ObjectiveAssess the impact of introducing a consensus guideline incorporating an adapted Sepsis Risk Calculator (SRC) algorithm, in the management of early onset neonatal sepsis (EONS), on antibiotic usage and patient safety.DesignMulticentre prospective studySettingTen perinatal hospitals in Wales, UK.PatientsAll live births ≥34 weeks’ gestation over a 12-month period (April 2019–March 2020) compared with infants in the preceding 15-month period (January 2018–March 2019) as a baseline.MethodsThe consensus guideline was introduced in clinical practice on 1 April 2019. It incorporated a modified SRC algorithm, enhanced in-hospital surveillance, ongoing quality assurance, standardised staff training and parent education. The main outcome measure was antibiotic usage/1000 live births, balancing this with analysis of harm from delayed diagnosis and treatment, disease severity and readmissions from true sepsis. Outcome measures were analysed using statistical process control charts.Main outcome measuresProportion of antibiotic use in infants ≥34 weeks’ gestation.Results4304 (14.3%) of the 30 105 live-born infants received antibiotics in the baseline period compared with 1917 (7.7%) of 24 749 infants in the intervention period (45.5% mean reduction). All 19 infants with culture-positive sepsis in the postimplementation phase were identified and treated appropriately. There were no increases in sepsis-related neonatal unit admissions, disease morbidity and late readmissions.ConclusionsThis multicentre study provides evidence that a judicious adaptation of the SRC incorporating enhanced surveillance can be safely introduced in the National Health Service and is effective in reducing antibiotic use for EONS without increasing morbidity and mortality.
Microbial resistance to antibiotics is a serious global health problem compounded by antibiotic overuse and limited investment in new antibiotic research. Inappropriate perinatal antibiotic exposure is increasingly linked to lifelong adverse outcomes through its impact on the developing microbiome. Antibiotic stewardship may be the only effective preventative strategy currently available. As the first tertiary neonatal unit in the UK to collaborate in an international quality improvement programme (QIP) with Vermont Oxford Network (VON), we present the results of our antibiotic stewardship initiative.The QIP was officially launched in January 2016 and aimed to reduce antibiotic usage rate (AUR) by 20% of baseline by 31st December 2016 without compromising patient safety. A multidisciplinary team of professionals and parent representatives shared good practices and improvement strategies through international webinars and local meetings, devised uniform data collection methodology and implemented a number of carefully selected ‘Plan–Do–Study–Act’ cycles. Run charts were used to present data and, where appropriate, statistical analysis undertaken to compare outcomes.The QIP resulted in a sustained reduction in AUR from a baseline median of 347 to 198 per 1000 patient-days (a reduction of 43%). The proportion of culture-negative sepsis screens where antibiotics were stopped within 36–48 hours increased consistently from a baseline of 32.5% to 91%. The antibiotic days per patient at discharge reduced from a median of 3 to 2 days, and there was a reduction in practice variation. Our annual mortality and necrotising enterocolitis rates for the VON cohort (<30 weeks or <1500 g) were the best ever recorded, 5.5% and 1.4%, respectively. Audits confirmed a high level of staff and family awareness of the QIP.The QIP achieved a sustained reduction in antibiotic use without compromising patient safety. Our challenge is to sustain this improvement safely.
Aims ATAIN (Avoiding Term Admissions Into Neonatal units) is an NHS England Quality Improvement initiative to reduce admission of full-term babies to neonatal care. All term admissions are collaboratively reviewed by neonatal and maternity teams to identify avoidable admissions and areas to focus quality improvement.We aimed to review our term admissions using the guidance for clinical review team questions (GCRTQs) published in NHS Improvement's 'Reducing harm leading to avoidable admission of full-term babies into neonatal units: findings and resources for improvement.' Methods All term (>37 weeks) admissions to the neonatal unit between April and June 2018 were identified. Badger and notes documentation was collaboratively reviewed and compared to the GCRTQs for respiratory symptoms, jaundice and hypoglycaemia.Results 50 babies were identified. 31/50 (62%) had respiratory symptoms. One baby was born by elective c-section before 39 weeks (with appropriate medical indication). 11/31 did not require respiratory intervention to warrant separation. However, 6 of these had evidence of infection, 1 had a moderate pneumothorax, 1 had recurrent dusky episodes, and 1 had a cleft palate. 2 were subsequently noted to have other problems (early jaundice and hypoglycaemia). None were deemed appropriate for transitional care (TC) at admission. Length of stay ranged from 1 to 11 days. No admissions were for default concerns, and intrapartum antibiotics were given appropriately.3/50 (6%) were jaundiced. Two were less than 24 hours old and all required high-intensity phototherapy. One Mum had refused anti-D.2/50 (4%) were hypoglycaemic. Both had risk factors, other associated clinical signs and required IV dextrose. Neither was hypothermic.The GCRTQs did not identify other issues for babies with jaundice or hypoglycaemia.13/50 (26%) were admitted for other reasons (of whom 6 had bilious vomiting, and 3 required observation for neonatal abstinence with associated social issues). Conclusion The GCRTQs did not identify specific clinical insights in our tertiary neonatal unit, which has relatively low term admission rates and well-established transitional care facilities. We suggest in such settings, rather than review of all term admission using GCRTQs, areas for quality improvement are more likely to be identified through collaborative review of clinical incidents related to term admissions, near-misses and unexpected term TC admissions.Aims Best practice international Respiratory Distress Syndrome (RDS) guidance advocates use of CPAP to support preterm infants at birth. In this quality improvement project our aim was to offer all spontaneously breathing infants born between 25+0 and 29+6 weeks gestation a trial of CPAP after birth. Methods Data collection from electronic admission records identified baseline data. Using quality improvement methodology and a multidisciplinary team approach we identified key areas to target for intervention. PDSA cycles included raising awareness of the evidence base, teaching and training events,...
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