JCAHO issues warning on kernicterus danger

The Joint Commission on Accreditation of Healthcare Organizations is warning health care providers that a devastating, yet almost always preventable condition can threaten otherwise healthy newborns and could be considered a sentinel event.

The Joint Commission’s alert cautions hospitals that while jaundice is common and usually not life-threatening in newborns, severe cases of jaundice put babies at risk for kernicterus, the medical term for brain damage caused by dangerous levels of bilirubin in the bloodstream. Bilirubin, which causes jaundice, is a naturally occurring by-product of decomposing red blood cells.

According to the alert issued recently, Joint Commission surveyors will address the issue during on-site surveys, asking accredited hospitals how they are protecting newborns from kernicterus. The Joint Commission’s warning about kernicterus is the latest in a series of patient safety alerts. Previous alerts have focused on medication mix-ups, patient suicides, and fatal falls among the elderly.

Medical experts have recently seen a re-emergence of this condition. Babies who survive usually suffer from a severe form of cerebral palsy, as well as hearing loss, upward gaze paralysis, and teeth malformations, says Sue Sheridan, spokeswoman for the advocacy and support group P.I.C.K. (Parents of Infants and Children with Kernicterus). She is the mother of a six-year-old who suffers from the condition. "This is probably happening more than clinicians know about. My family knows firsthand the tragic and profound consequences of kernicterus. It has challenged our lives emotionally, physically, and financially."

The Joint Commission’s Sentinel Event Alert warns that when high levels of bilirubin go unrecognized, babies may suffer the debilitating and potentially fatal consequences of kernicterus. Jeffrey Maisels, MD, chairman of the American Academy of Pediatrics’ subcommittee on neonatal hyperbilirubinemia and pediatrics chairman at William Beaumont Hospital in Royal Oak, MI, says monitoring can detect the problem before it is too late. "To make sure that we do not miss these rare newborns, we need to follow and measure serum bilirubin levels on many newborns who will probably never go on to develop severe hyperbilirubinemia."

Maisels says a combination of the following factors may put a newborn at risk for hyperbilirubinemia: jaundice appearing in the first 24 hours after birth, babies born three to five weeks early, inadequate nutrition and hydration resulting from insufficient breast-feeding, bruising which leads to an increase in bilirubin, siblings with significant jaundice, and being of Asian, African-American, or Mediterranean descent.

To protect babies from the condition, the Joint Commission alert draws attention to the evidence-based guidelines already issued by the American Academy of Pediatrics and recent recommendations from P.I.C.K. and its medical advisors for identifying at-risk newborns, diagnosing kernicterus, and treating the condition. The guidelines and recommendations call for hospitals to take these steps:

• Evaluate all cases of jaundice appearing in the first 24 hours.

• Create detailed treatment strategies for specific levels of bilirubin.

• Provide medical follow-up for newborns within 24 to 48 hours after discharge.

• Educate parents about jaundice and its potential risk.

• Provide proper equipment to detect and treat the condition.