Chorioamnionitis: Changing our Management of Mothers and Their Newborns New Term: Triple I Review CDC/COFN Guidelines Proposed Change to Management of “Chorio Babies” at Christiana Care: T.I.M.E. Pathway “Sepsis Calculator” Role of the LDR Nurse

Current State- CDC/COFN Guidelines & CCHS Practice All infants born to mothers with a diagnosis of “chorioamnionitis” are admitted to the NICU; regardless of absence of symptoms. Blood culture on admission and CBC monitoring Minimum 48 hrs of ampicillin/gentamicin Diagnosis of chorioamnionitis sometimes loosely applied. Maternal fever > 37.8° C and: Significant maternal tachycardia (>120 beats/min) Fetal tachycardia (>160-180 beats/min) Purulent or foul-smelling amniotic fluid or vaginal discharge Uterine tenderness Maternal leukocytosis (total blood leukocyte count >15,000-18,000 cells/μL)

Impact of “r/o sepsis chorio” admissions Asymptomatic Infant admitted for 48 hrs to ICN: Mother/baby separation Reduction in bonding Increased parental stress/anxiety Reduction in maternal breast milk production and feeding Increased exposure to formula and IV fluids Unnecessary lab draws Risk for extended hospitalization due to “culture negative” prolonged antibiotic use due to non-specific CBC lab abnormalities Weaning off of IVFs Adverse Events - IV infiltrates Dollars $500/patient hospital day compared to admission to term nursery Based on CCHS 2015 “chorio admission” data, this would be ~ $86,000-129,000/year

T.I.M.E. Pathway T = Triple M = Manage E = Early-onset Sepsis I = Intrauterine Inflammation and/or Infection M = Manage E = Early-onset Sepsis

Maternal Fever? “Isolated" Fever: “Documented” Fever: Temperature > 38 Repeated after 30 minutes Temp < 38 “Documented” Fever: Temp > 38 Any temperature > 39 – no need to repeat –This is considered a “documented” fever

Triple I Clinical Diagnosis Documented Maternal fever PLUS ONE OF THE FOLLOWING Clinical Findings: Fetal Tachycardia (>160 for 10 minutes) Purulent Discharge from the Cervical OS “Left shift in WBC”/WBC’s > 15,000

Kaiser Permanente Sepsis Risk Score Calculator

Kaiser Permanente Sepsis Risk Score Calculator Clinical Exam Description

L&D Nurse Flow Process Alert to Nurse with initial Newborn Vital sign documentation (@ 30 minutes of life) Fires alert to Nurse Provides URL access Opens Power Form from alert

1. Nurse clicks Sepsis Calculator Link (goes to URL) If all the necessary information is added to PowerChart, a nurse alert will appear to complete the Sepsis Calculator…Select Sepsis Calc 1st

Using Sepsis Calculator 7. Click Calculate 1. Select 0.5/1000 (CDC Incidence) 2. Enter Gestational Age 3. Highest maternal temp. within 24 hrs of delivery 4. ROM Duration 5. GBS status 8. Record these Clinical Recommendations into Cerner Powerform “Neonatal Sepsis Risk Assessment” 6. GBS Specific IAP Abx: Penicillin Ampicillin Clindamycin Erythromycin Cefazolin Vancomycin Broad Spectrum Abx: Other cephalosporins Fluoroquinolones Any extended spectrum β-lactams Any GBS IAP plus an aminoglycoside Access Sepsis Calculator via URL link in PowerChart…

8. Record these Clinical Recommendations into Cerner Powerform “Neonatal Sepsis Risk Assessment” Incidence: Always select CDC national. After you click calculate, the information in the Clinical Recommendation column is what is transferred to the Sepsis Form…

L&D Nurse Flow Process

Peds/DR provider fills out the rest #5 Record newborn 30 min vital signs 2. Record Sepsis Calculator Clinical Recommendations. *Fill in all that apply from the calculator Notify Peds DR team/provider and document who was notified Complete form Sign form #1 #2 #3 #4 Peds/DR provider fills out the rest Fill in Clinical Recommendations from the Sepsis Calculator for Well Appearing & Equivocal. Remember, Newborns assessed with clinical illness will be admitted to NICU

Nurse/Pediatric Delivery Room Provider IMPORTANT Points Peds/DR provider should be at all deliveries if there is a concern for fetal well being. Peds/DR does not need to be at all deliveries. If the mother only had an isolated fever these babies need a Sepsis Calculator score completed after delivery, notify Peds of the recommendations Call Peds/DR provider to notify them of mothers with fevers (when able to do so) and also after the Sepsis Calculator score has been completed for the newborn (if Peds not present for delivery). Call Peds/DR provider if there is concern for newborn instability or vitals abnormality (e.g. tachypnea). Peds/DR provider should assess all babies with any sign of clinical instability (e.g. tachypnea).

Nurse/Pediatric Delivery Room Provider IMPORTANT Points continued … If the baby appears to be stable and is demonstrating normal transitional physiology (ie: has tachypnea but no distress), he/she may remain with the mother per routine in L&D. The baby can always be brought to the NICU for OBS if indicated. “Equivocal” exam babies, by definition require 2-4 hours of persistent symptoms. Therefore, a tachypneic baby at 1 HOL may simply be demonstrating transitional physiology and does not necessarily meet criteria for “equivocal exam”. If concerned, discuss with Peds/DR or Neonatology. When the mother is ready for transfer to Well Baby floor, only “Well Appearing” babies who do not require NICU admission (per their Sepsis Calculator recommendations) are cleared for co-transfer to Well Baby floor. Any baby with ongoing transitional physiologic abnormalities, or any sign of distress must go to the NICU. If a baby goes to NICU for OBS and then has complete resolution of symptoms, clinical discretion can be used to allow this baby to return to Well Baby Floor with mother. The Peds/DR provider must notify the Well Baby provider or covering provider about the baby’s Sepsis Calculator recommendation and clinical disposition. Remember: The L&D nurse needs to include the Sepsis Calculator Score in the Mother/Baby report.

T.I.M.E. Pathway PowerChart Tags

Additions to OBIS for easy access to information…

Addition to OBIS Chalkboard to identify the need for Peds…

Key Issues to Remember The goal is to reduce unnecessary admissions to the NICU. Safety is key to making this a success. Any Well Baby/Floor newborn with possible signs of distress needs to be discussed with NICU team and the covering well baby doctor. Don’t delay in transferring a baby who has abnormal vitals or signs of distress to the NICU.

Go Live January 24, 2017