Chorioamnionitis : Changing our Management of Mothers and Their Newborns - PowerPoint Presentation

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Chorioamnionitis:Changing our Management of Mothers and Their NewbornsNew 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 PracticeAll 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/

μ

L)

Impact of “r/o sepsis chorio” admissionsAsymptomatic Infant admitted for 48 hrs to ICN:Mother/baby separationReduction in bondingIncreased parental stress/anxietyReduction in maternal breast milk production and feedingIncreased 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. PathwayT = Triple

I

= Intrauterine Inflammation and/or Infection

M

= Manage

E

= Early-onset Sepsis

Maternal Fever?“Isolated" Fever:Temperature > 38 Repeated after 30 minutes Temp < 38

“Documented” Fever:

Temperature

>

38

Repeated after 30 minutes

Temp

>

38

Any temperature

>

39 –

no need to repeat

–This is considered a “documented” fever

Triple I Clinical DiagnosisDocumented Maternal feverPLUS 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 CalculatorClinical Exam Description

L&D Nurse Flow ProcessAlert to Nurse with initial Newborn Vital sign documentation (@ 30 minutes of life)Fires alert to NurseProvides URL access

Opens Power Form

from

alert

If all the necessary information is added to PowerChart, a nurse alert will appear to complete the Sepsis Calculator…Select Sepsis

Calc

1st

1. Nurse clicks Sepsis Calculator Link (goes to URL)

Using Sepsis Calculator 11

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

1.

Select 0.5/1000 (CDC Incidence)

2. Enter Gestational Age

3.

Highest maternal temp. within 24 hrs of delivery

4.

ROM Duration

6

.

5.

GBS status

7. Click Calculate

8. Record

these Clinical Recommendations into Cerner Powerform

“Neonatal Sepsis Risk

Assessment”

Access Sepsis Calculator via

URL link in PowerChart…

Incidence: Always select CDC national. After you click calculate, the information in the Clinical Recommendation column is what is transferred to the Sepsis Form…

8. Record

these Clinical Recommendations into Cerner Powerform

“Neonatal Sepsis Risk

Assessment”

L&D Nurse Flow Process

Fill in Clinical Recommendations from the Sepsis Calculator for Well Appearing & Equivocal. Remember, Newborns assessed with clinical illness will be admitted to NICU

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

Peds

/DR provider fills out the rest

#1

#2

#3

#4

#5

Nurse/Pediatric Delivery Room Provider IMPORTANT PointsPeds/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

n

eeds 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 RememberThe 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