Pediatric emergency medicine trisk 0896 0896
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Discharge
Neonates with presumed physiologic jaundice whose serum bilirubin levels fall
below the threshold for intervention, are well appearing, able to maintain
adequate hydration, and have assurance of close follow-up, may be safely
discharged from the ED.
The AAP recommends home phototherapy as an option for neonates whose
TSB level does not cross the threshold for therapeutic intervention, but in whom
the rate of rise may be concerning. Home phototherapy is not indicated for infants
with TSB levels that are above phototherapy or exchange transfusion thresholds.
APPROACH
Clinical Pathway for Neonates
The main goal of the clinical pathway is to deliver consistent and efficient care to
neonates born at greater than 35 weeks of gestational age presenting with
jaundice or hyperbilirubinemia. The pathway emphasizes safe and consistent use
of phototherapy, in order to prevent occurrences of ABE and kernicterus ( Fig.
45.3 ). The pathway does not apply to infants with congenital medical or surgical
conditions, those who are not normothermic, or who are known to have elevated
serum bilirubin at the time of ED presentation.
The bedside nurse is charged with initiating the clinical pathway, providing
parents with basic education as to the goals of evaluation, and obtaining a total
and fractionated serum bilirubin via heel stick (capillary blood). Once the sample
is collected, the infant is placed on phototherapy. Logistically, by the time the
history and physical examination are completed, the result of the TSB is
available, allowing the clinician to rapidly make further diagnostic and
therapeutic decisions. The pathway provides links to education modules for
clinicians, discharge paper template that may be printed for patients, and the AAP
Subcommittee on Hyperbilirubinemia manuscript.
Implementation of this clinical pathway has been shown to reduce time to
phototherapy initiation, time to bilirubin measurement, and overall ED length of
stay.
