Patient population: This guideline applies to the management of indirect hyperbilirubinemia in neonates < 8 days of life and ≥ 35 weeks gestation. This guideline does not include the management of neonatal direct hyperbilirubinemia or hyperbilirubinemia in patients > 8 days of age. This guideline excludes premature neonates born prior to 35 weeks gestation.

Objectives: To create an evidence-based standard for the management of neonates with indirect hyperbilirubinemia across all care settings (newborn nursery, intensive care units, general inpatient service, home care, primary care, and emergency department) that provides appropriate care to patients, reduces unnecessary diagnostic tests and interventions, and improves patient outcomes.

Key points:

Prevention. Feed newborns, starting at birth, at least 8 times per day. Feedings should be based on feeding cues with attempts at least every 3 hours.

• Continue breastfeeding even if feeding difficulties arise. Expressed breast milk or formula supplementation may be warranted in certain circumstances. Discourage discontinuation of breastfeeding, even for diagnostic purposes in the setting of suspected breast-milk jaundice.
• Feeding supplementation is not indicated for sleepy neonates during first 24–48 hours, unless signs of dehydration, or weight loss more than the 95^th percentile per the newborn weight tool (NEWT).
• Feeding recommendations are not relevant if a patient is critically ill and enteral feeds are being withheld.

Diagnosis. The approach to diagnosing hyperbilirubinemia will differ depending on whether it is detected via screening during the birth hospitalization (Figure 1) or later in follow-up (Figure 2).

Figure 1

Birth Hospitalization.

Figure 2

Outpatient Hyperbilirubinemia. IJS = infant jaundice studies; HOL = hours of life; TcB =Transcutaneous Bili; TSB =Trans Serum Bilirubin; Tx =Treatment †Although there is no evidence to support its use, home phototherapy can be considered for infants (more...)

History. Assess all newborns for risk factors for developing hyperbilirubinemia (Table 1).

Table 1

Neurotoxicity Risk Factors.

Bilirubin Measurement. A total bilirubin (TSB or TcB) level should be measured on all newborns prior to discharge. [I-C*]

• Choose appropriate test for bilirubin levels (Table 4).
• If TSB is indicated, the first level should be fractionated to rule out direct hyperbilirubinemia. Subsequent measurements can be total bilirubin alone.
• The first measurement should be obtained at 16–24 hours of life. [I-C*]
• Discharge prior to 16 hours of life is strongly discouraged. If extenuating circumstances result in the discharge of a neonate prior to 16 hours of life, appropriate follow-up for evaluation of hyperbilirubinemia should be arranged.
• Total bilirubin levels should be plotted on the hour-specific nomogram to direct follow up (Figures 4–7). If POC bilirubin is obtained in the outpatient setting, consider that serum measurements can be 10% higher when interpreting the results.

Table 4

Indications for Bilirubin Testing Modalities and Infant Jaundice Studies.

Figure 4

Intensive Phototherapy Thresholds for Infants WITHOUT Neurotoxicity Risk Factors (see Table 1). Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin.

Figure 5

Intensive Phototherapy Thresholds for Infants WITH Neurotoxicity Risk Factors (see Table 1). Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin.

Figure 6

Exchange Transfusion Thresholds for Infants WITHOUT Neurotoxicity Risk Factors (see Table 1). Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin.

Figure 7

Exchange Transfusion Thresholds for Infants WITH Neurotoxicity Risk Factors (see Table 1). Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin.

Further investigation into underlying etiology. Investigation into rarer causes of hyperbilirubinemia is recommended in certain circumstances (Table 4).

Risk Stratification. To determine treatment thresholds, note gestational age at birth and determine presence of neurotoxicity risk factors (Table 1). [I-D*]

Treatment. For overview, see Figure 3.

• Decision to admit to the hospital and treat should be based on TSB. [I-D*]
• In the absence of clinical concerns necessitating emergency department evaluation, direct admission to an inpatient service should be facilitated
• Intensive phototherapy can be expected to decrease bilirubin levels by 30–40% in 24 hours, with most being in the first 4–6 hours. Intensive phototherapy should be initiated in the following circumstances:
  • - When total bilirubin is at or above the phototherapy treatment threshold based on hour-specific nomograms (Figure 4)
  • - When TSB rate of rise > 0.2 mg/dL/hour and TSB is predicted to cross treatment threshold prior to next evaluation. [I-D*]

Figure 3

Hyperbilirubinemia Treatment. *Continue to encourage breastfeeding. Consider lactation consultant. If clinically dehydrated, consider oral rehydration versus IVFs. Tx = treatment; TSB = Total Serum Bilirubin; IVF = IV Fluids

There is lack of evidence to support the routine use of home phototherapy when the bilirubin level is at, near, or above the treatment threshold. However, home phototherapy can be considered when bilirubin is 0–2 mg/dL below the treatment threshold at discharge from the birth hospitalization or in the outpatient setting in the following circumstances:

• Neonates who feed well, appear well, and have close follow up arranged.
• Neonates with no neurotoxicity risk factors. [III-C*]
• Neonates without prior history of intensive phototherapy treatment.

Home phototherapy equipment can no longer be obtained in or arranged by Children’s Emergency Services

When bilirubin values are at or near exchange transfusion values:

• Maximize surface area exposed to phototherapy by removing unnecessary clothing (minimal/no diaper)
• Surround the neonate using highly reflective materials to increase surface area exposed and irradiance.
• Use multiple light sources (measure irradiance at various sites).
• Consider adjunctive therapies, including Intravenous immunoglobulin (IVIG) and IV hydration.
• Turning baby from prone to supine in an alternating fashion has not been shown to be efficacious.

For most neonates, routine IV supplementation is not warranted. However, for neonates with severe hyperbilirubinemia, IV fluid administration may be useful and is recommended.

Use of IVIG may be useful in Rh or ABO disease.

• Restrict use to select neonates in the NICU with high bilirubin values or rapid rate of rise (at high risk for exchange transfusion).
• Monitor neonates closely.
• Dose 0.5g/kg over 2 hours, repeat as clinically indicated.

An exchange transfusion should be considered when a serum bilirubin value surpasses the applicable NCNC recommended threshold value (Figures 6 & 7).

Monitoring. Following the initiation of phototherapy, only serum bilirubin (TSB) levels are recommended.

• Stop phototherapy once serum bilirubin has fallen to a level at least 3 mg/dL below the phototherapy threshold.
• Rebound levels at 6 hours are not predictive of subsequent repeat phototherapy.
• Consider repeat TSB 24 hours after discontinuation of phototherapy if treated prior to initial hospitalization discharge (post-delivery). This may be performed as an outpatient.
• Recheck TSB 12–24 hours after discontinuation of phototherapy, if preterm, evidence of hemolysis, or treated after readmission and serum bilirubin is > 14. This may be performed as an outpatient (if bilirubin ≤14, routine repeat TSB is not indicated in all neonates).
• Recheck bilirubin q 4–6 hours, depending on the rate of decline, when treating with exchange transfusion.
• A neonate being treated with home phototherapy (fiber optic blanket, Bili Blanket) should have a TSB checked:
  • - Every 24–48 hours if the neonate is ≥ 38 weeks gestation.
  • - Every 24 hours if the neonate is < 38 weeks gestation.
• Do not delay discharge to obtain a rebound bilirubin level. Check rebound levels as an outpatient when indicated.

Follow-up. Timing and frequency of follow up after birth hospitalization should be influenced by risk of development of severe hyperbilirubinemia. This is determined by risk factors for development of severe hyperbilirubinemia (Table 2), as well as plotting TcB or TSB on the Bhutani nomogram (Appendix 1).

• Follow up should occur 1 day following birth hospitalization discharge, for those at higher risk.
• PCP follow-up should be arranged within 24 hours, or 48 hours when no serum bilirubin recheck is required (ie, discharge bilirubin <14), after hospital discharge from phototherapy,

Table 2

Risk Factors for the Development of Severe Hyperbilirubinemia.

Phototherapy Techniques. Fiberoptic Phototherapy Blanket: The fiber optic blanket is applied next to the neonate’s skin. The neonate may wear a diaper. The parents should swaddle the neonate with the fiber optic blanket next to the skin to avoid hypothermia. Feeding may continue with the blanket next to the neonate’s skin. If necessary, to optimize feeding, the neonate may be removed from the blanket for up to 30 minutes every 2–3 hours.

Inpatient Phototherapy:

• Babies receiving inpatient phototherapy should receive “intensive” phototherapy. [I-C*]
• For the majority of term neonates, phototherapy using a single overhead LED light source will provide intensive phototherapy and will be sufficient.
• Phototherapy using a single overhead LED light source and fiberoptic blanket may be indicated with the serum bilirubin value:
  • - Rising more than 0.5 mg/dL/hour.
  • - Within 3 mg/dL below the exchange transfusion threshold.
  • - Fails to respond to initial phototherapy.
• Use of 2 angled overhead lights, a fiberoptic blanket, and white sheets as a reflective surface may be indicated when bilirubin is at or above the exchange transfusion threshold. This is done in the NICU.
  • - Body surface area exposed and continuity of therapy (i.e. minimizing interruptions) will influence efficacy.
  • - Irradiance should be measured regularly.
  • - There is a lack of evidence to support the use of fiberoptic blanket alone.
• Phototherapy can be temporarily halted to allow for bonding and breastfeeding, when neonates are not considered high risk for exchange transfusion.

Definitions

Direct or conjugated hyperbilirubinemia

conjugated bilirubin of 1 mg/dL or more when total bilirubin is less than 5 mg/dL OR 20% of total bilirubin when total bilirubin is over 5 mg/dL.¹

Home phototherapy (Fiberoptic phototherapy Blanket)

phototherapy provided via a fiberoptic blanket in the home setting

Infant jaundice studies (IJS)

A set of tests including neonatal blood typing for ABO and Rh as well as direct antiglobulin test (DAT), typically performed using cord blood. Note: at UMHS, results regarding maternal ABO status are listed in “comment” area.

Inpatient phototherapy

All inpatient phototherapy is intensive. The method of delivery (number of light sources) is dependent on the clinical state of the infant.²

Intensive phototherapy

A light source that provides between 30 microwatts/cm2/nm and 65 microwatts/cm2/nm and delivered to as much of the infant’s surface area as possible.

Prolonged jaundice

> 14 days for term; > 21 days for preterm.

Total serum bilirubin (TSB)

A blood test to measure bilirubin levels, both direct bilirubin and indirect bilirubin.

Transcutaneous bilirubin (TcB)

A non-invasive measure to estimate serum bilirubin levels.

Abbreviations

AAP

American Academy of Pediatrics

ABE

Acute bilirubin encephalopathy

AOD

Admitting officer of the day (Hospitalist taking outside hospital transfer and direct admission calls)

Ca

Calcium

CBC

Complete blood count

CES

Children Emergency Services

DAT

Direct antiglobulin test

G6PD

Glucose-6-phosphate dehydrogenase

HOL

Hours of life

IJS

Infant (neonate) jaundice studies

IVIG

Intravenous immunoglobulin

MVN

Michigan Visiting Nursing

Na

Sodium

NCNC

Northern California Neonatology Consortium

NEWT

Newborn weight tool

NICU

Neonatal intensive care unit

PLT

Platelet

POC

Point of Care

TcB

Transcutaneous bilirubin

TSB

Total serum bilirubin

Tx

Treatment

UMHS

University of Michigan Health System

Clinical Background and Epidemiology

Between 0.4 and 6.2% of healthy > 35 week newborns receive phototherapy for indirect hyperbilirubinemia,^5,6 and severe hyperbilirubinemia occurs in approximately 7–45 neonates per 100,000 live births.⁷ The definition of severe hyperbilirubinemia varies, but typically refers to bilirubin levels between 25 to 30 mg/dL.

There are several factors that increase a newborn’s risk for development of severe hyperbilirubinemia. A systematic review done in 2010 concluded factors associated with severe hyperbilirubinemia were age < 38 weeks, jaundice within 24 hours of life and intention to breastfeed exclusively. In this review, four out of five studies evaluated family history of jaundice as a risk factor and four found it to be statistically significant.⁸ Large cohort studies since then confirm some of these findings. Male gender and non-Caucasian race increase the probability of high total serum bilirubin (TSB) as does evidence of cephalohematoma.⁷ “Dehydration/starvation,” usually measured as a percentage of weight loss since birth, is associated with hyperbilirubinemia. “Exclusive breastfeeding” is often found as a risk factor.^9,10

Complications

Unbound and unconjugated (free) bilirubin is neurotoxic.¹¹ Brain damage caused by hyperbilirubinemia requires that a quantity of (free) bilirubin to chemically interact with neurons. The concentration of bilirubin sufficient to cause neuronal cell injury is speculative. The concentration of free bilirubin in the central nervous system and the underlying “susceptibility” of neurons (independent of bilirubin concentration) are key determinants of injury, neither of which is easily measured. The amount of free bilirubin is dependent upon the total serum bilirubin value, the albumin (principle “binder” of bilirubin) concentration, and the chemical kinetics governing the binding of the two. This can be affected by gestational age, concomitant illness and any other compounds competing for bilirubin binding sites. A separate set of kinetics governs the transfer of bilirubin from blood into (and out of) the central nervous system (CNS). These kinetics can be affected by underlying illness.

At present there is no practical way to measure free CNS bilirubin; hence TSB is used as a surrogate. The susceptibility of the CNS is regional in nature; neurons in the basal ganglia and cerebellum appear most susceptible. It is reasonable to assume that underlying cellular “stress” can render certain neurons more vulnerable (e.g. hypoxia, inflammation).

The bottom line is that at any given time for any given baby, there exists a serum bilirubin value that can cause injury, but what that actual value is will always be speculative. Clinical studies in this area focus on values of TSB that are associated with acute bilirubin encephalopathy (ABE) and chronic bilirubin encephalopathy (CBE), and recognizable clinical conditions that are associated with ABE and CBE. These studies seek to define probability estimates (or action threshold probabilities) that trigger clinician behaviors (eg, identify risk, identify TSB threshold for phototherapy, and identify TSB threshold for exchange transfusion).¹² In the early phase of ABE, neonates are described as having poor feeding, lethargy, high-pitched cry, increased tone, opisthotonos, or seizures. Later acute encephalopathy is characterized by retrocollis-opisthotonos, shrill cry, no feeding, apnea, fever, deep stupor to coma, sometimes seizures, and death. Sequelae of CBE include: motor delay, sensorineural hearing loss, upward gaze palsy, dental dysplasia, athetoid cerebral palsy, or mental retardation.

The incidence of severe hyperbilirubinemia with subsequent encephalopathy is fairly consistent throughout large epidemiologic studies, at approximately 0.5 to 1.0 cases per 100,000 live births (Canada 2.5/100,000). Most provide no statistical data; the absolute number in each with CBE is very small. A large percentage of neonates with chronic bilirubin encephalopathy (CBE) had additional risk factors, among the most common being hemolysis (isoimmunization, G6PD deficiency, spherocytosis), late prematurity, and infection. Some had multiple risk factors.

The use of “high risk” categorization is justified in that risk factors are used in conjunction with TSB values to determine overall risk of extreme hyperbilirubinemia, a prerequisite for CBE.

Prevention

Exclusive breastfeeding is recommended during first 6 months of life, as all-cause mortality is less in exclusive breast fed neonates.¹³ Exclusive breastfeeding is strongly associated with an increased risk of hyperbilirubinemia, however, the hyperbilirubinemia appears to be primarily the result of less effective breastfeeding.^14–16 To ensure successful breast feeding, lactation support should be initiated in the hospital if any difficulty is suspected, and continued in the physician’s office and at home (e.g. at UMHS, patient educational materials such as Feeding the Baby Born Before 38 Weeks).⁴

The American Academy of Pediatrics recommends promoting breastfeeding for all term neonates at least eight to 12 times per day during first several days of life to reduce likelihood of dehydration.⁴ Breastfeeding women whose neonates are jaundiced are at increased risk of early cessation of breastfeeding.¹⁷ Mothers should be encouraged to breastfeed, and given lactation support if experiencing difficulty in breastfeeding, unless the level is approaching threshold for exchange transfusion.¹⁸ If phototherapy during breast feeding is possible, it can be encouraged.

Supplementation with formula may be considered if the neonate’s intake is inadequate, weight loss is more than the 95^th percentile per NEWT, the neonate appears dehydrated, or the jaundice is severe. Signs of adequate intake in breast-fed neonates include four to six thoroughly wet diapers per day, three to four stools per day by the fourth day of life, and a transition to seedy, mustard-colored stools by the third or fourth day of life.⁴

It is recommend that feeding of all newborns occurs at least eight times per day starting immediately following birth.¹⁹ We recommended that babies be kept skin to skin and feed based on feeding cues with attempts at least every three hours. Feeding supplementation is not indicated for sleepy neonates during first 24–48 hours, unless there are signs of dehydration or weight loss is > 95^th percentile per NEWT.⁴ UMHS guidelines for supplementation for difficult to latch term neonate during first 4 days are shown below. This recommendation is based on average intake of colostrum by healthy breast fed neonates.^20,21

Diagnostic Procedures and Considerations

A total bilirubin should be measured on all babies prior to discharge from the birth hospitalization.²² Compared with selective testing, universal screening reduces total blood draws and phototherapy rates.^23,24 While several clinical risk scores have been developed, none are as predictive of subsequent hyperbilirubinemia as a predischarge bilirubin level.²⁵

Transcutaneous (TcB) levels should be used for screening. Transcutaneous levels are reasonable estimates for serum levels, and can be done rapidly and without a blood draw.³ TcB should be obtained from the sternum in neonates to avoid false negative that may be associated with the neonates face being in the sun.

The predischarge TcB should be obtained between 16 and 24 hours of life. (UMHS guideline regarding measurement of transcutaneous bilirubin.) In cases where a rapid rate of rise of serum bilirubin may occur (eg, hemolysis) TcB can underestimate serum bilirubin values. A serum value may be more accurate.

Predischarge screening bilirubin levels should be used to guide follow-up. The hour-specific Bhutani nomogram can be used to predict the likelihood of subsequent significant hyperbilirubinemia found in Appendix 1.^22,26 Significant hyperbilirubinemia in this case is defined as > 95^th percentile on the nomogram, and does not necessarily correlate with a need for phototherapy or exchange transfusion, length of stay, or neurologic outcomes. The hour-specific nomogram has been validated for patients with ABO incompatibility and positive direct antiglobulin test, and may be used in this population.²⁷

A serum bilirubin (TSB) is recommended in the circumstances outlined in Table 4.

Infant jaundice studies [IJS; Neonatal blood typing for ABO and Rh as well as direct antiglobulin test (DAT)] should be obtained in circumstances outlined in Table 4.

Infant jaundice studies should not be measured routinely in all babies born to mothers with blood type O.^11,28 Only 15% of neonates with ABO-incompatibility and a positive DAT will develop significant hyperbilirubinemia.¹¹ Those that do have ABO-hemolytic disease develop clinically significant jaundice in the first 12–24 hours of life and will be recognized with routine screening.

TcB can be used in the outpatient setting, including in the clinic or by a visiting nurse, to assess jaundice. This will reduce lab draws by 20–50%.²⁹

Cord blood DAT should not routinely be tested for in a Rh+ neonate of a Rh− mother who was treated with RhoGAM. It has a low positive predictive value for later hyperbilirubinemia and there is a risk of false positive after RhoGAM. [III-C]³⁰ If phototherapy is being considered, DAT should be evaluated via cord blood or blood draw. [I-C]⁴

We recommend against withholding breast milk for diagnostic purposes in the setting of suspected breast milk jaundice. Significant hyperbilirubinemia is primarily the result of less effective breastfeeding, rather than breast-feeding itself.¹⁵ Neonates with jaundice were twice as likely as those without jaundice to have mothers who had stopped breastfeeding by one month (number needed to harm = 4).¹⁷

Common causes for hyperbilirubinemia include blood type incompatibility, G6PD deficiency, and infection. No cause was found in 1/3 of cases of neonates discharged healthy and returning with kernicterus in a sample of 125 neonates of ≥ 35 gestational age.^9,31 There are several instances when further investigation into underlying etiologies for hyperbilirubinemia are suggested (Table 4).

Suggested testing when investigating underlying etiologies for indirect hyperbilirubinemia include DAT if not previously done, G6PD, hemoglobin/hematocrit, reticulocyte count, peripheral smear (RBC indices), complete blood count with differential, blood cultures and urine cultures.

Risk Stratification

Neonates should be assessed for any neurotoxicity risk factors (Table 1). Using the gestational age at birth and presence or absence of neurotoxicity risk factors, treatment thresholds can be determined using the NCNC nomograms or website [I-D] (Figure 4–7).⁴

The risk level is used to determine the hour-specific threshold for phototherapy and exchange transfusion.

Do not presume the presence of hemolytic disease, and thus a neurotoxicity risk factor, solely on the basis of maternal blood type O. [III-C]^11,28,32 If there is clinical concern for hyperbilirubinemia, infant jaundice studies should be sent to further risk stratify neurotoxicity risk. A positive DAT indicates hemolysis and thus is considered a neurotoxicity risk factor. Of note, there are occasional false negative DAT tests. If there is high clinical concern for hemolytic disease despite a negative DAT, it is an option to risk stratify as having a neurotoxicity risk factor.

Neonates being treated with antibiotics for suspected sepsis should be considered to have a neurotoxicity risk factor [I-C].^33–35 In the presence of hyperbilirubinemia, sepsis increases the risk of bilirubin encephalopathy 20-fold or greater. This risk factor may be discounted when blood cultures return negative and antibiotics are discontinued.

Level of Care

Treatment can range from hospital care to home care. Considerations of the various levels of care are listed below.

Treatment

The goal of treatment is to prevent acute and chronic bilirubin encephalopathy. An additional goal of phototherapy is to prevent the need for exchange transfusion, a therapy that can acutely lower serum bilirubin values but also engenders risk. Phototherapy can also reduce serum bilirubin values but requires time for its therapeutic effect to become apparent. Because of this, risk-averse clinicians are obliged to “over treat” with phototherapy targeting neonates who are at risk for extreme hyperbilirubinemia. Once a neonate has crossed the risk threshold, treatment with a standardized approach to phototherapy is of value.

In the absence of high quality evidence for the thresholds at which hyperbilirubinemia should be treated, we rely on external guidelines. Given evidence of potential harms of treatment and safety of increased treatment thresholds, the Northern California Neonatology Consortium (NCNC) treatment thresholds have been adapted for use. These treatment thresholds are based on prior AAP National guidelines in addition to quality and safety projects in the Kaiser Northern California group showing decreased readmissions and inpatient phototherapy treatment without any increase in harm. [I-D]

Monitoring

Follow-up

Schedule outpatient follow-up within 1–3 days (see outpatient assessment) following birth hospitalization discharge to evaluate: neonates’ weight, percent change from the birth weight, adequacy of feeding, pattern of voiding and stooling, and presence of jaundice. Close follow up is recommended after initial evaluation after discharge to ensure adequate feeding in exclusively breast-fed neonates.

Order total serum bilirubin level for evaluation if ongoing feeding difficulties, dehydration, or other concerns are present at outpatient evaluations.

Management of TSB results:

• TSB is less than discharge level, no further measurement is needed.
• Rebound is noted but TSB lower than 2 below treatment threshold (unless concern for weight loss or feeding) no further test is needed.
• Rebound is noted and TSB is within 0–2 below level, recheck TSB in 1–2 days.
• Rebound is noted and TSB is at or above phototherapy level of appropriate neurotoxicity risk, the provider should arrange direct admission to the hospital unless the neonate needs evaluation by ED providers.

Guideline Creation Process and Considerations

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Appendix 1. Bhutani Nomogram

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 :6–14²⁶
Reproduced with permission from American Academy of Pediatrics Journal, Vol. 103, Page 9, copyright 1999 by AAP

Appendix 2. Internal UMHS Guidelines

Transfer of newborn from well newborn to the floor: http://www.med.umich.edu/i/nursing-birthcenter/docs/pt_placement.pdf

TcB measurement in the newborn nursery: http://cw.i.medicine.umich.edu/sites/default/files/policies/trans_bili.pdf

Visiting nurse TcB measurement: http://hcs.med.umich.edu/procedure/showdoc.ashx?docID=254.054

After hours phlebotomy: http://www.med.umich.edu/i/em/Clinical_Guidelines/Phlebotomy_After_Hours.pdf ; http://inted.sites.uofmhosting.net/sites/default/files/downloads/Phlebotomy_After_Hours.pdf

These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.