COMMENTARY |
Closing the Gap Between Guidelines and Practice: Ensuring Safe and Healthy Beginnings
North Carolina Center for Children’s Healthcare Improvement,
University of North Carolina,
Chapel Hill, NC 27599-7226
Department of Pediatrics,
Baylor College of Medicine,
Houston, TX 77030-2302
Abbreviations: AAP, American Academy of Pediatrics • ADHD, attention-deficit/hyperactivity disorder
Once you bring life into this world, you must protect it. We must protect it by changing the world.Elie Weisel
The revised American Academy of Pediatrics’ (AAP’s) guideline for the management of hyperbilirubinemia in infants 
35 weeks’ gestation,1 published in the July issue, provides a contemporary evidence-based approach to a condition that affects the majority of otherwise healthy newborns. Adherence by clinicians to the recommendations is expected to prevent most cases of kernicterus, the devastating, irreversible neurologic damage associated with excessive serum levels of bilirubin.
Despite the publication of a previous version of the guideline in 1994, kernicterus continues to occur.2 Many contributing factors may be at play. For example, the change to early discharge, often at <48 hours after birth, disrupted the previous patterns of care associated with a longer postpartum hospitalization.3 As a result, newborns now experience the usual peak of serum bilirubin concentration, at 3 to 5 days of age, at home rather than observed by clinicians in the nursery as in previous times. This change in clinical venue also contributes to gaps in communication, continuity, and parent education. Discharge now generally occurs before lactation is well established and often without adequate support, further increasing the risk of hyperbilirubinemia. Furthermore, follow-up visits are scheduled at a median of 1 week of age, later than would be optimal for assessment of jaundice and lactation.4 Another factor may be the current state of laissez-faire "jaundice-related thinking" among pediatricians and the health care community. One author suggested that because most pediatricians and family practitioners have never seen a case of kernicterus first hand, they commonly adopt a "not to worry" attitude.5 Finally, insurance policies do not always facilitate appropriate care for infants. These include lack of support for a prenatal visit with an infant health care provider, no reimbursement for transcutaneous bilirubin measurement, and lack of routine coverage for systematic follow-up by a clinician.3
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THE CHALLENGE OF TRANSLATING EVIDENCE INTO PRACTICE |
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Although guidelines provide an evidence-based approach, they frequently fail to translate into standard practice and improved care. Why is this? Multiple studies of strategies used to change practice demonstrate that the passive provision of information, as in traditional didactic continuing medical education, rarely achieves its intended goal.6–9 Knowledge is essential but not sufficient to produce behavior change.10, 11
Interventions that are based on assessment of potential barriers and multifaceted interventions that target different barriers to change are more likely to be effective than single interventions in changing practice or improving health outcomes.6–8 In particular, activities that seem to have a positive effect include those with active learning opportunities, learning delivered in a longitudinal or sequenced manner, and the provision of methods to facilitate implementation in the practice setting (eg, tools and resources).7 In addition, theories of the spread of innovations suggest that changes in practice disseminate more rapidly when they can be simplified so that limited adaptation is required. The use of simple tools and practical strategies that can help clinicians to make the transition from current processes to newer approaches is more likely to be successful in improving care and outcomes.12,13
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A FRAMEWORK FOR TRANSLATING POLICY INTO PRACTICE |
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Successful efforts to improve care recognize that multiple layers of the health care system need to work together to achieve better outcomes (Fig 1). The American Academy of Pediatrics (AAP) used this framework in developing its multifaceted program to translate the guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) into clinical practice. The ADHD effort consists of a several-year program of coordinated activities targeting the various levels of the health care system: advocacy efforts to dismantle financial and organizational obstacles to promote timely access to care in the medical home setting, structured educational efforts to support improved care in AAP chapters and residency programs, a toolkit and Web-based continuing medical education/quality improvement program for clinicians (the AAP’s Education for Quality Improvement in Pediatric Practice, www.eqipp.org), and the development of multiple resources for children and families (eg, a parent education brochure, a book, a video, patient education materials for teens). A key component of this effort has been supporting the development of systems linkages among clinicians, families, and the school.
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ENSURING SAFE AND HEALTHY BEGINNINGS |
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Building on what it has learned from implementing the ADHD guidelines, the AAP is developing a program to ensure that the strategies suggested in the bilirubin guidelines will be put into practice. This effort is the initial and key component of a broader initiative, Ensuring Safe and Healthy Beginnings, that will address management of several issues that are critical to a seamless and safe transition from the birth hospital to home and family during the first week of age. The program for implementation of the bilirubin guidelines will emphasize the following key messages:
- Each infant should have an evaluation for jaundice, including an objective predischarge assessment for the risk of severe hyperbilirubinemia.
- Every infant needs follow-up at 3 to 5 days of age, depending on risk.
- All breastfeeding mothers should receive appropriate lactation support.
We will build on multiple examples that illustrate the various components of what is needed to ensure a safe and healthy beginning for infants and their families:
- Frequently asked questions handout: published as an appendix to the AAP guideline, this handout answers many questions that parents are likely to ask.
- Development of an updated version of the AAP pocket reference card for the management of hyperbilirubinemia.
- The nomogram associating hour-specific bilirubin measurement with risk of severe hyperbilirubinemia, developed by Dr Vinrod Bhutani, is used to identify infants that need to be followed closely.15
- The use of weekend clinics as a safety net for early discharge; multiple safety net sites offer a daily clinic time on weekends and holidays to follow up newborn infants who are discharged without available follow-up.
- A successful example of a local improvement effort. In the Vermont Hospital Preventive Services Initiative, multidisciplinary teams at 12 hospitals worked collaboratively, with expert guidance and support, to improve hospital-specific bilirubin guideline implementation and affect process outcomes.16
The AAP program Ensuring Safe and Healthy Beginnings will make available a toolkit of practical tools and strategies for clinicians to use in the hospital and office, such as examples of medical order sheets for use in nurseries and hospital policies for recognition and evaluation of jaundice. We will also facilitate the development of this toolkit through AAP chapters and residency programs. In addition, we will participate with other national organizations in a parent education and public awareness campaign and develop a program to advocate for needed policy changes.
The beginning of life is a time of promise and hope. The new AAP program Ensuring Safe and Healthy Beginnings will facilitate implementation of the revised guideline for the management of hyperbilirubinemia in the newborn to ensure that the promise is kept.
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FOOTNOTES |
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Received for publication Apr 21, 2004; Accepted Apr 29, 2004.
Reprint requests to (C.L.) North Carolina Center for Children’s Healthcare Improvement, University of North Carolina, UNC CB 7226, Chapel Hill, NC 27599-7226. E-mail: clannon{at}aap.org
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REFERENCES |
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1. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics.2004; 114; 297 –316
2. American Academy of Pediatrics, Provisional Committee for Quality Improvement. Practice parameter: management of hyperbilirubinemia in the healthy term newborn.
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4. Britton J, Baker A, Spino C, Bernstein H. Postpartum discharge preferences of pediatricians: results from a national survey.
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5. Poland RL. Preventing kernicterus: almost there. J Pediatr.2002; 140 :385 –386[CrossRef][Web of Science][Medline]
6. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies.
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8. Mazmanian PE, Davis DA. Continuing medical education and the physician as a learner: guide to the evidence.
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9. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ.1995; 153 :1423 –1431[Abstract]
10. Ajzen I, Fishbein M. Understanding the Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980
11. Sligo FX, Jameson AM. The knowledge-behavior gap in use of health information. J Am Soc Inform Sci.2000; 51 :858 –869[CrossRef]
12. Margolis PA, Lannon CM, Stuart JM, Fried BJ, Keyes-Elstein L, Moore DE Jr. Practice based education to improve delivery systems for prevention in primary care: randomised trial.
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13. Shafer MA, Tebb KP, Pantell RH, et al. Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls.
JAMA.2002; 288
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14. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
15. Johnson L, Bhutani VK. Guidelines for management of the jaundiced term and near-term infant. Clin Perinatol.1998; 25 :555 –574[Web of Science][Medline]
16. Mercier C, Berry P, Davis W. Statewide quality improvement intervention to manage the risk of severe hyperbilirubinemia. Poster presented at: 2004 Pediatric Academic Society Meeting; May 1–4, 2004; San Francisco, CA
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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