'Halving the heel pricks': evaluation of a neonatal jaundice protocol incorporating the use of a transcutaneous bilirubinometer

Aim: This study aimed to assess the impact of implementing a new jaundice protocol incorporating the use of the Konica Minolta/Air Shields JM 103 Jaundice Meter (JM103) (Konica Minolta Sensing Inc., Osaka, Japan) in the setting of an Australian post-natal ward. Methods: A before-and-after study was completed following the introduction of a protocol integrating the use of the JM103 monitor on to the post-natal ward. Eligible infants were ≥36 weeks gestation, >24 h and <8 days of age. The number of Total Serum Bilirubin tests (TSBRs) were compared for the 12 months prior (T1) with a 6-month period and 6 months after protocol introduction (T2). Transcutaneous bilirubin (TcBR) results were also collected in T2. Rates of phototherapy and peak TSBRs at commencement were also compared as measures of safety. Results: Four hundred and twenty-six of the 2197 live births in T1 required one or more TSBRs compared with 119 of the 1169 live births in T2. This represents an odds ratio of 0.47 (95% confidence interval 0.38–0.58) for infants in T2 having ≥1 TSBR compared with T1. There was no difference between the groups for rates of phototherapy (3.8% vs. 3.0%; P = 0.2) nor any difference between the groups for peak SBR during phototherapy (301.9 μmol/L (standard deviation, SD 58) for T1 vs. 303.2 μmol/L (SD 54) for T2; P = 0.45). The estimated cost saving per year is $6966.00. Conclusion: TcBR measurement in conjunction with our protocol significantly reduces painful procedures and costs without increasing the risk of delaying treatment with phototherapy

Formalising medical quality indicators to improve guidelines

Abstract. Medical guidelines can significantly improve quality of medical care and reduce costs. But how do we get sound and well-structured guidelines? This paper investigates the use of quality indicators that are formulated by medical institutions to evaluate medical care. The main research questions are (i) whether it is possible to formalise those indicators in a specific knowledge representation language for medical guidelines, and (ii) whether it is possible to verify whether such guidelines do indeed satisfy these indicators. In a case study on two real-life guidelines (Diabetes and Jaundice) we have studied 35 indicators, that were developped independently from these guidelines. Of these 25 (71%!) suggested anomalies in one of the guidelines in our case study.

Using critiquing for improving medical protocols: Harder than it seems

Medical protocols are widely recognised to provide clinicians with high-quality and up-to-date recommendations. A critical condition for this is of course that the protocols themselves are of high quality. In this paper we investigate the use of critiquing for improving the quality of medical protocols. We constructed a detailed formal model of the jaundice protocol of the American Association of Pediatrics in the Asbru representation language. We recorded the actions performed by a pediatrician while solving a set of test cases. We then compared these expert actions with the steps recommended by the formalised protocol, and analysed the differences that we observed. Even our relatively small test set of 7 cases revealed many mismatches between the actions performed by the expert and the protocol recommendations, which suggest improvements of the protocol. A major problem in our case study was to establish a mapping between the actions performed by the expert and the steps suggested by the protocol. We discuss the reasons for this difficulty, and assess its consequences for the automation of the critiquing process