QI Initiative Updates:

Novant Health Forsyth Medical Center

Alok Ezhuthachan,.MD

Tinisha Lambeth,.DNP,.NNP:BC

3/1/18

Making'healthcare'remarkable
Initial Development

56#bed'level#III'NICU'at'Novant Health'Forsyth'Medical'
Center
! ~6000$deliveries$per$year$of$infants$>34$weeks
! Variability$in$ordering$practices
! Lack$of$reliable$objective$tool
Baseline Data

91%$>34$weeks$with$diagnostic$code$related$to$
suspected$sepsis$received$empiric$antibiotics
! None%with%culture.confirmed%EOS

39%$of$all$>34$weeks$received$empiric$antibiotics
! 68%%were%“unnecessary”%based%on%retrospective%application%of%
calculator
Methods
Methods

Continued)added)layer)to)decrease)antibiotic)use)(present)before)calculator)
! No#antibiotics#if:
– C/section#for#maternal#indication
– No#labor,#membranes#intact#at#time#of#delivery
What about the CBC?

! Poor$sensitivity,$specificity$impacted$by$low$EOS$rates
! 6:hour$instead$of$immediately$after$birth
! Highest$likelihood$ratios:

– WBC$<$5000
– ANC$<$2000
– I/T$>$0.3

Newman,$et$al.$Pediatrics 2010;126(5):903:9
Hornik,$et$al.$Pediatr Infect-Dis-J-2012;31:799:802
Results

Key$Events

A:$Staff%meeting%
introducing%initiative%
and%retrospective%data
B:$Staff%meeting%to%
review%calculator
C:$EBP%meeting%to%
discuss%guidelines
D:$EBP%meeting%to%
discuss%guidelines
E:$final%faculty%review%
of%guidelines

PDSA$Cycles

#1:$Go%Live%for%QI%
initiative
#2:$EOS%flowchart
#3:$Staff%meeting%for%
audit/feedback
#4:$Staff%meeting%for%
audit/feedback
#5:$EBP%guidelines%
published
#6:$Staff%meeting%for%
audit/feedback
#7:$Staff%meeting%for%
audit/feedback%and%
updated%EMR%template
Results

Unnecessary)antibiotics)decreased)from)68%!13%
– Down&to&6%&through&Dec&2016

Calculator)compliance)increased)from)38%!81%
– Up&to&85%&through&Dec&2016

Balancing)measure:)no)missed)cases)of)EOS)when)
calculator)recommended)“no)culture,)no)antibiotics”

Estimated)cost)savings)>$100,000/year
– Chorio practice&change,&antibiotics,&blood&cultures
 Results

Non$compliance,with,the,EOS,
calculator
100%
90%
80%
70%
60%
50% Non$compliant,due,to,restricting,
40%
30%
antibiotics
20% 100%
10% 90%
0% 80%
June0131July010 July0111Aug07 Aug081Sept04 Sept051Oct02 70%
60%
Non1compliant/total0cases0evaluated
50%
40%
30%
20%
10%
0%
June0131July010 July0111Aug07 Aug081Sept04 Sept051Oct02

Restricted0abx0when0calc0recommended/non1compliant0cases
Challenges

Slowed'workflow
! Flowchart
! Automated/data/
gathering

EHR'template
! Unclear/documentation
Conclusions

Implementation+of+a+revised+neonatal+EOS+protocol+
including+the+calculator+can+decrease+overall+empiric+
antibiotic+use
! Success&required&multiple&modes&of&education&and&repetition
! More&judicious&in&antibiotic&ordering&practices
Next Steps

Further'change'in'chorio practice

Education'to'front2line'providers'outside'of'the'NICU
Antibiotic Stewardship for
VLBW Infants

Making'healthcare'remarkable
SMART Aim

Decrease'the'percentage'of'VLBW'infants'that'received'antibiotics'within'the'first'48'
hours'of'life'from'78%'to'62%'for'~20%'reduction'by'December'31,'2016'and'sustain'
the'gains'in'2017.
 Novant-Health-Forsyth-Medical-Center
Key-Driver-Diagram:--Choosing-Antibiotics-Wisely
Aim Drivers Interventions-
• Engaged-hospital-leaders-of-the-adult-antibiotic-
Organizational-
Smart&AIM stewardship-program.---
commitment-and-
Our-aim-was-to- • Engaged-a-multidisciplinary-NICU-stewardship-team.
culture-for-
decrease-the- • Engaged-a-parent-as-a-team-member-and-partner-in-
appropriate-
percentage-of- improvement.
antibiotic-use-in-the-
VLBW-infants-that-- • Educated-clinicians-about-optimal-prescribing-for-
NICU
received-antibiotics- neonates.
within-the-first-48- • Reviewed-early-onPset-sepsis-literature-and-treatment-
hours-of-life-from- EvidencePbased-
recommendations.
78%-to-62%-for-~-- policies-and-
• Reviewed-and-updated-current-NICU-evidencePbased-
20%-reduction-by- procedures-for-
guidelines-for-treatment.
December-31,- suspected-early-onP
• Addressed-indications-for-treatment,-dose,-duration,-
2016-and-sustain-- set-sepsis.
and-stopping.
gains-through-
2017. PharmacyPdriven-
• Appointed-a-single-pharmacist-leader-responsible-for-
interventions-
improving-antibiotic-use-in-the-NICU.
GLOBAL&AIM designed-to-assure-
To-improve-the-
• Included-a-pharmacist-on-daily-medical-rounds.
appropriate-
quality,-safety,-and- • Monitored-prescribing-practices
antibiotic-treatment.
clinical-care-for-
newborns-and-
their-families-by-
focusing-on-safe-
Regular-reporting-on- • Used-audit-and-feedback-of-antibiotic-use.-
and-effective- antibiotic-use-and- • Generated-automated-Antibiotic-Use-Rate.
antibiotic-use--and- resistance-to-NICU- • Educated-NICU-staff-about-resistance-and-optimal-
decrease-antibiotic- staff.- prescribing.
usage-rate.
Challenges

Accessing(data(for(AUR

Ascertaining(level(of(risk(for(sepsis(in(VLBW(infants

Stopping(antibiotics(for(decompensating(infants(with(a(negative(blood(culture

Looking(for(other(causes(of(decompensation(with(a(negative(blood(culture

Remembering(to(order(additional(doses(once(the(decision(to(continue(antibiotics(was(
made

Sometimes(there(was(no(rationale(provided(by(physicians(for(continuing(antibiotics@
PQCNC(data(collection(
Acknowledgments

Parent'Champion:''Mr.'Linwood'Davis

Director'of'Women’s'and'Children’s'Health=Ann'Smith

Interim'Medical'Director=Dr.'Jennifer'Helderman

Antibiotic'Stewardship'Team

Neonatal'Nurse'Practitioner/Physician'Assistant'Group

Neonatologists

Neonatology'Fellows

NICU'Nurses

NICU'Pharmacists

Infectious'Disease'Specialist=Dr.'David'Priest