transcutaneous test is comparable to that of the serum test. The stress levels of infants, determined by measuring heart rates of infants during each type of test, proved to be significantly less using the transcutaneous method. In terms of nurse efficiency, the transcutaneous test took only 7 seconds to obtain bilirubin levels, while the serum test took 67 seconds to obtain a blood sample and an hour to receive the bilirubin level from the lab.
The new transcutaneous bilirubin test allows nurses to spend more time caring for infants - a very important factor for an organization that delivers nearly 8,000 babies a year.
Research acclaim
This clinical trial has received significant attention from professional organizations. The preterm study results were accepted for publication by the Society for Pediatric Research and were presented as a poster at the organization's annual meeting. In addition, the research and results were presented at The Medica, the world's largest medical trade fair in Dusseldorf, Germany.
Perhaps even more important than the correlation of the skin test and serum test is the time saved by nurses. The new technology gives bedside nurses more time for parent education, such as adjusting to having an infant or learning breast feeding skills. Simply stated, Virtua Health's decision to change its bilirubin testing protocols creates more time for nurses to be nurses.