Hyperbilirubinemia, or jaundice, is common in newborns, and usually does not result in serious harm. But severe hyperbilirubinemia can occur and can lead to potential serious complications, such as cerebral palsy, hearing loss, or even death. These events can be devastating, and are a potential source of medico-legal risk.
Here are some precautions that physicians can take to reduce the risk, based on a review of medico-legal cases in which the following points were identified by peer reviewers and experts.
In the majority of medico-legal cases (legal action, College or hospital complaint) closed between 2013-2022 where early newborn jaundice was an issue, healthcare providers recognized the condition. Peer expert concerns focused specifically on: delays in addressing the situation; the failure to recognize its severity; and poor decision-making (e.g. not starting therapy in a timely manner).
1. Assess the level of risk for jaundice
Some infants are at greater risk than others for pathologic jaundice. Physicians are expected to complete an appropriate history, noting relevant risk factors for jaundice (e.g. comorbidities, family history, birth trauma). Infants with significant risk factors should be identified as needing more focused follow-up. Jaundice might be easier or more difficult to determine depending on differing skin tone. With all newborns, there should be an objective assessment of jaundice.
2. Know what to look for
Consider establishing systems for the prompt identification and transfer of babies who require exchange transfusions and tertiary care. Physicians are encouraged to have a robust process in place to ensure that bilirubin results are reported to the most responsible physician in a timely fashion.
3. Be familiar with guidance and risk factors
Physicians working in obstetrical and neonatal care should be familiar with current guidelines for the detection, management, and prevention of jaundice. They should be aware of the delivery and neonatal characteristics that can place an infant at higher risk of severe jaundice. These characteristics might include prematurity, ABO incompatibility, exclusive breastfeeding, and jaundice within 24 hours after birth. Nursery protocols have been shown to be helpful to ensure consistent practices.
4. Develop situational awareness
A lack of situational awareness is a leading issue in cases of jaundice that lead to patient safety incidents. Physicians should consider the potential need for serial laboratory testing and early therapeutic treatments and should know when to consult with others.
5. Make informed choices
Clinical decision-making skills are another major factor in patient safety incidents with jaundice. Physicians might sometimes determine that a newborn’s jaundice is not severe enough to merit special attention, but before reaching such a conclusion, consider whether additional diagnostic tests or consultations could be needed. Algorithms and screening protocols may assist physicians in determining whether additional diagnostic tests or consultations would be appropriate.
6. Be thorough and mindful when discharging
Discharge decisions may depend on many patient factors, including weight, the level of bilirubin, and the quality of feeds, and might also depend on the possibility of timely outpatient follow-up. Upon discharge, clear instructions should be provided to parents, including guidance about when to seek further medical attention. Parents should also have a clear understanding of who to contact for advice and relevant contact information. Physicians might consider organizing specific post-discharge care, i.e. a community registered nurse to reassess bilirubin levels and infant weight. Put adequate post-discharge processes in place to ensure appropriate follow-up and testing of newborns.
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