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Clinical decision support tool for phototherapy initiation in preterm infants



Adherence to guidelines for phototherapy initiation in preterm infants was 39% in our academic NICU (61% of phototherapy was initiated at total bilirubin (TB) levels below recommended thresholds). We hypothesized that adoption of an electronic health record integrated clinical decision support (CDS) tool would improve adherence to phototherapy guidelines.

Study design

We developed and implemented Premie BiliRecs (PBR), a novel CDS tool for phototherapy initiation in preterm infants from 27 through 34 weeks postmenstrual age. The primary outcome measure was the proportion of phototherapy initiation events consistent with recommended TB thresholds.


Following the implementation of PBR, adherence to guidelines for phototherapy initiation in preterm infants increased to 69.8% (p < 0.001), an improvement of 77%. There was no increase in the incidence of severe hyperbilirubinemia nor exchange transfusions.


The adoption of PBR was associated with improved adherence to phototherapy guidelines in preterm infants without increased adverse events.

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Fig. 1
Fig. 2: Premie BiliRecs was implemented in the EHR in January 2016.


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In addition to the Stanford neonatology division and the Stanford Children’s Health Information Services department, the authors wish to acknowledge Gomathi Krishnan, PhD and the Stanford Center for Clinical Informatics for their assistance in extracting the clinical data required to make this project possible.

Author information




YA and JP conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. JB and JF collected data, carried out the initial analyses, and reviewed and revised the manuscript. VB conceptualized and designed the study, supervised data collection, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Jonathan P. Palma.

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Conflict of interest

The authors declare that they have no conflict of interest.


This project was reviewed and approved by the Stanford University School of Medicine Institutional Review Board. No protected health information is transmitted between the EHR and the web-based CDS tool. The CDS tool guidelines were extrapolated from existing expert-consensus guidelines, but we implemented safeguards to decrease the potential for inappropriate use and unintended consequences. Because lower treatment thresholds are required shortly after birth, the PBR homepage displays a reminder that the tool is not intended for use in infants less than 48 h of age, and we prevented the EHR-integrated link to PBR from displaying in patients less than 48 h of age.

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Arain, Y., Banda, J.M., Faulkenberry, J. et al. Clinical decision support tool for phototherapy initiation in preterm infants. J Perinatol 40, 1518–1523 (2020).

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