Improving the Evaluation and Management of Early Onset Sepsis in the Neonatal ICU (NICU) Using QI Methodology

Purpose/Objectives: Neonatal early onset sepsis (EOS) is an invasive bacterial infection of the blood or cerebrospinal fluid occurring in the first week of life. Signs of EOS are nonspecific and therefore difficult to diagnose clinically. EOS is associated with significant morbidity and mortality. In an attempt to avoid missing a diagnosis of EOS, providers may obtain serial complete blood counts with differential (CBC) and C-reactive proteins (CRP) that are not sensitive or specific for a diagnosis of EOS, along with blood cultures. Antibiotics are frequently used during sepsis evaluation. There is evidence associating early antibiotic use with long-term adverse effects. Research has now shown that use of the Kaiser Permanente neonatal sepsis calculator can reduce antibiotic use and unnecessary sepsis evaluation.

Design/Methods: We collected baseline data from 2018 by chart review from neonates >/= 35 weeks gestational age at birth that were inborn and admitted to the NICU. We included infants admitted with any concerns for sepsis (e.g., respiratory distress, hypothermia, hemodynamic instability, chorioamnionitis). We excluded infants with significant congenital anomalies. After review of the baseline data, we developed a SMART AIM to decrease overall antibiotic duration by 40% and unnecessary laboratory tests by 50% within 6 months of initiation of the use of sepsis calculator along with education on sepsis evaluations and the importance of using blood culture as the gold standard for determining if therapy is necessary. PDSA cycles also included incorporating use of the sepsis calculator into our documentation through autotext reminders and changing the amount of blood obtained per blood culture bottle to improve recovery of organisms and increase confidence in culture results. Balancing measures included monitoring for cases of sepsis that were missed by use of sepsis calculator and also readmission to our hospital within one week of discharge due to infection.

Results: Preliminary results illustrate significant reduction in infant laboratory testing. CRPs obtained decreased from 91% to 31%. Number of CRPs per patient decreased from a mean of 2.15 to 0. Number of CBCs per patient decreased from a mean of 2.36 to 1.25. There was a significant reduction in duration of antibiotics per patient from a mean of 103.5 hours to 48 hours. Balancing measures include monitoring for any cases of sepsis that were missed by use of the sepsis calculator and readmission to our hospital within one week of discharge due to infection (both were 0).

Conclusion/Discussion: Quality improvement methodology has led to a substantial change in our management of neonates with suspected EOS. Our changes have led to a significant reduction in antibiotic duration and unnecessary, painful and low value laboratory sampling. Ongoing efforts will include work towards elimination of obtaining a routine screening CBC for sepsis evaluation without blood culture.