Senn, Laura

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San Jose State University SJSU ScholarWorks Faculty Research, Scholarly, and Creative Activity 2019 Keeping Healthy “Chorio” Babies out of the NICU Laura Senn San Jose State University, laura.senn@sjsu.edu Follow this and additional works at: https://scholarworks.sjsu.edu/faculty_rsca  Part of the Maternal, Child Health and Neonatal Nursing Commons Recommended Citation Laura Senn. "Keeping Healthy “Chorio” Babies out of the NICU" Association of Women's Health, Obstetric, and Neonatal Nurses California Section (2019). This Presentation is brought to you for free and open access by SJSU ScholarWorks. It has been accepted for inclusion in Faculty Research, Scholarly, and Creative Activity by an authorized administrator of SJSU ScholarWorks. For more information, please contact scholarworks@sjsu.edu. Implementation of a QI projectusing the PDSA process:Keeping Healthy “Chorio” Babies Out of the NICUPlan, Do, Study, Adjust-IHI Quality Improvement Process• PLAN: • Background & Evidence• Barriers & Motivators • DO:• Staff Education• Go Live• STUDY & ADJUST:• Feedback & Data• Problem Prone & Lessons LearnedPLAN:Goals; Evidence; & Making it our OwnEvidence Based Practice Change-Going against the National Guidelines• Goals• Keep healthy babies with mothers• Keep NICU open for sick babies• Barriers• AAP guidelines 2010Evidence & Making it our Own• Kaiser • Created & tested EOS Calculator• Seamless organization• Stanford• Academic/Teaching hospital• Special Care Nursery• Sutter Medical Center Sacramento• Community hospital• Approx 40 OBs & 40 PediatriciansIOM QI Goals-Current  Condition• From Jan 2017 to April 2017 • Admission Rate to NICU for babies whose mothers were dx with chorio was 100%• They received blood cultures then 48 hours of IV antibiotics• This resulted in an economic cost of  approximately $____.  • Our target is to reduce the rate to 50% by Sept 2017MeasuresOutcome: Admission Rate to NICU for chorioProcess: Number of Intermediate Risk babiesNumber of problem prone issuesBalance:Negative newborn outcomesDO- Staff Education: Multiple Methods New Same as BeforeRevise Policy & New Clinical Exam TERMs-Well Appearing • Newborn with no abnormal physiologic eventsPersistent Abnormal Physiologic Event-• newborn with a physiologic abnormality lasting longer than 60 minutes per the following criteria:• Tachycardia (HR > 160)• Tachypnea (RR > 60)• Temperature instability • (> 100.4˚F or < 97.5˚F)• Respiratory distress • grunting, flaring, or retracting• not requiring supplemental O2 to maintain O2 sat >95%Equivocal Clinical Signs of EOS-• Newborn with a single persistent physiologic abnormality > 4 hr;    or• Newborn with 2 or more persistent physiologic abnormalities lasting for > 2 hrsClinical Signs of EOS• Persistent need for CPAP or mechanical ventilation (outside of the delivery room)• Hemodynamic instability requiring vasoactive drugs• Neonatal encephalopathy or Perinatal depression• Seizure• Apgar @ 5 minutes < 5• Need for supplemental O2 > 2 hrs to maintain oxygen saturations > 90% (outside of the delivery room)NOTE: abnormality can be intermittent2Q 2017- Staff EducationFAQs• When & Who screens the baby:• All newborns for first 3 months• At risk babies after 3 months• ALS or TNT in first 2 hours of life• What happens when:• Abnormal Vital Signs occur• ALS called to bedside for eval• Which babies go to Obs Nursery:• Intermediate risk- with anyabnormal VS• Low Risk- with persistent abnormal VS• When do they return to mom:• When stable, i.e. 1 set of normal VSVital Sign checks:• Every 8 hours for:• Term     or    Low EOS risk score• Every 4 hours for:• Late Preterm     or   Intermediate EOS risk score• Every 30 to 60 minutes** for:• Abnormal VS until stable for 2 hour**Depends on severity and complexity of abnormal physiologic eventAbnormal Physiologic Event-• Tachycardia (HR >160)• Tachypnea (RR >60)• Temperature Instability• > 100.4  or  <97.5 oF.• Respiratory DistressWho do we screen?Maternal Risk Factors • Gestational age • (risk increased when < 37 wks)• Maximum temperature in labor-• (risk increased if maternal temperature in labor >100.4)• Length of rupture of membranes • (risk increased when > 12 hrs)• GBS status-• (risk increased if positive or unknown)• Use of antibiotics in labor • (risk increased if GBS intrapartum prophylactic < 2 hours)Low or IntermediateEOS Risk?Birth> 35 weeks5 min Apgar >6ALS at Delivery?Admit to NICUVS q 30 minNOHigh EOS  RiskEOS Screen done by ALSYESVS stable-Baby stays with MotherVS stable-Baby stays with motherAbnormal Physiologic Event in 1st 2 hours of LifeALS Called to BedsideEOS Screen done by ALSVS q 30 minIntermediate  EOS Risk?Low EOS  Risk?Abnormal Physiologic Eventand Intermediate EOS Risk-ALS report to NEO; Possible transfer to NICUAbnormal Physiologic Event and Low EOS Risk; Baby stays with Mother to see if baby will transitionAbnormal Physiologic Event in 1st 2 hours of LifeVS stable x 2 hr-Baby stays with Mother, Couplet moves to PP  unitEOS Screen done by TNTAbnormal Physiologic Eventand Low EOS Risk; Baby stays with Mother to see if baby will transitionGetting the Newborn Screened in the 1st 2 hours of Life.eosSmartphraseScreen shot example;  Care Team note added by ALS or MNB Nursery nurseNewborn Clinical Exam-• Well Appearing • Equivocal• Clinical Illness• Low Risk- GREEN• Intermediate Risk- YELLOW• High Risk- REDMNB doesn’t look at the numbers.We only look at the color associated with the Well Appearing babyCase #1- Term; GBS negative,  No Abx;No maternal temp & ROM 8 hr-Single Abnormal Physiologic Event- Screen- Low RiskPersistent Abnormal Physiologic Event-Still Low RiskCase #2- Term; Mom temp- 102.0; ROM- 10 hr; GBS neg; Antibiotics > 4 hr (BSA)-Well Appearing & LOW Risk- No Labs & Routine CarePersistent Abnormal Physiologic Event-Now High Risk?!?!Case #3- Late preterm; Mom Temp- 102.5; ROM=12hr; GBS unk; Antibiotics 2 to 3.9 hr (BSA)Well Appearing & INTERMEDIATE Risk- BC & VS q 4 hr(for 48 hours; not 24 hours)  Persistent Abnormal Physiologic Event-Now High Risk?!?!HIGH Risk-Direct Admit to NICUCombined Maternal Risk Factors and Newborn Exam create Risk Levels:• Low Risk- GREEN• Intermediate Risk-YELLOWLow risk babies whose mother had a fever in labor will have a   Ton their green dotsIntermediate risk babies who had a blood culture drawn will have a  +on their yellow dotsGREENVS every 8 hourYELLOWVS every 4 hoursIntermediate EOS Risk Baby “Guilty until proven innocent”Criteria for Calling ALS to Evaluate the BabyPersistent Abnormal Physiologic Event-ALS Eval and Report to NEO;Newborn transferred to NICU?New Onset of Abnormal Physiologic Event (APE); Baby to OBS Nursery?, Interventions made to normalize vital signs;ALS Eval and Report to NEO; Transfer to NICU?VS stable-Baby stays with MotherVS every 4 hours, for 48 hoursIntermediate  EOS Risk-Yellow Dot on Crib CardIntermediate  PLUS EOS Risk-Yellow Dot with  Plus + Blood Cultures drawn at ~ 2 hours of ageBlood Cultures results evaluated every 24 hrsby PediatricianEffective May 23, 2017VS every 30 min until resolvedVS every 30 to 60 min**Not stable for  2 full hoursLegend:** depending on severity and complexity of APEAbnormal Physiologic Event  resolved;Baby returned to Couplet Care; VS every 30 to 60 min** until stable for 2 full hoursIf Baby not transferred to NICU;TNT notifies Pediatrician; Care depends on Orders? CXR; ECHO; Labs… Case #1- Late preterm; GBS+ but treated >2 hr;Low maternal temp (100.2) & ROM 24 hr- Intermediate RiskVS every 4 hours, Single Abnormal Physiologic Event- Low Temp= 97.4o F• Baby to Obs Nursery.• Interventions made to re-warm baby• ALS called to Eval, Report to Neo;• Not transferred to NICU.• 30 min later,  Temp= 97.9, but RR= 68.• ALS to bedside for eval, Report to Neo.• Transfer to NICULow EOS Risk Baby –“Innocent until proven Guilty”Criteria for Calling ALS to Evaluate the BabyAbnormal Physiologic Event  resolved;Baby returned to Couplet Care; VS q 30 to 60 min** until stable for 2 full hours, then VS every 4 hoursVS every 8 hours* until dischargeNew Onset of Abnormal Physiologic Event (APE);Baby can stay in Couplet Care;Interventions applied to normalize vital signsVS stable- Baby stays with MotherVS every 30 min until resolvedPersistent Abnormal Physiologic Event;Baby to OBS Nursery, ALS Eval and Report to NEO; NICU?Persistent Abnormal Physiologic Event;If Baby not transferred to NICU;TNT notifies Pediatrician; Care depends on Orders?CXR; ECHO; Labs… Low EOS  Risk- Green Dot with TLow EOS  Risk- Green Dot on Crib CardEffective May 23, 2017VS every 30 to 60 min**Not stable for full 2 hoursLegend:*VS every 8 hours unless required every 4 hours for Late Preterm or Hyperbili** depending on severity and complexity of APEAbnormal Physiologic Event  resolved;Baby returned to Couplet Care; VS q 30 to 60 min** until stable for 2 full hours, then VS every 4 hours for 24 hrCase #2- Late preterm; GBS+ but treated >2 hr;Low maternal temp & ROM 10 hr- Low RiskVS every 8 hours, Single Abnormal Physiologic Event-RR= 78 • Persistent Abnormal Physiologic Event-• RR= 78, interventions made,• then 30 min RR= 68, • To Obs Nursery- ALS Eval, Report to NEO;• Not transferred to NICU.• 30 min later, RR= 58, return to Mom.• Primary RN check VS every 30 to 60 min until 2 full hours of stable VS.Study & AdjustFirst 3 Month Overview &September 2017 Policy RevisionsProblem Prone AreasNeeding to be conservative to prevent a bad outcomeIncrease in the number of phone calls to ALS to evaluate babiesNewborns with Low EOS Risk who have tachypnea for more than 4 hoursEvery 30 min vital signs for …….. Hours!! Not sustainable.How to classify a newborn who has abnormal VS for > 4 hoursInitial “Well Appearing” newborn who was Low EOS Risk, but who is now ….3 Month Overview• Numerous cases of healthy appearing newborns who:• Did not have to be separated from his/her mother• Did not have to have lab work done• Did not have to have antibioticsPolicy Revisions• Screen fewer babies• about 20%• Simple process• when abnormal VS occur• Increase tachypnea threshold to • Greater than 70 bpm• for 1st 4 hrs of life• Reduce frequency of VS ✓ to hourly, • when VS are abnormalScreen Fewer Babies• Only screen newborns with  risk factors• Late preterm ~5%• Temp in labor ~5%• ROM > 12 hr ~10%• GBS pos /unk ~10%• Use of antibiotics in labor ~5%• 70 to 80% will NOT be screenedSimplified Process:When persistent abnormal physiologic event occurs-• Those that are screened • will be followed by Neonatologists• Those newborns who are notscreened • will be followed by their Primary ProviderIncrease tachypnea threshold to > 70 for 1st 4 hours of life• Fewer cases of abnormal VS• Newborn will declare himself by 1 of the following:• continue tachypnea after 1st 4 hours• developing respiratory distress•  RR > 70 bpmWHEN VS ARE ABNORMALREDUCE FREQUENCY OF VS RE-CHECKSTO EVERY 60 MINEXCEPT FORLATE PRETERM INFANTSEOS /Chorio Babies QI Project Outcomes:Pre-Implementation• For the first 43/4 months of 2017, • 64 cases of Chorio, • all 64 babies admitted to the NICU (100%)Post-Implementation• For the first 41/4 months after new process• 68 cases of Chorio, • only 8 babies were admitted to the NICU (11.7%)• Significant  in NICU admissions• No adverse outcomesJan 1st to May 22ndMay 23rd to Sept 30th6208132414152111620813173 31 1JAN FEB MAR APR MAY JUN JUL AUG SEPPre & Post Neonatal EOS Risk Screeningchorio cases NICU admitsMeeting our Goals::• 2013- 14• 2014- 32• 2015- 109• 2016- 42• 2017- 14• 9 post implementationEvidence-Based Literature Sources

Keeping Healthy “Chorio” Babies out of the NICU

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Keeping Healthy “Chorio” Babies out of the NICU

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