Early-Onset Sepsis Risk-Calculator Curbs Antibiotic Overuse in Newborns

By Marilynn Larkin

July 08, 2019

NEW YORK (Reuters Health) - Integrating an early-onset sepsis (EOS) risk calculator into the electronic health record (EHR) reduced antibiotic orders in a newborn nursery, with no increase in adverse events, researchers say.

Along with the usual consequences of antibiotic overuse, "For newborns, there are other important costs, such as separation of mother and infant, delayed initiation of breastfeeding, and painful blood draws," Dr. Carole Stipelman of the University of Utah School of Medicine in Salt Lake City told Reuters Health by email.

"Newborn sepsis screening and treatment guidelines have recommended a low threshold for initiating antibiotics for infants, based in part on subjective risk factors for the birth that do not take into account the clinical status of the infant," she said.

"The Neonatal Early-Onset Sepsis Calculator (https://k-p.li/2XTkwbs) provides a risk estimate of neonatal sepsis and recommendations for care by combining the birth risk factors with the infant's clinical status," she explained. "Even with some risk factors for infection at birth, antibiotics are often not recommended by the calculator if an infant remains well in the newborn period."

"We were able to decrease antibiotic use from 7% to 1% with minimal EHR redesign and medical staff training, without any increase in bad clinical outcomes for our newborn patients," she said. "With an 86% reduction in use of antibiotics, the potential annual hospital savings for a hospital like ours could exceed $1 million. Translated nationally to the 3,800,000 annual U.S. births, if every hospital incorporated this calculator with the same success, potential cost savings could exceed $1 billion."

As reported online July 5 in Pediatrics, phase one of her team's intervention included programming an EHR form containing fields that were outside of the infant's admission note with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds.

During phase one, which lasted 14 months, EOS calculator scores were entered for a mean 59% of infants, with wide variability around the mean and indication of special-cause variation.

Phase two included discrete data entry elements in the EHR admission form and a hyperlink to the calculator web site. Weekly entry of risk scores and antibiotic orders were assessed, as was the trend of such orders.

During phase two, which lasted two years, the mean frequency of calculator use increased to 85% of infants, with considerably less variability around the mean.

Further, as Dr. Stipelman noted, the frequency of antibiotic orders decreased from preintervention (7%) to the final six months of phase 2 (1%).

"The calculator is practice changing," Dr. Stipelman said. "Many institutions have already adopted it but some are reluctant to do so. This may be due to concerns about the potential for poor outcomes for newborns or concerns about how difficult it may be to incorporate the calculator into the EHR."

"Our study provides evidence that this decision-support tool is both safe for newborns and easy to integrate into the EHR," she concluded.

Dr. C. Anthoney Lim, Director of Pediatric Emergency Medicine for the Mount Sinai Health System in New York City, commented in an email to Reuters Health, "The risk calculator used in this study is validated, the intervention described by the authors follows the general approach used in many quality improvement studies, and the results are impressive."

"This approach can be - and has been in many cases - adapted to other clinical areas, such as the pediatric emergency department, inpatient units, and critical care units," he noted. "Limitations are often provider use and implementation."

"As demonstrated in the study, it took over three years to fully implement the risk calculator to obtain the widespread use resulting in decreased antibiotic prescribing. The timing in other areas may be different but will often require a combination of physician education and integration of the scoring system into current workflows to be successful," Dr. Lim concluded.

SOURCE: http://bit.ly/2XPMaWU

Pediatrics 2019.