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Appendix E

Implementation tools

BiliWheel

Currently jaundice is recognised by visual inspections of the baby. The evidence reviewed in
this guideline demonstrated that inspection of a baby by the parent, health visitor or midwife
can determine the presence of jaundice in most cases, but it is not an accurate method for
determining the severity of jaundice. Severity of jaundice is assessed by measurement of the
bilirubin level (using a serum sample or a transcutaneous bilirubinometer). The clinical
significance of the bilirubin level must be interpreted taking into account the baby’s age (in
hours). Errors are easily made when calculating a baby’s age and this could lead to failure to
recognise the need for treatment. For example, it is difficult to quickly and accurately mentally
calculate the postnatal age of a baby whose bilirubin has just been measured at 6.30 am on a
Monday and who was born at 7.45 pm on the previous Friday.
The BiliWheel was inspired by discussions within the Guideline Development Group. It is a
handy pocket-sized device (diameter 115 mm) comprised of three concentric wheels designed
to help health visitors and community midwives determine the clinical significance of the
bilirubin level by calculating a baby’s age in hours and relating this to the bilirubin level. It is
similar in concept to the gestation wheel, with which midwives and community health visitors
are familiar.

Using the BiliWheel, the community health visitor or community midwife will be able to position
the ‘0’ hour mark of the outer disk (which is 0–168 hours) at the time/day of birth on the inner
disk (divided into days and hours) and will then read the age in hours at the current time.
Once the baby’s age has been determined, the health visitor or community midwife will
interpret the baby’s bilirubin level using the data on the reverse side of the BiliWheel. The
pointer on the second outer disk is rotated to the age (in hours) on the inner wheel. A window
shows four threshold bilirubin levels corresponding to four stepped intervention based on
treatment threshold adopted by the GDG:
1. Repeat transcutaneous bilirubin/serum bilirubin measurement (6 – 12 hours)
2. Consider phototherapy
3. Phototherapy
4. Exchange transfusion
The GDG anticipates that the BiliWheel will:
• prevent delays in treatment
• reduce readmission rates for mothers and babies
• raise awareness of key issues relating to the management of jaundice with community-based
healthcare professionals
• support implementation of the guideline.
A prototype of the BiliWheel has been developed and a validation study is underway. The
validation study will recruit practising and student midwives at two centres.. The primary
outcome will be the accuracy of the BiliWheel in determining age in hours and correct
intervention using six case vignettes. An iterative development and testing process will be used
enabling feedback from each round of testing to inform the final design and additional content
of the BiliWheel.
If validated, a printable version of the BiliWheel will be available in pdf format for downloading
from www.ncc-wch.org.uk following publication of the guideline.

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