1. Jaundice Community Project Dr Arun Ramachandran Consultant Neonatologist Singleton Hospital ABMU Health Board

2. Background Neonatal Jaundice affects approximately 60% of term neonates Neonatal Jaundice affects approximately 60% of term neonates One of the commonest causes of readmission to hospital One of the commonest causes of readmission to hospital Kernicterus is a preventable cause of severe disability Kernicterus is a preventable cause of severe disability NICE guideline (CG98) 2010 NICE guideline (CG98) 2010 - Reduce variations in care - Reduce variations in care - Visual estimation of jaundice alone is prone to error. Levels should be measured using TcB or serum levels - Visual estimation of jaundice alone is prone to error. Levels should be measured using TcB or serum levels

3. Phase 1 (2011) – TcB in post natal wards ( Singleton Hospital, POW Hospital, Neath birth centre)

4. Phase 2 ( 2013 ) Pilot project in ABMU community

6. Phase 3 ( 2013 - 14 ) A TcB for every community midwife in ABMU Funding obtained from Health Technology Fund through competitive business case Funding obtained from Health Technology Fund through competitive business case JM 103 selected as the most suitable device JM 103 selected as the most suitable device Negotiated agreement with Draeger for 7 year free service Negotiated agreement with Draeger for 7 year free service Training in neonatal jaundice management and TcB use provided to all community midwives in ABMU Training in neonatal jaundice management and TcB use provided to all community midwives in ABMU Project implementation & evaluation teams established Project implementation & evaluation teams established

7. Phase 3 evaluation results 1 st Feb – 31 st July 2014

8. Effect on admission rates with TCB equipped community midwives Percentage

9. Maximum serum bilirubin levels in babies admitted to hospital Serum bilirubin level micromol/litre Babies admitted to hospital

10. Comparison between 2013 & 2014 waiting times of jaundiced babies in the children’s assessment unit Minutes

11. Specificity and Sensitivity How good is the transcutaneous bilirubinometer at predicting need for phototherapy? How good is the transcutaneous bilirubinometer at predicting need for phototherapy? ◦ 100% specificity (95% CI 85.1%-100%) ◦ 31% sensitivity (95% CI 14.4%-51.8%) ◦ Positive predictive value 100% (95% CI 62.9%-100%) ◦ Negative predictive value 55.1% (95% CI 39.8%-71.5%) How good is the transcutaneous bilirubinometer at predicting need for admission? How good is the transcutaneous bilirubinometer at predicting need for admission? ◦ 100% specificity (95% CI 79.2%-100%) ◦ 24.2% sensitivity (95% CI 11.1%-42.3%) ◦ Positive predictive value 100% (95% CI 62.9%-100%) ◦ Negative predictive value 39% (95% CI 24.2%-55.5%)

12. Parent satisfaction with TCB testing Number of parents

13. Conclusions High quality care delivered at home The TcB is a minimally invasive and painless device well liked by staff and parents The TcB is a minimally invasive and painless device well liked by staff and parents In community TcB has high specificity in determining need for admission and phototherapy with no increase in morbidity and mortality. In community TcB has high specificity in determining need for admission and phototherapy with no increase in morbidity and mortality. Training of community midwives in managing jaundice and equipping them with TcB will reduce unnecessary referrals to hospital. This reduces staff workload and cost and inconvenience to parents. Training of community midwives in managing jaundice and equipping them with TcB will reduce unnecessary referrals to hospital. This reduces staff workload and cost and inconvenience to parents. Along with appropriate referral pathways TcB reduces waiting times for neonates in PAU. Along with appropriate referral pathways TcB reduces waiting times for neonates in PAU.

14. Team Lesley Owen and community midwives Lesley Owen and community midwives Dr Arun Ramachandran Dr Arun Ramachandran Dr Jamie Evans, Dr Gemma Trays, Dr Amit Kandhari - Phase 1 Dr Jamie Evans, Dr Gemma Trays, Dr Amit Kandhari - Phase 1 Dr Rachael Morris, Dr Daniel Dogar - Phase 3 Dr Rachael Morris, Dr Daniel Dogar - Phase 3 Medical physics team ABMU Health Board Medical physics team ABMU Health Board Management team ABMU HB Management team ABMU HB R&D department ABMU HB R&D department ABMU HB My colleagues in Singleton, Morriston, POW and Neath My colleagues in Singleton, Morriston, POW and Neath Emma Hughes & Draegar product development team Emma Hughes & Draegar product development team

15. Spin-offs Selected by RCM as one of the top 3 innovation projects in UK in 2014 Selected by RCM as one of the top 3 innovation projects in UK in 2014 Product development and improvement of TcB Product development and improvement of TcB Oral presentations, posters, abstracts in national and international conferences Oral presentations, posters, abstracts in national and international conferences Publication in peer reviewed journal accepted Publication in peer reviewed journal accepted Positive report by BBC and local news papers Positive report by BBC and local news papers Feedback from happy parents and staff Feedback from happy parents and staff

16. References American Academy of Paediatrics. Subcommittee on Hyperbilirubinaemia: Management of hyperbilirubinaemia in the newborn infant 35 or more weeks of gestation. Paediatrics. 2004; 114(1): 297-316. American Academy of Paediatrics. Subcommittee on Hyperbilirubinaemia: Management of hyperbilirubinaemia in the newborn infant 35 or more weeks of gestation. Paediatrics. 2004; 114(1): 297-316. National Institute of Health and Care Excellence. Guideline CG98. 2010; www.nice.org.uk/CG98 National Institute of Health and Care Excellence. Guideline CG98. 2010; www.nice.org.uk/CG98 www.nice.org.uk/CG98 National Institute of Health and Clinical Excellence. Postnatal care: routine postnatal care of women and their babies. Clinical guideline 37. 2006; www.nice.org.uk/CG037 National Institute of Health and Clinical Excellence. Postnatal care: routine postnatal care of women and their babies. Clinical guideline 37. 2006; www.nice.org.uk/CG037 Kevin Ives N. Neonatal Jaundice. In: Janet M. Rennie, Ed. Rennie and Roberton textbook of neonatology. Churchill Livingtone: Elsevier 2012; 672-92. Kevin Ives N. Neonatal Jaundice. In: Janet M. Rennie, Ed. Rennie and Roberton textbook of neonatology. Churchill Livingtone: Elsevier 2012; 672-92. John. F. Watchko. Neonatal indirect hyperbilirubinaemia and kernicterus. In: Christine. A. Gleason, Sherin U. Devaskar, eds. Avery’s diseases of the newborn. Elsevier Saunders. 2012; 1123-1142. John. F. Watchko. Neonatal indirect hyperbilirubinaemia and kernicterus. In: Christine. A. Gleason, Sherin U. Devaskar, eds. Avery’s diseases of the newborn. Elsevier Saunders. 2012; 1123-1142.

17. References Gottstein R, Cooke RWI. Systematic review of intravenous immunoglobulin in haemolytic disease of the newborn. Arch Dis Child Fetal Neonatal Ed 2003; 88: F6-F10. Gottstein R, Cooke RWI. Systematic review of intravenous immunoglobulin in haemolytic disease of the newborn. Arch Dis Child Fetal Neonatal Ed 2003; 88: F6-F10. Mannning D, Todd P, Maxwell M, Jane Platt M. Prospective Surveillance study of severe hyperbilirubinaemia in the newborn in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed; 2007 Sep; 92 (5): F342-6. Mannning D, Todd P, Maxwell M, Jane Platt M. Prospective Surveillance study of severe hyperbilirubinaemia in the newborn in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed; 2007 Sep; 92 (5): F342-6. Ramachandran A, Owen L, Morris R. Impact of transcutaneous bilirubinometer testing of babies with visible jaundice by community midwives of hospital referrals. Arch Dis Child 2015; 100 (Suppl 3): A48. Ramachandran A, Owen L, Morris R. Impact of transcutaneous bilirubinometer testing of babies with visible jaundice by community midwives of hospital referrals. Arch Dis Child 2015; 100 (Suppl 3): A48. Rubaltelli FF, Gourley GR, Loskamp N, et al. Transcutaneous bilirubin measurement: a multicentre evaluation of a new device. Paediatrics. 2001; 107:1264-1250 Rubaltelli FF, Gourley GR, Loskamp N, et al. Transcutaneous bilirubin measurement: a multicentre evaluation of a new device. Paediatrics. 2001; 107:1264-1250 L Johnson, V K Bhutani, K Karp, EM Sivieri, SM Shapiro. Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). Journal of Perinatology; 2009; 28, S25- S45. L Johnson, V K Bhutani, K Karp, EM Sivieri, SM Shapiro. Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). Journal of Perinatology; 2009; 28, S25- S45.