4/3/2018

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Post-delivery disposition and risk

stratification for the near term and term

newborns born to mothers with

chorioamnionitis (“Triple I”)

Cindy Osborn, RN

Alexander Gurfinkel, MD

April 13, 2018

Disclosures

• I have nothing to disclose

Objectives

• Recognize and implement the new Triple I criteria into your practice

• Explain and utilize the EOS (Early Onset Sepsis) calculator to determine the initial EOS score for newborn assessment.

• Identify the multi-disciplinary culture changes required for successful implementation

• Identify tools for sustaining this process in YOUR workplace

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Background

• Chorioamnionitis complicates 2-3% of term

pregnancies in the US.

• Up to 40-70% of preterm pregnancies

• In term and near term infants the incidence of

sepsis is extremely low (0.14%-0.3%)

• Currently ALL infants are recommended to

receive antibiotics (CDC, 2010)

Chorioamnionitis

• Fever PLUS 1 or 2 of the following:

–Maternal leukocytosis (>15,000)

– Fetal tachycardia

– Foul smelling amniotic fluid

–Maternal tachycardia

– Uterine tenderness

• Practitioner to practitioner variation in making

diagnosis

“Triple I” - huh?

• “Intrauterine Infection, Inflammation or both”

• Chorioamnionitis is ambiguous

• Known risk factor for EOS (Early Onset Sepsis),

therefore standardization is needed

• Isolated maternal fever is NOT synonymous

with chorioamnionitis

ACOG Committee Opinion #712 (2017)

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Diagnosing Triple I

• Isolated fever, taken ORALLY

– >39 C (102.2 F) once, OR

– >38 C (100.4 F) on two occasions 30 minutes apart

• Suspected Triple I: Fever plus any of

–Maternal leukocytosis (>15,000)

– Fetal tachycardia (baseline >160)

– Purulent fluid from the cervical os

• Confirmed Triple I: pathology proven

ACOG Committee Opinion #712 (2017)

Higgins et al. (2016)

Chorioamnionitis

• Fever PLUS 1 or 2 of the following:

–Maternal leukocytosis (>15,000)

– Fetal tachycardia

– Foul smelling amniotic fluid

–Maternal tachycardia

– Uterine tenderness

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Suspected Triple I

• Fever PLUS ANY of the following:

–Maternal leukocytosis (>15,000)

– Fetal tachycardia (>160 BPM)

– Purulent fluid from the cervical os

–Maternal tachycardia

– Uterine tenderness

• Temperature is assessed twice 30 min apart

allowing for earlier recognition and treatment

Isolated Maternal Fever

Potential Causes

• Epidural anesthesia

• Room temperature

• Prostaglandin use

• Hyperthyroidism

• Dehydration

Treatment

• Isolated fever

–Monitor for other signs

– Treat underlying cause as appropriate

• Suspected Triple I

– Antibiotics are indicated

– Ampicillin and Gentamicin are a frequently used

combination

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Work that is underway

• A Pathway is being proposed for consistent care and treatment- all stakeholders are reviewing this for an anticipated “Go live” in May

• An update to the Triple I Maternal Order Set-various antibiotic combinations based on ACOG’s recommendation on GBS status and allergy status.

QI Project

Problem

• All newborns born to mothers with a diagnosis of chorioamnionitis at delivery are being separated from mothers and admitted to the NICU for IV antibiotic therapy

• Bonding immediately after birth is critical, as lack of it may lead to:

– Increase in stress levels

– Thermoregulation issues

– Delayed initiation of breastfeeding

– Increased cost of care

– Utilization of NICU beds by healthy newborns

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Current State Process

AIM Statement

• Increase in eligible newborns rooming in with

their mothers diagnosed with

chorioamnionitis at delivery from 0% to at

least 90% within 6 months, with 100% of

those infants having Early Onset Sepsis (EOS)

stratification performed at birth

• Balancing measure-newborns free from

adverse outcomes during hospitalization.

Inclusion criteria

- Maternal diagnosis of chorioamnionitis

- Gestational age >35 weeks

- Newborn weight of >1800 grams

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Description of Project

• Risk of EOS is calculated based on 5 maternal factors:

Gestational age of baby at delivery

Rupture of membranes duration

Highest degree of maternal fever

GBS status

Timing of prophylactic antibiotics while in labor

• Numerical score is assigned based on the algorithm

Description of Project

Infants with EOS score of 1.54 or less (“mild” and “moderate” risk)

would be admitted to the NFCC (“eligible”)

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Project Measures

– At least 90% of eligible newborns will be admitted to NFCC (Newborn Family Care Center-Postpartum) versus NICU

– Exclusive breastfeeding at discharge from the NFCC

– Performance of Escobar stratification

– Start infusion of initial antibiotic within 1 hour of birth

– Chorio order set entered by APP at delivery

–Missed identification of sepsis or delay in NICU transfer of baby with adverse change in condition

Implementation

Communication:– Large group of stakeholders of leaders and staff

– Created current and future state maps

– Held meetings every 2 weeks to work out details and for staff input

– OB, Neonatology and Pediatric providers notified of change

2 simulations conducted to identify gaps in process

Staff training (about 400 people in total)– Implemented “Escobar risk stratification” tool (EOS calculator)

– Education of L&D and NFCC staff on management of IV lines

Implemented: November 28, 2016

What does nursing need to know?

• Is this baby well enough to stay with mom?

• What are the signs and symptoms of EOS

(Early Onset Sepsis)?

• Now we need to learn newborn IV therapy?

• What are the assessments for newborns at

risk for EOS?

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What does nursing need to know-

(cont)

• Do these newborns need closer monitoring?

• How do we staff for these babies?

• Epic modifications for documentation

• Escobar build

Care of the Newborn-education needs

• Newborn IV management

• Antibiotic administration

• Early Onset Sepsis signs and symptoms

• Central capillary refill and blood pressure

assessments- mean cuff pressure

• Pulse oximetry- assessed with vital signs

Critical

Determinants

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Staff Roles and ResponsibilitiesRoles for Newborn Early Onset Sepsis Process

NICU/APP Shared

NICU/L&D

L&D NFCC

Su

pp

lie

s

[ ] PIV start kit

[ ] Venipuncture/Arterial stick Kit

[ ] Umbilical Cord Cart

[ ] Medfusion pump/pole

[ ] Microbore tubing- 60”

[ ] One Link IV Connector

(hub)

[ ] Space Lab Monitor

[ ] BP cuff

[ ] Extra tubing/supplies for PIV

[ ] Space lab monitor

Task

s

[ ] Exam

[ ] Assign Apgar’s

[ ] Disposition Decision

[ ] Update family w/ plan

[ ] Place PIV

[ ] Blood Culture (venipuncture

or placental)

[ ] Label and bring cultures to

NICU lab

[ ] APP to enter Newborn Sepsis

Prevention order-set

[ ] APP enters .escobar note and

billing note

[ ] Chart interventions (including

LDA for the PIV, enter vitals

and weight)

[ ] Release Blood Culture Lab

order

[ ] Weight

[ ] Set of

vitals

[ ] Baby

Bands

[ ] Calculate initial EOS

score

[ ] Start Amp (1st) & Gent

(2nd) when arrives from

main pharmacy

[ ] Continue Vital Signs

[ ] POC glucose

[ ] Acknowledge EOS orders

[ ] Pediatric provider to interpret CBC

results

[ ] Provider to check on culture results

daily

[ ] Lock PIV

[ ] Complete Antibiotic course

[ ] Replace any infiltrated PIVs

1. Vascular Access

2. Ped’s Flyer

3. NICU staff

4. Consider IM if only 1 Amp dose

remains. Call NICU APP to order IM

Amp as concentration is different.

[ ] Discuss PIV removal with provider

[ ] Hearing screen after antibiotics are

infused

Newborn Management Highlights

• CBC drawn at 24h

• Blood culture at birth (placenta or peripheral)

• Antibiotics for 48 hrs

Vitals (frequency)Other Vital

Signs/AssessmentsProvider Evaluation

At birth x1

q15” x4

q30” x4

q2° x4

q3-4° until 48o

then unit routine

BP, mean BP, central cap

refill:

x1 in L&D

w/ all VS after

If newborn vitals fall outside

of order set parameters,

contact the hospitalist for

newborn evaluation.

Role of the Delivering staff

• Initial EOS scoring with diagnosis

• Preparation of pump and IV tubing

• If at time of delivery the newborn is vigorous,

may go skin-to-skin

• Delayed cord clamping

• APP will examine the newborn

• NICU staff will obtain blood cultures from the

placenta

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Role of the Delivering staff (cont)

• Weigh the newborn asap for antibiotic order

• NICU staff to start IV

• Pharmacy provides RTA antibiotic versus needing to reconstitute

• Labor and Delivery nurse to start IV antibiotic within 1 hour of delivery- preferably Amp

• The labor nurses will determine who will coordinate VS, glucose check, release of Suspected Sepsis order set

Role of the Postpartum staff

• Hand off from Labor and Delivery staff

• Assessment of mother and baby on arrival

• Pediatric notification of newborn on the unit

• PIV restarts- Should the PIV infiltrate, consider

if last dose of Ampicillin can be given IM. NICU

IV restart versus Vascular Access team

• Timing of hearing screen

Role of the Postpartum staff (cont)

• Discharge timing- the newborn should not be

discharged sooner than 48 hours after birth

due to antibiotic therapy

• The mother is able to be discharged if meets

discharge milestones, baby remains a patient

until appropriate

• No change to the newborn bath timing- bath

does not need to be delayed or expedited

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General

• Poor feeding

• Irritability

• Lethargy

• Temperature instability

Central nervous system

• Hypotonia, stupor, poor spontaneous

movement, coma

• Irritability

• Seizures, rigidity

• Bulging anterior fontanelle

Respiratory

• Grunting

• Nasal flaring

• Intercostal retractions

• Tachypnea, apnea, irregular respirations

• Abnormal breath sounds, decreased breath

sounds, rales

Circulatory

• Bradycardia, tachycardia

• Hypotension

• Cyanosis

• Decreased perfusion (pallor, gray,

mottled, ashen, delayed capillary refill)

Metabolic

• Hypoglycemia/Hyperglycemia

Other

• Jaundice

The clinical signs of early onset sepsis are nonspecific and are associated with the causative organism. Therefore,

it is prudent to provide treatment for suspected neonatal sepsis while excluding the presence of infection.

A frequent indication of serious

infection is an inability to

maintain the body temperature in

the neutral thermal zone

(usually 97.7°F and 99°F axillary).

Newborn Suspected Sepsis Management Order Set

Frequency of Vital Signs (HR, RR,

Temperature, Oxygen Saturation

and Central Capillary Refill)

• At Birth

• Every 15 minutes X4

• Every 30 minutes X4

• Every 2 hours X4

• Every 3-4 hours with feeding

cues and cares

Blood pressure (including mean

pressure)

• Once in the delivery room

within 2 hours after birth

• Every 3-4 hours with feeding

cues and cares

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The newborn will receive more frequent monitoring of clinical presentation

and vital signs for the first 12 hours. Notify the APP if the newborn has, at

least 2 instances of 1 of the following, with “instance” meaning that there

were 2 measurements 2 hours apart.

• Report abnormal findings to the APP.

• Heart rate greater than 160

• Temperature greater than 100.4oF or

less than 97.5oF

• Respiratory distress (grunting, flaring, or

retracting)

Newborn Suspected Sepsis Management Order Set

• It is important to obtain, monitor and document mean cuff pressure

{arterial pressure (MAP)} in the newborn born with risk of early onset

sepsis.

• The mean pressure is an important indicator of blood pressure change,

and represents the newborn’s average tissue perfusion pressure.

• Mean cuff pressure values are easier to trend than changes in systolic or

diastolic pressures.

IMPORTANCE OF MEAN CUFF PRESSURE

Report a mean cuff pressure of

less than 35 mmHg to the APP.

Determine and document mean

cuff pressure with every BP.

Although you may hear this value reported as the MAP (mean arterial pressure), it is more accurate to refer

to this value as the mean cuff pressure. A MAP is used when monitoring arterial BPs via an arterial line.

Hypotension with decreased perfusion and diminished pulses are signs of early onset sepsis. In

addition to vital signs like blood pressure, signs of decreased perfusion must be evaluated in the

newborn at risk for EOS.

Central capillary refill will be evaluated with each vital sign.

1. Blanch the skin on the newborn’s chest.

2. Watch for blood return.

3. If capillary refill takes greater than 3 seconds, report

capillary refill time, blood pressure, and mean cuff

pressure to the NNP.

ASSESSING CENTRAL CAPILLARY REFILL

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• The newborn at risk for early onset sepsis

is at risk for metabolic symptoms including

hypoglycemia.

• Blood glucose will be checked in the

delivery room 30 minutes after the first

feeding attempt but no later than 2 hours

of age.

• If the baby has other risk factors for

hypoglycemia, initiate the hypoglycemia

order set and algorithm.

How should I staff for these babies?

Labor: Staff a nurse for mom and a nurse

for baby with the delivery.

Postpartum: Consider staffing up the first

several hours of life.

Utilize the Resource Nurse to assist with

vitals, etc.

Outcomes

Measure Target, % Actual, %

Accurate documentation of Escobar stratification 100 75

Percentage of eligible newborns born to mothers

with Triple I who were managed on NFCC

90 100

Start infusion of initial antibiotic within 1 hour of

birth

100 41

Newborn EOS order set entered by APP at delivery 100 100

Exclusive breastfeeding at discharge (those babies

who were admitted directly to the NFCC)

95 62

Missed identification of sepsis or delay in NICU

transfer of baby with adverse change in condition

0 0

All infants were appropriately dispositioned.

22 in NFCC

15 in NICU (7 were transferred to NFCC once stable)

Families expressed relief not being separated from their babies

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Patient Experience

• “I felt so comfortable having my baby in my

room with me and knowing that we both had

the same nurse, put me at ease.”

• “I am so thankful to have my baby with me. I

can hold her and breastfeed anytime I want.”

• “Thank you for letting my baby stay with me.”

Lessons… Issues…

• Assess the scope of your project as you learn more about the

issue

• Identify the right team and engage early in regular

communications

• Ask for honest feedback

• Look at education gaps and roll out learning modules early in

the process

• Ask for EPIC builds early

– Automated reporting of new cases is currently being trialed

– Need for institution-specific baseline EOS data

• Acknowledge staff efforts

Sustainability

• Stressing the importance of this project to our

customers and the organization

• Clearly assigned roles, becomes part of the routine

• Regular review of cases every 2 months

• We have a small number of subjects (may see a

bump)

– Historically UMMC has seen 44-45 “chorio” infants admitted

to NICU annually

– Visual reminders

• Posting results

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Project Evolution

• Roll out: Ridges and in process at Maple Grove

and the University of Chicago. Interest shown

at Mercy Hospital in Des Moines

• State, National and International OB and

Hospitalist conferences and workshops

• 2018 National AWHONN conference- poster

• Selective use of antibiotics is a possibility in

the future as results are analyzed

Acknowledgements

• Tom George, MD

• Cathy Bendel, MD

• Angela Hanson, MD

• Marla Mills, RN

• Shelly Krueger, RN

• Cathy McCarty, RN

• Becky Gams, APNL

• Nanette Vogel, CDS

• Janet Kubly, RPh

• Christie McNeil, RN

• Kim Killam, RN

• Marylou Salzer, RN

• Darla Nyquist, NNP

• Julianne Cramer, APNL

• Caroline Kaylor, NNP

• Brittany Stanley, NNP

• Jodie Allen, RN

• Sheila Powers, RN

• Lisa Archer, RN

• Debbie Allen, IBCLC, NNP

• Sponsor: Jordan Marmet, MD

• Sponsor: Jody Rock, RN

• Coach: Kyung Park, RN

This project would not be possible without

the support and dedication of these people

THANK YOU!

• “We see our customers as invited guests to a party, and we are

the hosts. It’s our job every day to make every important aspect

of the customer experience a little bit better.” (Jeff Bezos)

• “You’ve got to start with the customer experience and work

back toward the technology, not the other way around.” (Steve

Jobs)

4/3/2018

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Contact Information

• Cindy Osborn

• cosborn1@fairview.org

• Alexander Gurfinkel

• agurfink@umn.edu

References

• ACOG (2017). Intrapartum management of intraamniotic infection. Committee. Opinion No. 712. American College of Obstetricians and Gynecologists. Obstetrics & Gynecology, 130 (2). e95–101.

• Escobar, G. J., Puopolo, K. M., Wi, S., Turk, B. J., Kuzniewicz, M. W., Walsh, E. M., Newman, T. B., Zupancic, J. Lieberman, E. & Draper, D. (2014). Stratification of risk of early-onset sepsis in newborns ≥ 34 weeks’ gestation. Pediatrics 133(1), 30-36. doi: 10.1542/peds.2013-1689

• Higgins et al. (2016). Evaluation and management of women and newborns with a maternal diagnosis of chorioamnionitis: Summary of a workshop. Obstetrics & Gynecology, 127 (3), 426-36. doi: 10.1097/ACOG.0000000000001246

• Puopolo, K.M. (2016, September 9). Assessing risk of early onset sepsis among term infants. Retrieved from http://www.d6an.org/uploadFunctionality2/files/Puopolo%20Early%20Onset%20Sepsis.pdf

• Puopolo, K. M., Draper, D., Wi, S., Newman, T. B., Zupancic, J., Lieberman, E., Smith, M.Y. & Escobar, G. J. (2011). Estimating the probability of neonatal early-onset infection on the basis of maternal risk factors. Pediatrics, 128(5), e1155-1163. doi: 10.1542/peds.2010-3464

Let’s Review

Early Onset Sepsis QUIZ