ASNS:%Celebrating%the%Transformation%of%Perinatal%

Care%Through%Quality%Improvement

Martin'J'McCaffrey,'MD,'CAPT'USN'(Ret)
Clinical'Professor'of'Pediatrics
Director'of'the'PQCNC'
For'the'PQCNC

No#disclosures#to#report.
We’re%making%changes,%are%we%changing%culture?
ASNS$Final$Data$Review
 ASNS$Demographics
• 49#Total#teams#in#43#hospitals
• Total#of#46,480#deliveries#in#these#hospitals#over#the#collaborative#
period#(38%#of#all#live#births#in#NC#in#2017)
• Total#of#13,526#NICU#admissions#(JanGDec)
• 681#infants#in#NBN#treated#with#antibiotics#(JanGDec)
• 3791#infants#in#NICUs#treated#with#antibiotics#(JanGDec)
ASNS$in$NC$Newborn$Nurseries
55%#Reduction
30%$Reduction
47%$Reduction
Kaiser'Sepsis'Calculator'(KSC)
 NC#NBN#Percent#KSC#Use
100%

80%

60%

40%

20%

0% Feb March April May June July Aug Sept Oct Nov Dec
Percent:KSC:Use 12% 29% 44% 51% 57% 54% 67% 69% 55% 77% 63%
29%
22%
 NC(NBN(Maternal(Risk(Factors(for(Antibiotics
100.0%

95.5%
600
90.0%

81.6%
80.0%
500

70.0%
66.7%
400
60.0%

50.0%
300
271
42.2%
40.0%

200
30.0%
157 24%

20.0%
96 15% 89
100 14%

10.0%
29 5%

0 0.0%
Diagnosis(of Maternal(Temp(of(>100.4F Pos/Unk(GBS ROM(>18h PTL/PROM
Chorioamnionitis
ASNS$in$NC$NICUs
14%$Reduction
22%#Reduction
36%$Reduction
19%$Reduction$(if$32$to26%)
Total&NICU who&did&not&
implement&
Teams:&& KSC:&&6
26
 NC#NICU
Percent#KSC#Use
100%

80%

60%

40%

20%

0% Feb March April May June July Aug Sept Oct Nov Dec
Percent:KSC:Use 31% 37% 46% 45% 45% 40% 42% 42% 31% 51% 40%
20%

12%
32%

18%

11%
8%
31%

18%

7%
2%
33%

18%

4%
2%
18% 17% 16% 15%
 NC#NICU
Percent#Exposure#to#Antibiotics#by#Ethnicity
60%

50%

40%

30%

20%

10%

0%
American)Indian)or Asian)American Black)or)African Hispanic)or)Latino Multiracial Native)Hawaiian)or Refused White
Alaskan)Native American Pacific)Islander
 NC#NICU#
Percent#Continuation#after#48h#with#a#
negative#blood#culture#by#ethnicity
60%

50%

40%

30%

20%

10%

0%
American1Indian Asian1American Black1or1African Hispanic1or Multiracial Native1Hawaiian Refused White
or1Alaskan American Latino or1Pacific
Native Islander
 Percent:of:Infants:22?31:weeks:continued:on:antibiotics:after:48:hours:of:negative:cultures
30%

25%

38%$reduction
20%

15%

10%

Baseline:data

5%

0%
Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec
Percent:of:Infants:22?31:weeks:continued 22.0% 26.0% 19.2% 14.7% 17.5% 20.7% 12.0% 15.4% 11.9% 17.9% 16.8% 8.8% 17.5% 13.6%
 Average0#0of0antibiotic0doses0by0gestational0age0grouping0for0infants0continued0on0
antibiotics0after048h0with0neg BC

25

20

15

10

0
Feb March April May June July Aug Sept Oct Nov Dec
22%31 32%36 37%42
 NC'NBN'Well'Appearing'Infants'Continued'on'
Antibiotics'after'48h'with'a'Negative'Blood'Culture

566#
infants'on'antibiotics'after'2/1/17'and'>'34'weeks

279
infants'had'KSC'used'in'their'indication'for'antibiotics

134 (48%)
infants'were'well'appearing

16 (12%)
well'appearing'infants
continued
 NC'NICU'Well'Appearing'Infants'Continued'on'
Antibiotics'after'48h'with'a'Negative'Blood'Culture

2233#
infants'on'antibiotics'after'2/1/17'and''>'34'weeks

932
infants'had'KSC'used'in'their'indication'for'antibiotics

105
infants'were'well'appearing

4 (3.8%)
well'appearing'infants
continued
 Opportunities+in+ASNS

• Kaiser+Sepsis+Calculator
• Universal+application
• In+NBN:+KSC+for+infants+>+34+weeks+and+well+appearing
• In+NICU:+KSC+for+infants+>+34+weeks+well+appearing+or+with+presumed+TTNB
• Reduce+initiation+of+antibiotics
• In+NICU:+Preterm+infants+(delivery+for+maternal+indications)
• In+NICU+Preterm+infants+with+minimal+respiratory+needs+(TTNB+or+RDS)
• Reduce+continuation+of+antibiotics+with+negative+cultures
• RDS+vs+pneumonia+?
• Mec aspiration+vs+bacterial+pneumonia?
• The+“clinically+concerning”+infant:+hypotension,+seizures,+hypoglycemia,+isolated+
neutropenia+or+thrombocytopenia+
 What%Have%We%Done?
• Eliminated*antibiotic*exposure*for*792*NBN*babies*annually
• Reduced*continuation*of*antibiotics*after*48*hours*of*negative*cultures*for*
110*NBN*babies
• Reduced*NICU*antibiotic*days*by*22%,*442*days*a*month*or*5,304*annually
• Ended*antibiotic*exposure*after*negative*cultures*at*48*hours*for*an*
additional*27*NICU*infants*per*month,*324*annually.*
• Trend*to*reducing*continuation*of*antibiotics*after*48*hours*in*22K31*week*
infants*by*36%...avoided*antibiotic*continuation*in*72*infants*<*31*week*
infants*per*year.*
• With*a*NNTH*of*22*for*NEC/death,*we*have*likely*spared*at*least*3*infants*
from*those*complications.
Cotten CM*et*al.*Prolonged*duration*of*initial*empirical*antibiotic*treatment*is*associated*with*increased*rates*of*necrotizing*
enterocolitis and*death*for*extremely*low*birth*weight*infants.*Pediatrics.*2009*Jan;123(1):58K66.*
 How$Do$We$Follow$the$ASNS$Act?
• That%is%the%question%you%are%asking%yourselves%about%PQCNC%and%what%happens%in%North%Carolina%newborn%nurseries,%mom=baby%units%and%NICUs%after%
an%amazingly%successful%Antibiotic%Stewardship%Newborn%Sepsis%(ASNS)%initiative.%I%mean%it's%tough%to%top%reducing%antibiotic exposure%in%Nurseries%by%
50%%and%reducing%antibiotic%courses%extending%beyond%48%hours%after%negative%cultures%by%40%.%I%mean%we%have%directly%reduced antibiotic%exposure%
for%over%1100%babies%in%one%year.%We've%kept%microbiomes%intact,%babies%and%moms%together%and%we'll%see%but%likely%avoided%some%deaths%and%NEC.
• Hypoglycemia%offers%PQCNC%teams,%collaborating%together,%a%tremendous%opportunity%to%standardize%care%within%hospitals%for%this%challenging%
problem,%bring%Newborn%and%NICU%teams%together,%limit%separation%of%mother%and%baby,%support%breastfeeding,%encourage%skin%to skin%care,%consider%
evolving%therapies%like%glucose%gel%and%limit%hospital%days%in%the%NICU.%If%we%replicate%the%participation%in%Hypoglycemia%that%we%have%with%ASNS,%we%
can%potentially%impact%the%care%of%5000%babies%and%mothers%statewide.%This%project%screams%PQCNC....spreading%best%practices, partnering%with%
patients%and%families,%and%optimizing%resources.

• Interested%in%participating%or%in%learning%more?%Click%here%to%stay%informed

• To%start,%we%want%you%to%join%the%PQCNC%Hypoglycemia%Expert%Team.%In%ASNS%58%of%you%statewide%(Parents,%Pharmacists,%Nurses,%Practitioners,%Docs,%
Hospital%Leaders,%DPH%folks,%Infection%Control%Specialists)%joined%to%design%the%aim%statement,%action%plan,%and%key%data%elements%to%be%deployed%in%
ASNS.%We%hope%100%folks%will%step%up%to%help%craft%Hypoglycemia!%What's%required?%An%interest,%a%willingness%to%read%some%basic%background%
evidence,%and%commitment%to%try%and%attend%2%webinars%and%maybe%a%face%to%face%day%meeting.

• The%success%of%any%PQCNC%initiative%starts%with%the%commitment%of%an%Expert%Team%that%owns%the%challenge,%feels%its%urgency%and%relentlessly%
develops%an%aim%statement,%action%plan%and%measures%that%will%lead%hospitals%to%change%practice.%Be%part%of%the%solution.
 I"Have"An"Idea……Actually….

Hypoglycemia,in,Newborns,and,
the,NICU?
 Why$Hypoglycemia?
• The$scourge$of$nurseries$and$NICUs.$
• Estimates$are$hypoglycemia$occurs$in$5<15%$of$newborns.$
• There$are$potential$short$and$long$term$developmental$risk$factors.
• There$is$uncertainty$about$what$normal$glucose$levels$are$in$newborns.$
• There$are$variable$treatment$algorithms$used$for$its$evaluation$and$treatment.$
• The$evaluation$of$hypoglycemic$babies$requires$separation$of$mom$and$baby.$
• This$interrupts$skin$to$skin$time,$an$antagonist$to$hypoglycemia
• Interferes$with$the$establishment$of$breastfeeding.$
• May$require$intravenous$fluids$with$the$newborn$completely$separated$from$the$
mother$in$a$special$care$area$or$NICU.
 Why$Hypoglycemia?
• Offers&PQCNC&teams,&collaborating&together,&a&tremendous&opportunity&to&standardize&
care&within&hospitals
• Bring&hospital&Newborn&and&NICU&teams&together…AGAIN!&
• Reduce&separation&of&mom&and&baby
• Support&breastfeeding&and&skin&to&skin&care
• Explore&newer&therapies&like&glucose&gel&
• Limit&hospital&days&in&the&NICU.&
• If&we&recruit&all&hospitals&in&NC&we&can&potentially&impact&the&care&of&12,000&babies&and&
mothers&statewide.
• If&10%&of&these&infants&require&IVF&and&NICU/SCN&transfer,&we&can&potentially&avoid&50%&
of&these&transfers&(500&infants&and&1000&NICU&days)&&
• This&project&screams&PQCNC....spreading&best&practices,&partnering&with&patients&and&
families,&and&optimizing&resources.
 Why$Hypoglycemia?

This%project%screams%PQCNC....spreading%best%practices,%
partnering%with%patients%and%families,%and%optimizing%
resources!!!!!!!!!!!!!
 Newborn(Hypoglycemia(Prevention(and(Care
(NHPC)

• Join%the%Expert%Team!%(Nurses,%Parents,%LCs,%Docs,%Pharmacists,%
Practitioners…come%one%come%all%
• Go%to%www.pqcnc.org or%https://www.pqcnc.org/node/13901 and%sign%up!%
NHPC