uchealth memorial nicu: expanding newborn antibiotic ......uchealth memorial nicu: expanding newborn...
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UCHealth Memorial NICU: Expanding Newborn Antibiotic Stewardship Beyond the NICU
and Our HospitalMary R Laird, MD
NeonatologistUCHealth Memorial Hospital and Parkview Medical Center
Steering Committee Colorado [Neonatal] Antibiotic Stewardship [email protected]
CPCQC August 3, 2018
NICU AntibioticStewardship
110
59
133
166
64
54
81
140
49
59
40
81
47
3136
30
17
50
15 13 11
Median
Goal
0
0
20
40
60
80
100
120
140
160
180
Jul-1
6
Au
g-1
6
Se
p-1
6
Oct-1
6
Nov-1
6
Dec-1
6
Jan
-17
Fe
b-1
7
Ma
r-17
Ap
r-17
Ma
y-1
7
Jun
-17
Jul-1
7
Au
g-1
7
Se
p-1
7
Oct-1
7
Nov-1
7
Dec-1
7
Jan
-18
Fe
b-1
8
Ma
r-18
Ap
r-18
Ma
y-1
8
Antibiotic Utilization Rate in the NBNAUR
1
2 543 6
1. NBN manager and CHIPS group Pediatric Hospitalists introduced to EOS SRC—Feb 20172. Team developed to implement EOS SRC tool in NBN (Peds, RN staff, manager, IT, Neo), historic data on septic
newborns gathered--March 20173. Research/discussions--April 20174. Presentation at Ped Section, consensus to proceed with use of EOS SRC—July 20175. Policy drafted, education of staff and providers—Oct/Nov 20176. Go-live full implementation—Dec 2017
Result: Fewer antibiotics
Result: Fewer blood cultures
9
15 15 15
19
21
9
13
12
17
12 12
11
14 14
7
10
7
5
8
3
5
4
1
4
Median
Goal
0
0
5
10
15
20
25
Ma
y-1
6
Jun
-16
Jul-1
6
Au
g-1
6
Se
p-1
6
Oct-1
6
Nov-1
6
Dec-1
6
Jan
-17
Fe
b-1
7
Ma
r-17
Ap
r-17
Ma
y-1
7
Jun
-17
Jul-1
7
Au
g-1
7
Se
p-1
7
Oct-1
7
Nov-1
7
Dec-1
7
Jan
-18
Fe
b-1
8
Ma
r-18
Ap
r-18
Ma
y-1
8
Num
ber
of blo
od c
ulture
s
month
Blood cultures sent from Memorial Newborn Nursery
EOS sepsis risk calculator benefits at Memorial• Standardized Care• The EOS SRC is evidence based and based on current epidemiology, is a
more accurate assessment of sepsis risk• Promotes antimicrobial stewardship principles• Eliminates the “chorioamnionitis dilemma”• Fewer blood cultures• No CBCs for routine evaluation of EOS• Fewer patients on antibiotics• Fewer stressed parents• Fewer babies/moms interrupted for blood draws and IV placement• No “missed” cases of sepsis
• Some things to know about the SRC• It’s intended to replace another national guideline (unlike other guidelines we
work on) for babies >/=34 weeks
• Lowest hanging fruit for reducing antibiotic usage rates in newborns
• Its intended to be universally implemented in a birth population—any delivery hospital in US can use it
Colorado Antibiotic Stewardship
Collaborative (11)
Additional centers achievement of 1 or more CDC core elements (target 10 by Dec 2018)
Colorado Perinatal Care Quality Collaborative (37)
Colorado Delivery Centers (62)
National multicenter neonatal antibiotic stewardship collaborative (via Vermont Oxford Network)
Guidelines
Two requests from a Memorial Neonatologist for presentationsRequest 1: for talk on implementing the Kaiser EOS SRC
Physicians and some staff aware of Kaiser EOS SRC
Currently utilize the CDC EOS guidelines but Pediatricians would like to implement Kaiser EOS SRC
1,800 deliveries annually
Capacity for sepsis evaluations and antibiotics; access to resources and education
Request 2: for talk on newborn sepsis
Few babies evaluated for sepsis, unclear if any guideline routinely applied
<200 deliveries annually
High risk population (my observation)
Very engaged nursing staff—cover L and D, postpartum moms and babies, resuscitations and stabilizations
Very engaged provider group, mostly Family Practice, care for wide range of disease processes
Content of presentations
Presentation 1
Brief review of antimicrobial stewardship concepts and the development of the Kaiser SRC
Implementation process at Memorial
Process for using the SRC at Memorial
Order set and policy
Memorial outcomes
Review of use of the SRC
Offer support/resources
Presentation 2
Antimicrobial Stewardship general/newborns
Development of the Kaiser SRC and f/u validation
Implementation at Memorial
Order set and policy
Review use of SRC
Memorial outcomes
Management of sepsis, including antibiotic selection
Offer support/resources
Objectives
Demonstrate use of the early onset sepsis risk calculator (EOS SRC) in patients >/34 weeks at birth
Understand the special risks to newborns of antibiotic overuse
Know about the Colorado [Newborn] Antibiotic Stewardship Collaborative
Discuss regional resources to help implement the EOS SRC if desired
Selected slides from MRL’s CASC presentations at hospitals
2013,In US
Selected slides from MRL’s CASC presentations at hospitals
Selected slides from MRL’s CASC presentations at hospitals
Guidelines
Selected slides from MRL’s CASC presentations at hospitals
https://neonatalsepsiscalculator.kaiserpermanente.org/
Caveats for use of the EOS SRC• The EOS SRC is intended to be used to calculate sepsis risk for all births >/=34 weeks
• Some centers choose to use it for selected patients, ie for infants of mothers with chorioamnionitis
• Premature infants are at much higher risk of sepsis than late preterm or term; the EOS SRC is not intended for use in these patients
• Lab tests eg CBC are not part of the evaluation in this model (ask me about our NICU use of CBC’s)
• If the recommendation is “begin antibiotics”, don’t forget to obtain a blood culture
• If the clinical condition CHANGES, look at the recommendations for the new category
• The EOS SRC may IDENTIFY patients at risk who are not suspected by the CDC guideline
• Following the recommendations of the EOS SRC will result in FEWER patients treated than the CDC 2010 guideline
• Clinical concern for illness caused by sepsis is always a reasonable indication for antibiotics
Selected slides from MRL’s CASC presentations at hospitals
Empiric therapy and further evaluation and treatment• May vary by geography, but in our region
• Ampicillin 50mg/kg/dose q 12 hours IV
• Gentamicin 4mg/kg q 24 hours IV if >/35 weeks (there are other dosing regimens for gent as well)
• Make a habit/hospital policy of ordering stop dates on all antibiotics• “Culture negative sepsis” is rare
• 96% of cultures positive by 24 hours
• ~100% of cultures positive by 36 hours
• Inadvertent prolonging of antibiotics causes harm
Neofax; Lefebvre 2015 Journal of Pediatric Infectious Diseases society; and others
Selected slides from MRL’s CASC presentations at hospitals
Support for implementing the EOS SRC as a QI project
• I am happy to connect resources as able, answer questions, provide literature, or help with steps to obtain American Board of Pediatrics MOC part IV• [email protected] or [email protected]
• 719 339-7969
• Dr Samantha Milne, Ped Hospitalist at Memorial, and Connie Hathaway RN, IT at Memorial, have offered to meet by phone with IT support or others (Connie’s phone: )
• Colorado Antibiotic Stewardship Committee members are developing strategies to support non-CASC hospitals
Selected slides from MRL’s CASC presentations at hospitals
Outcomes of presentations
Presentation 1Discussion of roles if decide on universal implementationIT contact copied me on communications about system-wide EMR utilization of a sepsis note and link to Kaiser SRCI will check back with contacts about implementation and about replying to CASC survey on CDC Core elements
Presentation 2Physicians from other hospitals attended; target hospital attendingscould not be there but expressed interestNursing staff engaged, described how they might easily implement; volunteered presentation to physician staffI will check back with contacts about implementation and about replying to CASC survey on CDC Core elements