Method

All neonates born after gestational

week 37 that are admitted to the

Neonatal Intensive Care Unit at

Stavanger University Hospital, Norway,

with suspected Early onset Sepsis

(start of antibiotic before 72 hours of

age) are clinically evaluated by a nurse

every hour using a standardized

assessment form.

Results

Process Change: “how good by when?”

Process-Background:

Neonatal sepsis is associated with high mortality and morbidity (1) but symptoms are unspecific.

No diagnostic tools are available at the time antibiotic treatment is started.

Empirical antibiotics given to 2-10 % of all term neonates in Europe and USA are implemented because of the fear

of sepsis (1)

Antibiotics given in the first year of life are linked to an increased risk for death, nosocomial infection, Chronic lung

disease, Asthma, eczema and Juvenile Arteritis (2,3). In addition to the increasing concern for multi resistant bacteria.

Process-Aim:

To reduce the use of antibiotics administered to term neonates within the first 4 days of life in a single Norwegian

NICU within August 2016 by:

1. Reduce the use of antibiotics administered to term healthy neonates to below 1 %

Healthy neonates = neonates treated with antibiotic and treated for less than 5 days without proven sepsis

2. Reduce the total use of antibiotics to less than 3,0 % of neonates

3. Balancing question (4): No increase in mortality or delay in start of treatment to neonates with infection

Change: Improved assessment sheet of neonates to predict if the neonate has sepsis or other common postnatal condition

The assessment form for neonates with suspected early onset

sepsis is an efficient and safe tool to reduce the use of antibiotics to

term healthy neonates in the Neonatal Intensive Care.

Conclusions

Further information contact: Anlaug.vatne@gmail.com

Consultant Anlaug Vatne (1), Solfrid Orre (1), Eli Sanne (1), Karin Jensvold (2), Knut Øymar (1,3).1.Pediatric Department, Stavanger University Hospital, Stavanger, Norway2. Department of Patient safety and Quality, Stavanger University Hospital, Stavanger, Norway

3- Department of Clinical science, University of Bergen, Bergen, Norway

Achievements

Increased knowledge among staff in

neonatal observations and assessments

Increased knowledge and use of Plan-Do-

Study-Act circles

Focus on correct use of antibiotics in the

NICU

Change takes time: multiple small steps will

gradually deliver results as knowledge

increases, cultures develop and people

adapt

Involvement is key to success: engagement

and involvement bring commitment,

ownership and willingness

Reducing variations is a goal: to maintain

stability and predictability. Variations should

be limited to increased patient safety.

“ If I had to reduce my message for

management to just a few words, I’d say

that it all had to do with variations” (5)

Key Learning Points

Key Reference Materials

(1) Fjalstad, J.W, Early-onset sepsis and antibiotic exposure in term infants: a nationwide population-based study in Norway. Pediatr Infect Dis J, 2016. (2)

Johson, C.C et al. Antibiotic exposure in early infancy and risk for childhood atopy. J Allergy Clin Immunol, 2005.(3) Antiobiotic Exposure and Juvenile

Idiopathic Artheritis, Pediatrics, 2015 (4)Quality Health Care, Robert Loyd. (5) Out of the crisis, W.E.Deming. (6)The Improvement Guide. Langley J et al

Improved antibiotic treatment in Neonatal Intensive Care – a Quality

Improvement project among term infants at Stavanger University Hospital

Next steps

• Evaluation of project August 2016 to show reliability and sustainability

over time

• Publish project

• Continue improvement work in Unit

• Increased focus on patient’s involvement

«I think that we put too many babies on

antibiotics. It is difficult to clinically assess if

a baby has an early infection or not. I think

that we can now better evaluate this. I feel

this is safer and I hope we can treat less

babies with antibiotics» Junior doctor «« I have been afraid that the junior doctors

on duty wouldn’t pay attention to my

concern if a baby is getting increasingly ill.

Remember the baby that died in November

from Sepsis, I’ve been afraid that this can

happen again. The new assessment sheet

gives me a better tool to communicate my

concerns for the baby to the doctor on duty

to secure correct treatment» Neonatal

nurse

«I feel the assessment sheet is much safer. I

can safely postpone start of antibiotic in a

non-critically-ill neonate and assesss if the

symptoms are caused by other common after-

birth conditions and wait for bloodtests. It

feels more safe for the baby» Consultant

Neonatology

1. Healthy neonates treated with antibiotics:SPC Chart (Statistical Process Chart) shows a shift after the start of the project with 10 data points below center. This is statistically significant. The mean is consequently reduced in the second chartMean declined from 1,4 % to 0,5 % after the start of the project.

2. All term neonates: SPC Chart does not show any trend or shift after start of project.A decline in total number of neonates treated with antibiotics from 3,1 % to 1,2 % afterthe start of the project. This is not statistically significant, and could be a result of a common variation. Outbreak of Klebsiella in the unit could be a reason for this.

3.No increase in hours from birth till start of antibiotics/no delayed treatment in neonates withinfection= balancing question

This allows for an improved

prediction for sepsis and evaluation

for the start of antibiotics.

Information and repeated education

for nurses, junior doctors and

consultants.

Questioners given to staff for

continuously evaluation