Jaundice: home phototherapy

• Selection of patients for home phototherapy must be discussed with the relevant service consultant and GGC Neonatal Care at Home Team ( Contact number 07866 957 495 0900-2100hrs )
• Once accepted into H@H babies will be placed on the Virtual Ward handover and it will be the responsibility of the supervising Consultant for H@H to ensure that results are actioned and parents are informed of management plans. For patients to be considered for home phototherapy they must meet all the following criteria as judged by clinical staff:

• ≥36 weeks i.e. from 36+0 weeks gestation
• And/or 36 weeks corrected gestation , i.e. born at 35 weeks but now 36+0 or greater corrected weeks
• Bwt ≥2kg
• ≥48 hrs. of age
• DCT negative
• Require single phototherapy only
• Baby should be feeding well, passing urine and pigmented stool, with no concerns regarding weight gain. They should have no more than 10% weight loss Baby should be  reviewed by the neonatal clinical team (ST/ANNP) and deemed  clinically well and otherwise ready for discharge or already be at home and requiring re-admission solely for phototherapy
• Rate of rise of bilirubin < 6µmmol/hr
• SBR at referral > 50µmmol from  consideration of “exchange line”
• No safeguarding concerns
• Access to telephone and able to follow instruction NB information available in relevant languages , English as a first language is NOT a requirement for referral to H@H

• They should be trained how to use the Bili cocoon safely
• The home environment should be deemed suitable for home phototherapy
• The family must live within 15 miles of the Queen Elizabeth University Hospital Complex and have access to return to the hospital at any time should there be any problems. Living at distance greater than this has patient safety implications for prompt return to hospital if there are concerns as well as timely review by a team member in the event of a parental concern.
  • The Family home address must be within the postcodes covered by NHS GGC ( refer to list if unsure as some postcodes can be NHS Lanarkshire)

After fulfilling the patient eligibility criteria staff must have the opportunity to discuss single unit phototherapy with the eligible family and determine if they agree to undertake home phototherapy. Following this, a clinical review must be completed on Maternity Badger.

If based in the community the family must be invited to the department of the birth hospital for assessment.  At this point ensure the H@H team are aware of this anticipated referral (07866 957 495) If on Postnatal Ward the team must ensure the following have been completed.

Clinical review completed on Maternity Badger

• Examination
• Current weight and temperature
• Maternal blood group
• Infant blood group if available
• Coomb’s test (DCT) if available , can be taken at assessment
• Full blood count (FBC)
• Total serum bilirubin (SBR) with conjugated bilirubin level
• (Where indicated glucose-6-phosphate dehydrogenase (G6PD) level (See map of affected populations: Figure 1, this investigation should not be required at point of referral but considered if the bilirubin is slow to fall or jaundice recurs

Figure 1: Distribution of G6PD worldwide

NHS GGC  Neonatal Hospital at Home Service strive to provide this service to all eligible families this may not always possible  due to capacity and certain service requirements must be met before accepting a family for home phototherapy as listed below:

• H@H Team members must be available to monitor the infants progress throughout the course of treatment including over the weekends with a team available for a minimum of 3 consecutive days following initiation of treatment
• H@H Nursing Staff must be available to provide daily contact and review with the family during the period of treatment
• Serum bilirubin levels must be measured every 18 to 24 hours
• Serum bilirubin must be re-measured within 24 hours after discontinuation of phototherapy to look for a rebound in bilirubin levels
• The infant must be hospitalised if;
  • They show signs of illness
  • Serum bilirubin level continues to rise despite phototherapy
  • Non-concordance with treatment instructions

Home phototherapy shall be undertaken utilising the Bilicocoon system. In addition to the equipment below provided by staff (Figure Two), a cot or bassinette (family’s own) is required. Protective eye wear for the infant will also be provided.

Fig 2. Bilicocoon system

Parent training and education should be undertaken by a member of the Home Phototherapy team prior to commencing therapy. Parents must be deemed competent in the use of equipment by the team.

This education will include information on the following:

1. How to use the bilicocoon
   https://www.neomedlight.com/bilicocoon-training-tutorials/

How to use the BiliCocoon Bag Phototherapy system (youtube.com)

2. Safe sleep and swaddling during use
3. Feeding, bathing and temperature monitoring during use
4. Explanation of daily home visits and blood tests taken during and following home phototherapy treatment and the importance of these being carried out
5. Explanation of potential need for readmission should clinical condition change
6. Recognition of poor feeding/unwell baby and possible unwanted effects from phototherapy
7. Who and how to contact if there is a problem

Parents/carers must only turn equipment ON/OFF. No other adjustments should be made.

Families will be provided with our parent information sheet: ‘Information on Home Phototherapy for Parents and Carers’ (Appendix 2), this has been reviewed by clear to all, and given the opportunity to ask questions and discuss with the team. Following this, together with a member of the team, they should complete the ‘Home Phototherapy Checklist’ and ‘Parental Agreement Form’ (Appendix 3 and 4) documentation.

Phototherapy

• Baby should be positioned in the bilicocoon. This should be in a supine (on their back) position unless other clinical conditions prevent this
• Baby must only wear a nappy and care should be taken to ensure treatment is applied to the maximum area of skin
• The baby should wear eye protection for the duration of phototherapy treatment
• Monitor the baby’s temperature and ensure the baby is kept in an environment that will minimise energy expenditure (thermoneutral environment)
• Emphasis on continuous phototherapy use at home, interrupted only for travel to home and for short breaks of up to 30 minutes for breastfeeding, nappy changing, bathing and cuddles
• Families need to remain at home for the duration of treatment

Home Visits and Monitoring

Staff from the Care At Home team will visit and support the family and carers daily during treatment including encouraging them to interact with their baby whilst undergoing treatment. They will undertake a daily review including the following aspects:

• Clinical review and assessment of infant including temperature check
• Feeding review including adequate stool and urine output
• Tolerance of phototherapy
• Check equipment is being used properly e.g. eye mask being worn, baby on correct side of bili-cocoon

Staff will also discuss the phototherapy use with the family with the opportunity to address any problems or concerns.

A serum bilirubin (SBR) will be performed daily (levels must be measured every 18 to 24 hours), with any additional blood tests as indicated, to assess and monitor treatment. Baby should remain on treatment until contacted by member of hospital staff with results.

Blood samples are then returned to the local laboratory. Results should be chased in a timely fashion and plotted on the appropriate jaundice treatment chart within Maternity Badger.

Results

All SBR results must be plotted and recorded on the treatment charts as available on Maternity Badger. Care must be taken to ensure that the baby’s age in hours has been accurately calculated and results plotted appropriately. Treatment thresholds vary with gestation and postnatal age so it is vital that plotting is accurate.

A rate rise must be calculated and documented:

If greater than 6 micromol/l/hr then patient should be admitted for inpatient phototherapy.

Each patient must be discussed daily with H@H team to plan ongoing phototherapy treatment or cessation of treatment and timing of rebound SBR.

Criteria for admission/readmission to hospital

• A rising SBR despite phototherapy.
• Inability to maintain temperature or concerns regarding weight gain.
• Any concerns regarding the baby from the community teams or the parents/carers.

Stopping phototherapy

Phototherapy can be discontinued once serum bilirubin has fallen to a level at least 50 micromol/litre below the phototherapy threshold (see threshold table and treatment threshold graphs).

NICE recommend a check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin measurement 18-24  hours after stopping phototherapy.

Families should retain equipment until after a satisfactory rebound bilirubin level has been obtained. The device should then either be collected by the within 24 to 48 hours of discharge from home phototherapy services.

In-between uses the equipment shall be thoroughly cleaned in line with the locally developed SOP, supported by the manufacturer. Equipment will be checked for any faults and reported as necessary.

You can contact the Hospital at Home team between 8am and 8pm on 07866 957 495.

Outwith these hours you can contact: Royal Hospital for Children: 0141 452 4929.

Information about Home Phototherapy Parent Leaflet (pdf)

Checklist for the Home Phototherapy Service (pdf)

Phototherapy at Home Service Agreement Form (pdf)