Effect of educational program and interview on adoption of guidelines for the management of neonatal hyperbilirubinemia Douglas D. McMillan, MD, FRCPC; Jocelyn M. Lockyer, MHA; Leona Magnan, RN; Albert Akierman, MD, FRCPC; John T. Parboosingh, MD, FRCSC Objectives: To determine (a) whether physicians are adhering to the guidelines for the management of neonatal hyperbilirubinemia, (b) what influences their decisions to investigate and treat the condition and (c) the effect of an educational program and clinical recall interview on compliance with the guidelines. Design: Retrospective chart audit. Setting: Urban tertiary care hospital. Participants: All term neonates who received phototherapy but were not admitted to the neonatal intensive care unit. Interventions: Educational program and clinical recall interview. Measures: Charts were reviewed from March to May 1986 (period I, before publication of the guidelines) and from November 1986 to January 1987 (period II, after publication and after the educational program). The audits were repeated from April to June 1989 (period III, during the interview phase) and from October to December 1989 (period IV, 6 months after the interviews). Two criteria determined the appropriate use of phototherapy: the serum bilirubin level and the postnatal day on which phototherapy was started. Results: The proportion of infants receiving phototherapy for whom there were orders for complete blood counts to investigate hyperbilirubinemia increased from 20% in period I to 37% in period IV. The frequency of orders to determine the proportion of reticulocytes did not change significantly. The number of infants receiving phototherapy decreased over the study periods. The proportion receiving phototherapy in accordance with the criteria for the serum bilirubin level increased from 10% to 17% after the educational program (insignificant difference) and to 31% after the interviews (p = 0.02). Compliance with the guidelines was greater before the infants were 2 days old than when they were 3 days old or more (p = 0.01). Of the 45 physicians who prescribed phototherapy (for 94 infants) during period IV 26 never prescribed in accordance with the guidelines. The other 19 prescribed in accordance with the guidelines for 30 of 52 infants. Decisions to investigate and treat with phototherapy were affected by clinical and parental factors in addition to the guidelines. Two of the 25 physicians interviewed stated that the interview would influence their management of future cases of hyperbilirubinemia. Conclusion: A clinical recall interview can have a greater impact on changing physician management practices than factual communication on a group basis.
Objectifs : Determiner (a) si les medecins se conforment aux lignes directrices relatives au traitement de l'hyperbilirubinemie neonatale, (b) ce qui les amene a decider de proceder a des examens et de prescrire des traitements et (c) l'effet d'un programme Dr. McMillan is associate professor ofpediatrics, University ofCalgary, and chiefofthe Division of Neonatology, Foothills Provincial General Hospital, Calgary, Alta. Ms. Lockyer is administrative coordinator, Office of Graduate Clinical and Continuing Medical Education, and adjunct assistant professor, Office of Medical Education, Faculty ofMedicine, University of Calgary. Ms. Magnan is a neonatal research nurse at Foothills Provincial General Hospital. Dr. Akierman is assistant professor ofpediatrics, University ofCalgary, and a neonatologist at Foothills Provincial General Hospital. Dr. Parboosingh is assistant dean of continuing medical education and professor ofobstetrics and gynecology, University ofCalgary.
Reprint requests to: Dr. Douglas D. McMillan, Division of Neonatology, Foothills Provincial General Hospital, 1403 29 St. NW, Calgary, AB T2N 2T9 -
For prescribing information see page 792
CAN MED ASSOC J 1991; 144 (6)
707
d'information et d'entrevue de rappel clinique sur l'observation des lignes directrices. Conception : Verification retrospective des dossiers. Contexte: H6pital urbain de soins tertiaires. Participants: Tous les nouveau-nes a terme qui ont recu de la phototherapie mais n'ont pas e admis au service des soins intensifs pour nouveau-nes. Interventions: Programme d'information et entrevue de rappel clinique. Mesures: On a analyse les dossiers de mars a mai 1986 (periode I, avant publication des lignes directrices) et de novembre 1986 a janvier 1987 (periode II, apres publication et apres le programme d'information). On a repete les verifications pour les periodes d'avril a juin 1989 (periode III, au cours de la phase des entrevues) et d'octobre a decembre 1989 (periode IV, 6 mois apres les entrevues). L'utilisation appropriee de la phototherapie etait fonction de deux criteres, a savoir le taux de bilirubine serique et le jour suivant la naissance oii la phototherapie a e commencee. Resultats: La proportion de nouveau-nes recevant de la phototherapie pour lesquels il existait des commandes d'hemogrammes afin de depister l'hyperbilirubinemie est pass6e de 20 % au cours de la periode I a 37 % au cours de la periode IV. La frequence de commandes d'analyse du taux de reticulocytes n'a pas change de facon significative. Le nombre de nouveau-nes qui ont recu de la phototherapie a diminue au cours des periodes d'etude. La proportion des sujets qui ont recu de la phototherapie conformement aux criteres relatifs au taux de bilirubine serique est passee de 10 % a 17 % apres le programme d'information (difference sans importance) et a 31 % apres l'entrevue (p = 0,02). On a observe davantage les lignes directrices avant que les nouveau-nes aient 2 jours que lorsqu'ils avaient 3 jours ou plus (p = 0,01). Parmi les 45 medecins qui ont prescrit la phototherapie (pour 94 nouveau-nes) au cours de la periode IV, 26 n'ont jamais prescrit de phototherapie conformement aux lignes directrices. Les 19 autres medecins ont prescrit la phototherapie conformement aux lignes directrices pour 30 nouveau-nes sur 52. La decision de proceder a des examens et de prescrire des traitements de phototherapie etait influencee par des considerations cliniques et parentales en plus des lignes directrices. Deux des 25 medecins interviewes ont declare que l'entrevue influerait sur leur facon de traiter des cas futurs d'hyperbilirubinemie. Conclusion: L'entrevue de rappel clinique peuvent aider beaucoup plus a modifier les methodes de soins des medecins que des communications de faits destinees a un groupe en particulier.
V isible jaundice develops in about 50% of term neonates.' Physicians have to decide how to investigate hyperbilirubinemia and whether to use phototherapy. By 1986 there was sufficient scientific evidence to support a standardized approach to treatment that the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS) established and disseminated guidelines for appropriate care.' Specific suggestions were made regarding laboratory investigation of neonates with hyperbilirubinemia, and the indication for phototherapy was based on a combination of postnatal age and serum bilirubin level, as proposed by Cockington.2 The purpose of our study was twofold. First we set out to determine whether physicians were adhering to the guidelines as reinforced through a local educational program. When it became apparent that the educational program and guidelines were having a limited effect we then conducted clinical recall interviews to determine what factors were influencing the decision to investigate and treat neonatal hyperbilirubinemia and assessed the impact that these interviews had on subsequent adoption of the
guidelines. 708
CAN MED ASSOC J 1991; 144 (6)
Methods Educational program A three-part educational program was started in September and October 1986, within 3 months after publication of the CPS guidelines,' to promote the use of the guidelines in the Foothills Provincial General Hospital, Calgary. First, pediatricians and family physicians on staff received a letter informing them of the guidelines. Second, a joint educational "rounds" for the departments of Pediatrics and Family Medicine was held to present and discuss the use of the guidelines with two case studies. Finally, posters indicating the suggested investigation and the bilirubin levels that indicated phototherapy2 were placed in the newborn nursery, where they were easily seen by the physicians writing orders.
Chart audits To assess the effect of the guidelines as presented in the educational program we reviewed the charts of all neonates receiving phototherapy in the newborn nursery and discharged home from March
to May 1986 (period I, before publication of the guidelines) and from November 1986 to January 1987 (period II, after publication and after the educational program). To examine the effect of the interviews on physician practice we reviewed the charts again from April to June 1989 (period III, during the interview phase) and from October to December 1989 (period IV, 6 months after the interviews were completed). In the last study period we reviewed the phototherapy prescribing of individual physicians to assess the consistency with which they followed the guidelines. The indication for phototherapy was based on a combination of postnatal age and serum bilirubin level. Two measures were selected to determine whether infants met this criterion. The first was the overall number of babies receiving phototherapy whose serum bilirubin level was sufficiently elevated to warrant such treatment. The second was a more precise look at the serum bilirubin level by postnatal day to determine whether the phototherapy should have been started on the day specified. To ensure that the babies were comparable throughout the study periods information was included on common problems potentially associated with hyperbilirubinemia. Problems such as bruising, cephalhematoma and infection were noted from the findings at physical examination on admission and the physician's notes. Gestational age was obtained from the maternal data unless otherwise recorded by a physician. Requested investigations, including measurement of the serum bilirubin level before and after the start of phototherapy, were taken directly from the chart. Infants who were in the neonatal intensive care unit (NICU) at any point were excluded. No information was collected on babies not receiving phototherapy except with regard to the number of consultations for hyperbilirubinemia and exchange transfusions.
home a questionnaire was mailed to the physician to determine whether the interview affected the subsequent management of that infant or would affect management of future cases.
Interview andfollow-up questionnaire
Although the number of infants with ABO incompatibility (as indicated by a positive Coombs' test result) did not change, the proportion of such infants for whom phototherapy was prescribed increased significantly between periods II and IV (p = 0.02) (Table 1). Of these babies 12% had anti-A antibodies, 3% had anti-B antibodies, and 2% had other antibodies. The number of babies with polycythemia (venous hematocrit greater than 65%) increased significantly between periods II and IV (p = 0.03). There was no significant difference in the incidence of cephalhematoma or recorded bruising between the periods. The actual incidence of urinary
The clinical recall interviews were conducted from Mar. 9 to July 15, 1989, and each lasted 10 to 15 minutes. All of the infants in the newborn nursery who received phototherapy were identified. Each physician was interviewed only about the -first patient even though he or she may have prescribed phototherapy several times during the interview phase. An experienced neonatal nurse conducted the interview on the weekday after phototherapy was started and held it adjacent to the nursery so that thephysician could consult the hospital chart. The nurse used the patient's case to review the physician's knowledge and use of the CPS guidelines, approach to the case and plans to modify the management. About 1 week after the infant was discharged
Statistical analyses The results of the chart audits, interviews and follow-up questionnaire were analysed descriptively. We used x2 analyses to determine whether the proportion of babies receiving phototherapy and the investigations performed differed before and after the interviews.
Results Chart audit The number of infants receiving phototherapy decreased over the four periods (Table 1). The difference was significant between periods I and IV (p = 0.02) but not between periods I and II. From November 1988 to January 1989, 17% of the infants in the newborn nursery received phototherapy; thus, no change in the proportion of babies receiving phototherapy was evident during the 2 years between periods II and III. The male:female ratio was 1.2:1 on average and did not differ significantly between the periods. The proportion of low-birth-weight babies (those weighing less than 2500 g) varied from 4% to 6% and the proportion of high-birth-weight infants (those weighing more than 4000 g) from 5% to 11%; the proportions did not differ significantly between the periods. The mean birth weights in each period were similar and varied from 3276 to 3380 g. There were no differences in the mean gestational ages, which were from 38.4 to 39.0 weeks.
Problems associated with hyperbilirubinemia
tract infection was difficult to determine because a number of babies (especially in the last two periods) either had a positive urine culture result but were not treated or received antibiotics without having a CAN MED ASSOC J 199 1; 144 (6)
709
posiivecultre esut. Nne
f te inant ha
positive culture result. None of the infants had period 1 17 (10%) of 163, period II 22 (17%) of 128, period III 30 (28%) of 106 and period IV 29 (3 1%) of 94 (Fig. 1). The difference between periods I and II (before and after publication of the guidelines) was not significant, whereas it was significant between periods II and IV (before and after the interview) (p = 0.02). The number of infants who received phototherapy in accordance with the criteria by postnatal age is shown in Fig. 2. During all of the periods phototherapy was more likely to be prescribed in accordance with the guidelines before day 2 (67% of infants) than on day 2 (19%) or thereafter (7%) (p = 0.01). The numbers of infants receiving photo-
pneumonia, meningitis or septicemia.
Investigation practices Complete blood counts were ordered for 20% of the infants receiving phototherapy before the guidelines were published (period I) and 33% after the educational program (period II). During the interview phase (period III) they were ordered for 39%, a rate similar to the 37% observed 6 months later
(period IV).
Despite the fact that determination of the proportion of reticulocytes was suggested in the guidelines the frequency was minimal throughout the study: period I 0%, period II 5%, period III 3% and period IV 3%. During all the periods the Coombs' test was routinely performed when a cord blood sample was available but otherwise required a physician order; one baby was "missed" in the final period. Similarly, both total and conjugated serum bilirubin levels were routinely determined when measurement of the serum bilirubin level was ordered; the conjugated bilirubin measurement was missed in four babies in period I and two in period II. One infant was transferred to the NICU with severe jaundice during period II but improved without the need for exchange transfusion. Consultations for jaundice were infrequent, four to seven occurring Fig. 1: Proportion of term infants who received photoin each period. The only exchange transfusions therapy in accordance with the Canadian Paediatric Society performed were for premature infants in the NICU. (CPS) criteria for serum bilirubin level by study period. Period I was before publication of the guidelines, period II was after publication and after the educational program, period III was during the interview phase, and period IV was 6 months after the interviews were completed. Differences in proportions between period II and periods III and IV were significant (p < 0.05).
Initiation ofphototherapy The number of newborns who received phototherapy in accordance with the criteria for serum bilirubin levels by study period were as follows: Eaose -lunciae-rt.Xtr iiJOIFfS
...wimPolrdy associaterc Arh nvpertw'ruorneria *imc.ct -
larnts recevivrq 2rtDleo
Ier o
(and
AB3 .-ncompatibiwtv kpositir,i
13
C'oombs test r esult'i zolycythernnia (hem at o
.. .
:
epDhalhemat(on,ir.-
^ (7) 4.6 (28l 3
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rimanar tract Irnfen.To'-..
:otai El
o. receevlr
c'hototherapi ctarira -ey lO twas baTc ou --,yper blIirubinernia period lii was after VSa s r rrnti m at-A)ase. anrd period 5) Io
710
hurra .:
CAN MED ASSOC J 1991; 144 (6)
163 (17; *
9523
CI 2i 1
in :fantt-
20)
ci (6)
15 (14) 41 (39) (1) 8 (8) 128 (16) 106 (12) ( *. 820) 843) 13 (10) 47 (37)
:--. t24,
36 (38s i.
Z 441(i
-737
s -Jariaciaia Paediatric Society guidelines for the tmanagemer-nt *-eonatai ublicatiolo and after the educational program. periond IiI was durinq ths nter"iev nte,rviews were ronipleted
therapy in accordance with the guidelines by postnatal day were as follows: 7 (100%) of 7 before day 1, 40 (63%) of 63 on day 1, 35 (19%) of 180 on day 2, 10 (6%) of 174 on day 3 and 6 (9%) of 67 on days 4 to 6. Except for one infant in period II phototherapy was not stopped until the serum bilirubin concentration was below the recommended level. In all of the infants the serum bilirubin level was determined before the start of phototherapy. The mean level did not differ between the study periods: period I 200 ,umol/L, period II 214 ,umol/L, period III 214 ,umol/L and period IV 209,umolVL. The peak levels were 208, 224, 223 and 222,umol/L on average respectively. The corresponding bilirubin levels after the discontinuation of the phototherapy were 174, 184, 184 and 183,umol/L; the values were more than 100 ,umol/L below the level at which phototherapy is recommended among infants of normal birth weight 4 to 5 days of age.2 Among the infants receiving phototherapy the mean number of bilirubin measurements was similar in all the periods (4.3, 4.3, 4.5 and 4.2 respectively). An analysis of the prescribing patterns by individual physicians was undertaken in the final period (6 months after the interview). During that time 45 physicians (6 pediatricians) prescribed phototherapy for 94 infants, 29 of whom received it in accordance with the guidelines. The 19 physicians who followed the guidelines at least once during this period prescribed phototherapy in accordance with the guidelines for 30 (58%) of 52 infants. There were 26 physicians who never prescribed phototherapy in accordance with the guidelines during this period; 1 did so nine times, 1 four times, 1 three times, 3 twice and 20 once.
Interview andfollow-up questionnaire
Ten of the 35 physicians who prescribed phototherapy during the interview period could not be interviewed because they visited the hospital outside of office hours. The remaining 25 (5 pediatricians) accounted for 60% of the infants managed during period III. Although this study was not designed to differentiate patient care by specialty the proportion of infants who received phototherapy ordered by pediatricians was similar to that in the other periods. The physicians cared for 0 to 247 (mean 59.9) newborns during 1988, the year before the interview. They reported caring for 0 to 50 (mean 15.4) newborns with hyperbilirubinemia. All but one of the physicians were aware of the guidelines. All 25 believed that it was beneficial to investigate infants with hyperbilirubinemia. In the case discussed their decision to investigate was influenced by visible jaundice (76% of the physicians), the potential harmful effects of hyperbilirubinemia (64%), recent experience with similar babies (60%), concerns expressed by other health professionals (52%), parental concerns (36%) and issues of cost (4%). The source of information affecting the decision to prescribe phototherapy included the CPS guidelines (88%), past experience (80%), published articles (72%), continuing medical education courses (72%), hospital rounds (52%), advice from colleagues (44%) and medical school or residency training (44%). The decision to prescribe phototherapy was influenced by the clinical course and laboratory results (80%), the potential harmful effects on the baby (68%), recent experience with similar babies (56%), concerns expressed by other health care professionals (40%), parental concerns (28%) and issues of cost (12%). At the midpoint of the interview the physicians 100 were given an opportunity to reflect on the care 90provided. In retrospect 23 of the 24 who answered said that they would not have modified their investi80of the hyperbilirubinemia. For the prescripgation 70tion of phototherapy 21 of the 23 respondents stated 60 " c that they would not have modified their treatment; of the remaining 2 physicians 1 indicated that phototherapy would not have been used if there had not been parental pressure because of related health co10problems in previous cases, and the other said that 020,, he would have delayed the order. All 25 physicians responded to the follow-up 1 2 3 5 0 4 6 questionnaire. Only one indicated that the interview Postnatal age, d had influenced his subsequent management of the Peri Period II PerioldIV Period I infant discussed. Another physician, who initially indicated that the interview had not influenced his Fig. 2: Proportion of infants who received phototherapy in management, later responded that he had discharged accordance with the CPS criteria by postnatal age at which the infant earlier than he might have otherwise and therapy was started. provided a different follow-up. CAN MED ASSOC J 1991; 144 (6)
711
When asked whether they expected the interview to influence their management of future cases of hyperbilirubinemia two physicians responded Yes. They stated that they would change the way in which they initiated phototherapy, discontinued it, attended to parental concerns, discharged patients and followed up patients after discharge.
Discussion Guidelines represent a consensus of clinically interpreted scientific evidence. The CPS guidelines,' based on the work of Cockington,2 suggest a conservative approach, recommending phototherapy at relatively low serum bilirubin levels. In contrast, Lewis, Campbell and Hambleton3 suggested that phototherapy among otherwise healthy term neonates might be delayed until the level reaches 320 ,mol/L. The distribution of the guidelines only minimally influenced the physicians in their investigation of hyperbilirubinemia. The proportion of physicians who prescribed phototherapy in accordance with the guidelines increased after the educational program. None the less, the increase was insignificant. The fact that the proportion increased significantly during the interview period and was the same 6 months later suggested that a personalized approach was more beneficial. Compliance with the guidelines was greater during the first two postnatal days than afterward, when phototherapy was more often prescribed at a serum bilirubin level well below the recommended level. Although the interviews provided information about factors affecting the physicians' decision-making and identified the importance of clinical and social influences on care they were not designed to ascertain the reasons for deviation from the protocol. A number of possible explanations exist for failure to comply with the guidelines. Physicians may not accept the scientific evidence supporting the guidelines. There may be a tendency to prescribe phototherapy at a given bilirubin level regardless of postnatal age. Alternatively, physicians may react differently if they know that patient discharge is imminent. Even though guidelines do not have universal acceptance and some investigators have found poor compliance with protocols4-6 we expected that the CPS guidelines would have had a greater influence on behaviour. They were well known and readily accessible through posters in the nursery. On the whole, the communication of the guidelines through impersonal channels (i.e., letters, rounds and posters) had less of an impact than the interviews. Individualized education has consistently been
712
CAN MED ASSOC J 1991; 144 (6)
shown to have the greatest impact on care practices.7 Different physician practices and forms of educational programs may result in a more uniform approach in other centres. Because we did not include all physicians who cared for newborns additional factors that affect the investigation and management of neonatal hyperbilirubinemia may have been overlooked. Additional insight might have been obtained from physicians who seldom prescribe phototherapy (perhaps demonstrating greater compliance with the guidelines) had they been included. Our study reinforces the belief that adoption of change is complex. Educators interested in effecting change have been encouraged to develop strategies that accommodate the learner's needs to have a personal commitment to the change, a lengthy change process involving multiple experiences, an opportunity to build concepts to reinforce practices and an opportunity to deliberate over the information instrumental to the change.8 We have shown that clinical recall interviews are valuable. To be more effective, guidelines for patient care must be accompanied by more personal interaction with the
physicians. We thank Tunde Gondocz, Nimira Dhanani, Penny Jennett and the members of the Value Improvement Program and Health Records Department, Foothills Provincial General Hospital, for their contributions to the study. This study was supported by grants from the Association of Canadian Medical Colleges and the Foothills Provincial General Hospital Research and Development Fund.
References 1. Fetus and Newborn Committee, Canadian Paediatric Society: Use of phototherapy for neonatal hyperbilirubinemia. Can Med Assoc J 1986; 134: 1237- 1243 2. Cockington RA: A guide to the use of phototherapy in the
3. 4. 5.
6.
7.
8.
management of neonatal hyperbilirubinemia. J Pediatr 1979; 95: 281-285 Lewis HM, Campbell RH, Hambleton G: Use or abuse of phototherapy for physiologic jaundice of newborn infants. Lancet 1982; 2: 408-410 Kosecoff J, Kanouse DE, Rogers WH et al: Effects of the National Institutes of Health consensus development program on physician practice. JAMA 1987; 258: 2708-2713 Hill MN, Levine DM, Whelton PK: Awareness, use, and impact of the 1984 Joint National Committee consensus report on high blood pressure. Am J Public Health 1988; 78: 11901194 Lomas J, Anderson GM, Domnick-Pierre K et al: Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med 1989; 321: 13061311 Soumerai SB, McLaughlin TJ, Avorn J: Improving drug prescribing in primary care: a critical analysis of the experimental literature. Millbank Q 1989; 67: 268-313 Fox RD, Mazmanian PE, Putnam RW: Changing and Learning in the Lives ofPhysicians, Praeger, New York, 1989: 174
Objectifs : Determiner (a) si les medecins se conforment aux lignes directrices relatives au traitement de l'hyperbilirubinemie neonatale, (b) ce qui les amene a decider de proceder a des examens et de prescrire des traitements et (c) l'effet d'un programme Dr. McMillan is associate professor ofpediatrics, University ofCalgary, and chiefofthe Division of Neonatology, Foothills Provincial General Hospital, Calgary, Alta. Ms. Lockyer is administrative coordinator, Office of Graduate Clinical and Continuing Medical Education, and adjunct assistant professor, Office of Medical Education, Faculty ofMedicine, University of Calgary. Ms. Magnan is a neonatal research nurse at Foothills Provincial General Hospital. Dr. Akierman is assistant professor ofpediatrics, University ofCalgary, and a neonatologist at Foothills Provincial General Hospital. Dr. Parboosingh is assistant dean of continuing medical education and professor ofobstetrics and gynecology, University ofCalgary.
Reprint requests to: Dr. Douglas D. McMillan, Division of Neonatology, Foothills Provincial General Hospital, 1403 29 St. NW, Calgary, AB T2N 2T9 -
For prescribing information see page 792
CAN MED ASSOC J 1991; 144 (6)
707
d'information et d'entrevue de rappel clinique sur l'observation des lignes directrices. Conception : Verification retrospective des dossiers. Contexte: H6pital urbain de soins tertiaires. Participants: Tous les nouveau-nes a terme qui ont recu de la phototherapie mais n'ont pas e admis au service des soins intensifs pour nouveau-nes. Interventions: Programme d'information et entrevue de rappel clinique. Mesures: On a analyse les dossiers de mars a mai 1986 (periode I, avant publication des lignes directrices) et de novembre 1986 a janvier 1987 (periode II, apres publication et apres le programme d'information). On a repete les verifications pour les periodes d'avril a juin 1989 (periode III, au cours de la phase des entrevues) et d'octobre a decembre 1989 (periode IV, 6 mois apres les entrevues). L'utilisation appropriee de la phototherapie etait fonction de deux criteres, a savoir le taux de bilirubine serique et le jour suivant la naissance oii la phototherapie a e commencee. Resultats: La proportion de nouveau-nes recevant de la phototherapie pour lesquels il existait des commandes d'hemogrammes afin de depister l'hyperbilirubinemie est pass6e de 20 % au cours de la periode I a 37 % au cours de la periode IV. La frequence de commandes d'analyse du taux de reticulocytes n'a pas change de facon significative. Le nombre de nouveau-nes qui ont recu de la phototherapie a diminue au cours des periodes d'etude. La proportion des sujets qui ont recu de la phototherapie conformement aux criteres relatifs au taux de bilirubine serique est passee de 10 % a 17 % apres le programme d'information (difference sans importance) et a 31 % apres l'entrevue (p = 0,02). On a observe davantage les lignes directrices avant que les nouveau-nes aient 2 jours que lorsqu'ils avaient 3 jours ou plus (p = 0,01). Parmi les 45 medecins qui ont prescrit la phototherapie (pour 94 nouveau-nes) au cours de la periode IV, 26 n'ont jamais prescrit de phototherapie conformement aux lignes directrices. Les 19 autres medecins ont prescrit la phototherapie conformement aux lignes directrices pour 30 nouveau-nes sur 52. La decision de proceder a des examens et de prescrire des traitements de phototherapie etait influencee par des considerations cliniques et parentales en plus des lignes directrices. Deux des 25 medecins interviewes ont declare que l'entrevue influerait sur leur facon de traiter des cas futurs d'hyperbilirubinemie. Conclusion: L'entrevue de rappel clinique peuvent aider beaucoup plus a modifier les methodes de soins des medecins que des communications de faits destinees a un groupe en particulier.
V isible jaundice develops in about 50% of term neonates.' Physicians have to decide how to investigate hyperbilirubinemia and whether to use phototherapy. By 1986 there was sufficient scientific evidence to support a standardized approach to treatment that the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS) established and disseminated guidelines for appropriate care.' Specific suggestions were made regarding laboratory investigation of neonates with hyperbilirubinemia, and the indication for phototherapy was based on a combination of postnatal age and serum bilirubin level, as proposed by Cockington.2 The purpose of our study was twofold. First we set out to determine whether physicians were adhering to the guidelines as reinforced through a local educational program. When it became apparent that the educational program and guidelines were having a limited effect we then conducted clinical recall interviews to determine what factors were influencing the decision to investigate and treat neonatal hyperbilirubinemia and assessed the impact that these interviews had on subsequent adoption of the
guidelines. 708
CAN MED ASSOC J 1991; 144 (6)
Methods Educational program A three-part educational program was started in September and October 1986, within 3 months after publication of the CPS guidelines,' to promote the use of the guidelines in the Foothills Provincial General Hospital, Calgary. First, pediatricians and family physicians on staff received a letter informing them of the guidelines. Second, a joint educational "rounds" for the departments of Pediatrics and Family Medicine was held to present and discuss the use of the guidelines with two case studies. Finally, posters indicating the suggested investigation and the bilirubin levels that indicated phototherapy2 were placed in the newborn nursery, where they were easily seen by the physicians writing orders.
Chart audits To assess the effect of the guidelines as presented in the educational program we reviewed the charts of all neonates receiving phototherapy in the newborn nursery and discharged home from March
to May 1986 (period I, before publication of the guidelines) and from November 1986 to January 1987 (period II, after publication and after the educational program). To examine the effect of the interviews on physician practice we reviewed the charts again from April to June 1989 (period III, during the interview phase) and from October to December 1989 (period IV, 6 months after the interviews were completed). In the last study period we reviewed the phototherapy prescribing of individual physicians to assess the consistency with which they followed the guidelines. The indication for phototherapy was based on a combination of postnatal age and serum bilirubin level. Two measures were selected to determine whether infants met this criterion. The first was the overall number of babies receiving phototherapy whose serum bilirubin level was sufficiently elevated to warrant such treatment. The second was a more precise look at the serum bilirubin level by postnatal day to determine whether the phototherapy should have been started on the day specified. To ensure that the babies were comparable throughout the study periods information was included on common problems potentially associated with hyperbilirubinemia. Problems such as bruising, cephalhematoma and infection were noted from the findings at physical examination on admission and the physician's notes. Gestational age was obtained from the maternal data unless otherwise recorded by a physician. Requested investigations, including measurement of the serum bilirubin level before and after the start of phototherapy, were taken directly from the chart. Infants who were in the neonatal intensive care unit (NICU) at any point were excluded. No information was collected on babies not receiving phototherapy except with regard to the number of consultations for hyperbilirubinemia and exchange transfusions.
home a questionnaire was mailed to the physician to determine whether the interview affected the subsequent management of that infant or would affect management of future cases.
Interview andfollow-up questionnaire
Although the number of infants with ABO incompatibility (as indicated by a positive Coombs' test result) did not change, the proportion of such infants for whom phototherapy was prescribed increased significantly between periods II and IV (p = 0.02) (Table 1). Of these babies 12% had anti-A antibodies, 3% had anti-B antibodies, and 2% had other antibodies. The number of babies with polycythemia (venous hematocrit greater than 65%) increased significantly between periods II and IV (p = 0.03). There was no significant difference in the incidence of cephalhematoma or recorded bruising between the periods. The actual incidence of urinary
The clinical recall interviews were conducted from Mar. 9 to July 15, 1989, and each lasted 10 to 15 minutes. All of the infants in the newborn nursery who received phototherapy were identified. Each physician was interviewed only about the -first patient even though he or she may have prescribed phototherapy several times during the interview phase. An experienced neonatal nurse conducted the interview on the weekday after phototherapy was started and held it adjacent to the nursery so that thephysician could consult the hospital chart. The nurse used the patient's case to review the physician's knowledge and use of the CPS guidelines, approach to the case and plans to modify the management. About 1 week after the infant was discharged
Statistical analyses The results of the chart audits, interviews and follow-up questionnaire were analysed descriptively. We used x2 analyses to determine whether the proportion of babies receiving phototherapy and the investigations performed differed before and after the interviews.
Results Chart audit The number of infants receiving phototherapy decreased over the four periods (Table 1). The difference was significant between periods I and IV (p = 0.02) but not between periods I and II. From November 1988 to January 1989, 17% of the infants in the newborn nursery received phototherapy; thus, no change in the proportion of babies receiving phototherapy was evident during the 2 years between periods II and III. The male:female ratio was 1.2:1 on average and did not differ significantly between the periods. The proportion of low-birth-weight babies (those weighing less than 2500 g) varied from 4% to 6% and the proportion of high-birth-weight infants (those weighing more than 4000 g) from 5% to 11%; the proportions did not differ significantly between the periods. The mean birth weights in each period were similar and varied from 3276 to 3380 g. There were no differences in the mean gestational ages, which were from 38.4 to 39.0 weeks.
Problems associated with hyperbilirubinemia
tract infection was difficult to determine because a number of babies (especially in the last two periods) either had a positive urine culture result but were not treated or received antibiotics without having a CAN MED ASSOC J 199 1; 144 (6)
709
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positive culture result. None of the infants had period 1 17 (10%) of 163, period II 22 (17%) of 128, period III 30 (28%) of 106 and period IV 29 (3 1%) of 94 (Fig. 1). The difference between periods I and II (before and after publication of the guidelines) was not significant, whereas it was significant between periods II and IV (before and after the interview) (p = 0.02). The number of infants who received phototherapy in accordance with the criteria by postnatal age is shown in Fig. 2. During all of the periods phototherapy was more likely to be prescribed in accordance with the guidelines before day 2 (67% of infants) than on day 2 (19%) or thereafter (7%) (p = 0.01). The numbers of infants receiving photo-
pneumonia, meningitis or septicemia.
Investigation practices Complete blood counts were ordered for 20% of the infants receiving phototherapy before the guidelines were published (period I) and 33% after the educational program (period II). During the interview phase (period III) they were ordered for 39%, a rate similar to the 37% observed 6 months later
(period IV).
Despite the fact that determination of the proportion of reticulocytes was suggested in the guidelines the frequency was minimal throughout the study: period I 0%, period II 5%, period III 3% and period IV 3%. During all the periods the Coombs' test was routinely performed when a cord blood sample was available but otherwise required a physician order; one baby was "missed" in the final period. Similarly, both total and conjugated serum bilirubin levels were routinely determined when measurement of the serum bilirubin level was ordered; the conjugated bilirubin measurement was missed in four babies in period I and two in period II. One infant was transferred to the NICU with severe jaundice during period II but improved without the need for exchange transfusion. Consultations for jaundice were infrequent, four to seven occurring Fig. 1: Proportion of term infants who received photoin each period. The only exchange transfusions therapy in accordance with the Canadian Paediatric Society performed were for premature infants in the NICU. (CPS) criteria for serum bilirubin level by study period. Period I was before publication of the guidelines, period II was after publication and after the educational program, period III was during the interview phase, and period IV was 6 months after the interviews were completed. Differences in proportions between period II and periods III and IV were significant (p < 0.05).
Initiation ofphototherapy The number of newborns who received phototherapy in accordance with the criteria for serum bilirubin levels by study period were as follows: Eaose -lunciae-rt.Xtr iiJOIFfS
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therapy in accordance with the guidelines by postnatal day were as follows: 7 (100%) of 7 before day 1, 40 (63%) of 63 on day 1, 35 (19%) of 180 on day 2, 10 (6%) of 174 on day 3 and 6 (9%) of 67 on days 4 to 6. Except for one infant in period II phototherapy was not stopped until the serum bilirubin concentration was below the recommended level. In all of the infants the serum bilirubin level was determined before the start of phototherapy. The mean level did not differ between the study periods: period I 200 ,umol/L, period II 214 ,umol/L, period III 214 ,umol/L and period IV 209,umolVL. The peak levels were 208, 224, 223 and 222,umol/L on average respectively. The corresponding bilirubin levels after the discontinuation of the phototherapy were 174, 184, 184 and 183,umol/L; the values were more than 100 ,umol/L below the level at which phototherapy is recommended among infants of normal birth weight 4 to 5 days of age.2 Among the infants receiving phototherapy the mean number of bilirubin measurements was similar in all the periods (4.3, 4.3, 4.5 and 4.2 respectively). An analysis of the prescribing patterns by individual physicians was undertaken in the final period (6 months after the interview). During that time 45 physicians (6 pediatricians) prescribed phototherapy for 94 infants, 29 of whom received it in accordance with the guidelines. The 19 physicians who followed the guidelines at least once during this period prescribed phototherapy in accordance with the guidelines for 30 (58%) of 52 infants. There were 26 physicians who never prescribed phototherapy in accordance with the guidelines during this period; 1 did so nine times, 1 four times, 1 three times, 3 twice and 20 once.
Interview andfollow-up questionnaire
Ten of the 35 physicians who prescribed phototherapy during the interview period could not be interviewed because they visited the hospital outside of office hours. The remaining 25 (5 pediatricians) accounted for 60% of the infants managed during period III. Although this study was not designed to differentiate patient care by specialty the proportion of infants who received phototherapy ordered by pediatricians was similar to that in the other periods. The physicians cared for 0 to 247 (mean 59.9) newborns during 1988, the year before the interview. They reported caring for 0 to 50 (mean 15.4) newborns with hyperbilirubinemia. All but one of the physicians were aware of the guidelines. All 25 believed that it was beneficial to investigate infants with hyperbilirubinemia. In the case discussed their decision to investigate was influenced by visible jaundice (76% of the physicians), the potential harmful effects of hyperbilirubinemia (64%), recent experience with similar babies (60%), concerns expressed by other health professionals (52%), parental concerns (36%) and issues of cost (4%). The source of information affecting the decision to prescribe phototherapy included the CPS guidelines (88%), past experience (80%), published articles (72%), continuing medical education courses (72%), hospital rounds (52%), advice from colleagues (44%) and medical school or residency training (44%). The decision to prescribe phototherapy was influenced by the clinical course and laboratory results (80%), the potential harmful effects on the baby (68%), recent experience with similar babies (56%), concerns expressed by other health care professionals (40%), parental concerns (28%) and issues of cost (12%). At the midpoint of the interview the physicians 100 were given an opportunity to reflect on the care 90provided. In retrospect 23 of the 24 who answered said that they would not have modified their investi80of the hyperbilirubinemia. For the prescripgation 70tion of phototherapy 21 of the 23 respondents stated 60 " c that they would not have modified their treatment; of the remaining 2 physicians 1 indicated that phototherapy would not have been used if there had not been parental pressure because of related health co10problems in previous cases, and the other said that 020,, he would have delayed the order. All 25 physicians responded to the follow-up 1 2 3 5 0 4 6 questionnaire. Only one indicated that the interview Postnatal age, d had influenced his subsequent management of the Peri Period II PerioldIV Period I infant discussed. Another physician, who initially indicated that the interview had not influenced his Fig. 2: Proportion of infants who received phototherapy in management, later responded that he had discharged accordance with the CPS criteria by postnatal age at which the infant earlier than he might have otherwise and therapy was started. provided a different follow-up. CAN MED ASSOC J 1991; 144 (6)
711
When asked whether they expected the interview to influence their management of future cases of hyperbilirubinemia two physicians responded Yes. They stated that they would change the way in which they initiated phototherapy, discontinued it, attended to parental concerns, discharged patients and followed up patients after discharge.
Discussion Guidelines represent a consensus of clinically interpreted scientific evidence. The CPS guidelines,' based on the work of Cockington,2 suggest a conservative approach, recommending phototherapy at relatively low serum bilirubin levels. In contrast, Lewis, Campbell and Hambleton3 suggested that phototherapy among otherwise healthy term neonates might be delayed until the level reaches 320 ,mol/L. The distribution of the guidelines only minimally influenced the physicians in their investigation of hyperbilirubinemia. The proportion of physicians who prescribed phototherapy in accordance with the guidelines increased after the educational program. None the less, the increase was insignificant. The fact that the proportion increased significantly during the interview period and was the same 6 months later suggested that a personalized approach was more beneficial. Compliance with the guidelines was greater during the first two postnatal days than afterward, when phototherapy was more often prescribed at a serum bilirubin level well below the recommended level. Although the interviews provided information about factors affecting the physicians' decision-making and identified the importance of clinical and social influences on care they were not designed to ascertain the reasons for deviation from the protocol. A number of possible explanations exist for failure to comply with the guidelines. Physicians may not accept the scientific evidence supporting the guidelines. There may be a tendency to prescribe phototherapy at a given bilirubin level regardless of postnatal age. Alternatively, physicians may react differently if they know that patient discharge is imminent. Even though guidelines do not have universal acceptance and some investigators have found poor compliance with protocols4-6 we expected that the CPS guidelines would have had a greater influence on behaviour. They were well known and readily accessible through posters in the nursery. On the whole, the communication of the guidelines through impersonal channels (i.e., letters, rounds and posters) had less of an impact than the interviews. Individualized education has consistently been
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CAN MED ASSOC J 1991; 144 (6)
shown to have the greatest impact on care practices.7 Different physician practices and forms of educational programs may result in a more uniform approach in other centres. Because we did not include all physicians who cared for newborns additional factors that affect the investigation and management of neonatal hyperbilirubinemia may have been overlooked. Additional insight might have been obtained from physicians who seldom prescribe phototherapy (perhaps demonstrating greater compliance with the guidelines) had they been included. Our study reinforces the belief that adoption of change is complex. Educators interested in effecting change have been encouraged to develop strategies that accommodate the learner's needs to have a personal commitment to the change, a lengthy change process involving multiple experiences, an opportunity to build concepts to reinforce practices and an opportunity to deliberate over the information instrumental to the change.8 We have shown that clinical recall interviews are valuable. To be more effective, guidelines for patient care must be accompanied by more personal interaction with the
physicians. We thank Tunde Gondocz, Nimira Dhanani, Penny Jennett and the members of the Value Improvement Program and Health Records Department, Foothills Provincial General Hospital, for their contributions to the study. This study was supported by grants from the Association of Canadian Medical Colleges and the Foothills Provincial General Hospital Research and Development Fund.
References 1. Fetus and Newborn Committee, Canadian Paediatric Society: Use of phototherapy for neonatal hyperbilirubinemia. Can Med Assoc J 1986; 134: 1237- 1243 2. Cockington RA: A guide to the use of phototherapy in the
3. 4. 5.
6.
7.
8.
management of neonatal hyperbilirubinemia. J Pediatr 1979; 95: 281-285 Lewis HM, Campbell RH, Hambleton G: Use or abuse of phototherapy for physiologic jaundice of newborn infants. Lancet 1982; 2: 408-410 Kosecoff J, Kanouse DE, Rogers WH et al: Effects of the National Institutes of Health consensus development program on physician practice. JAMA 1987; 258: 2708-2713 Hill MN, Levine DM, Whelton PK: Awareness, use, and impact of the 1984 Joint National Committee consensus report on high blood pressure. Am J Public Health 1988; 78: 11901194 Lomas J, Anderson GM, Domnick-Pierre K et al: Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med 1989; 321: 13061311 Soumerai SB, McLaughlin TJ, Avorn J: Improving drug prescribing in primary care: a critical analysis of the experimental literature. Millbank Q 1989; 67: 268-313 Fox RD, Mazmanian PE, Putnam RW: Changing and Learning in the Lives ofPhysicians, Praeger, New York, 1989: 174
