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Fighting Resistance:

Integration of Neonatal Sepsis Calculator into an EMR

James Perciaccante, MD
September 21, 2017 WakeMed Health & Hospitals
WakeMed Health and Hospitals
Private Non-Profit Hospital System
3 Inpatient Hospitals with obstetric delivery services
Three Well Newborn Nurseries
Two Special Care Nurseries
One Neonatal Intensive Care Unit
8000+ deliveries per year
1/3rd of newborns are cared for by community pediatric
providers
Epic 2017
Neonatal Sepsis CDC
guidelines
Neonatal Sepsis Challenges
Rare but severe disease
Definition/diagnosis of maternal
chorioamnionitis
Under-treatment may lead to sepsis and
significant morbidity/mortality
Over-treatment may lead to prolonged
hospitalization, separation of mother-baby,
and unnecessary exposure to
antibiotics/alteration of the microbiome
Neonatal Early-Onset Sepsis
Calculator
Cohort of 600,000 babies from California and
Massachusetts
Model estimates the probability of neonatal
early-onset bacterial infection based on
maternal intrapartum factors:
Highest maternal temperature during labor
Gestational age
Duration of rupture of membranes
Antepartum antibiotics
GBS status
Clinical status of the infant

Puopolo et al. Pediatrics. 2011 Nov; 128 (5):e1155-63.


Rate of EOS by Gestational Age

Slide courtesy of Karen Puoplolo


Rate of EOS by
Highest Maternal Temperature

Slide courtesy of Karen Puoplolo


Rate of EOS by Duration of ROM

Slide courtesy of Karen Puoplolo


Online Calculator
WakeMed and Neonatal
Sepsis
300 well newborns receive
antibiotics at WakeMed each year
Implementation of the EOS
calculator has potential to decrease
antibiotic use by 50% without
increasing number of babies who
will develop early-onset sepsis
Online Calculator

External site
Transcription
errors
Not part of
medical record
Not codified data
Limits reporting
WakeMed Workflow
EOS Calculator

Nursery
Admission Provider
Birth
RN evaluation Evaluation/Exam
Standing Orders
Calculator and Epic
UCSF presented at UGM 2016
Pop Health for Bunnies:
Decision Support Tools for the
NICU
Required CACHE programming
WakeMed utilized existing Epic
Tools to integrate the calculator
Decoding the Calculator

UGM 2016 Pop Health for Bunnies: Decision Support Tools for the NICU
Existing Epic Tools and
Calculator
Flowsheet
Navigator
Print Groups/Reports
BPAs
CER Rules
Order Panels
SmartTools
Flowsheet
Nurse enters
variables on
admission
Calculates
coefficients and
variables behind
the scenes
Generates risk
scores
Navigator
Print Groups/Reports
Best Practice Advisories - Nurse

Risk at birth >1


Recommendations:
Neonatology Consult
Frequent Vital Signs
48 hour Hospitalization
Best Practice Advisories
Providers
Risk at birth >1
Well Appearing
Risk < 1
Recommendation:
Frequent Vital
Signs
48 hour
hospitalization
Best Practice Advisories
Providers
Well Appearing
Risk > 1 and < 3
Recommendation:
Frequent Vital
Signs
Blood culture
48 hour
hospitalization
Best Practice Advisories
Providers

Well Appearing
Risk > 3
Recommendation:
Blood culture
Antibiotics
Order Panels
CER Rules
Inborn newborns
> 34 weeks gestational age
Print Group Colors
Green: Risk at birth < 1/1000 and well-appearing
Routine vital signs. No antibiotics. No culture.
Yellow: Risk at birth >1 and well or baby is equivocal and
equivocal score < 1
Vital Signs every 4 hours x 48 hours. No culture. No antibiotics.
Orange: Well or equivocal risk is > 1 and < 3
Blood culture. No antibiotics. Vital signs every 4 hours.
Red: Risk at birth >3
Blood culture. Ampicillin and gentamicin. Possible admission to
SCN/NICU.
Documentation: Smart
Links, Lists, Phrases
.FLOW[XX]
.EOSSEPSISCALC
Roll out
Prelaunch
Go Live Liftoff!
Go Live Final Stage
Missteps
Keys to Success
Newborn Nurseries
Antibiotic Utilization Rate
Results: Antibiotic Use in NBN

Antibiotic
Patient Average Antibiotic Exposure
Admissions Days LOS Days (%) AUR
Oct-16 642 1418 2.2 49 21 (3.3) 3.5%
Nov-16 647 1363 2.1 43 16 (2.5) 3.2%
Dec-16 666 1444 2.2 48 21 (3.2) 3.3%
Jan-17 565 1268 2.2 23 10 (1.8) 1.8%
Feb-17 566 1215 2.1 34 19 (3.4) 2.8%
Mar-17 568 1205 2.1 26 19 (3.4) 2.2%
Apr-17 536 1120 2.1 8 6 (1.1) 0.7%
May-17 627 1324 2.1 11 9 (1.4) 0.8%
Jun-17 611 1305 2.1 17 9 (1.5) 1.3%
Jul-17 652 1389 2.1 15 8 (1.2) 1.1%
Aug-17 697 1483 2.1 2 1 (0.1) 0.1%
LOS Length of Stay; AUR Antibiotic Utilization Rate
Lessons Learned
Education is key
Multidisciplinary buy-in
Integration into existing workflow
Importance of automation and
simplicity
Standardization of practice is both a
benefit and challenge
Importance of exam replacing
antibiotics
Contact Information
Jim Perciaccante
jperciaccante@wakemed.org
Sharon Reif
sreif@wakemed.org
Jonathan Seigel
jseigel@wakemed.org

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