Have you ever been enamored by a piece of software that you just had to take a pause, inhale slowly and say "wow!?" Well I did just that this last weekend. One of our beloved nurses on the floor, decided that she had had enough of the waffling that most physicians do when they get a bilirubin level on a newborn. She had been made aware, by the Residents-in-Training of a new online tool called BILITOOL.ORG. This online program allows you to put in the date and time of birth of a baby and the hour at which the blood was drawn (if you know the age of the baby already, it has the ability to accept that as well). It will then take all of the data from the now relished and quoted BHUTANI GRAPH and display not only the risk category that your baby is in, but offer suggestions about when to place the baby on phototherapy.
I keep a copy of the BHUTANI GRAPH in my pocket at all times. I made a copy of it when the paper first came out and decreased its size, laminating it and saving it in my wallet. I do the same thing for the immunization schedules. My decision making is always done on a patient by patient basis mainly taken from BHUTANI's paper (Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics . 1999;103:6-14).
So, if I have a baby who is term and has a lot of bruising or a cephalohematoma, I know very well that within the first 24 hours, that baby is going to have a high bilirubin level. Whether it is high enough to start phototherapy has always been the issue. Many of us will not do this unless the numbers approach 18; then there are some who will wait for 20; or 14 (all numbers at 48 hours). However, for myself, if the index of suspicion is high ie. ABO incompatibility, uncertain dates, prolific jaundice after 12 hours, a mother with beta strep, I am inclined to start phototherpy a lot earlier than the allotted 24 hours. In fact, I am inclined to order a bili at 12 hours based on my index of suspicion and the aforementioned issues (obvious jaundice and decreased responsiveness) and on the AAP guidelines. But not everyone will do this. As clinicians, we still have that index of suspicion and clinical awareness and independence.
So where is the line drawn? For our seasoned nurse, it became a never ending battle among physicians. One would start phototherapy, one would not. Same scenario, different treatment plans. And none of the plans were wrong, usually leading to the same outcome --> Healthy baby.
Naturally, I was skeptical about BILITOOL at first, until I found that it conformed to the BHUTANI graph completely. I was particularly fascinated by the fact that the program took into account the various factors that accompanied the baby. All of the ones listed above are incorporated into the decision making model. A link to the Pediatrics listing for risk factors is a plus. The decision to start phototherapy is outlined in a nice table. See the diagram below:
What is an added plus for this program is the fact that the program, in addition to being online, is also available as a standalone download for all Palm devices. And does it work brilliantly? It is probably even better on the Palm than online. You are again greeted with two different ways to enter data, either by length of time or by date and time of birth:
Once the data is entered, you press (Calculate Risk Zone) and voila, you are greeted with the essential information taken from the BHUTANI GRAPH:
The beauty of this is that not only is there risk stratification, there is also a guideline as to whether to start Phototherapy or not:
Risk stratification is further defined by pressing one of the icons, where you are led to definitions of high, medium and low risk:
In the event that you have a baby "who is on the fence," you are also given the neurotoxicity risk factors to consider. As the adage goes, "Cure the problem and you'll cure the disease." So correcting the acidosis or the sepsis will enhance the correction of the bilirubinemia. This is priceless, particularly if you are not thinking about G6PD deficiency or hypoalbuminemia:
And finally, threshold guidelines are given for the baby, with age and other considerations given. This is really priceless:
Again, these numbers correspond not only to the BHUTANI GRAPH and paper, but also to the American Academy of Pediatrics (AAP) guidelines on the treatment of hyperbilirubinemia, with risk factors. This is really an impressive piece of work.
The authors are also impressive. Drs. Tony Burgos and Chris Longhurst are both Assistant Professors at Stanford University School of Medicine. Dr. Burgos is the Medical Director at Stanford's Lucille Packard Children's Hospital, while Dr. Longhurst is Physician lead and director of Informatics. Dr. Stuart Turner is at the Health Informatics Graduate Program at U.C. Davis.
This is an impressive lead of physicians heading this program. The software is free and appears to be a part of the Creative Commons license. Unbelievable, for the amount of work that must have gone into this piece of software, both on the online side and on the Palm side. I commend Drs. Burgos, Longhurst and Turner for creating this incredible tool. It is one of the best that I have seen in a long time.
If you deal with newborn babies, this piece of software is a must-have in your collection. I am still looking for flaws after a week of dealing with 3 hyperbili babies and I have yet to find one. The papers used for reference are of the finest caliber that can be found on the subject. They are peer reviewed and in the authoratitive journal on Pediatrics in America. Again, I highly recommend that you go to www.bilitool.org, you will not be disappointed.