1. Chorioamnionitis: Changing our Management of Mothers and Their Newborns New Term: Triple I
Review CDC/COFN Guidelines
Proposed Change to Management of “Chorio Babies” at Christiana Care: T.I.M.E. Pathway
“Sepsis Calculator”
Role of the LDR Nurse

2. Current State- CDC/COFN Guidelines & CCHS Practice
All infants born to mothers with a diagnosis of “chorioamnionitis” are admitted to the NICU; regardless of absence of symptoms.
Blood culture on admission and CBC monitoring
Minimum 48 hrs of ampicillin/gentamicin
Diagnosis of chorioamnionitis sometimes loosely applied.
Maternal fever > 37.8° C and:
Significant maternal tachycardia (>120 beats/min)
Fetal tachycardia (> beats/min)
Purulent or foul-smelling amniotic fluid or vaginal discharge
Uterine tenderness
Maternal leukocytosis (total blood leukocyte count >15,000-18,000 cells/μL)

3. Impact of “r/o sepsis chorio” admissions
Asymptomatic Infant admitted for 48 hrs to ICN:
Mother/baby separation
Reduction in bonding
Increased parental stress/anxiety
Reduction in maternal breast milk production and feeding
Increased exposure to formula and IV fluids
Unnecessary lab draws
Risk for extended hospitalization
due to “culture negative” prolonged antibiotic use due to non-specific CBC lab abnormalities
Weaning off of IVFs
Adverse Events -
IV infiltrates
Dollars
$500/patient hospital day compared to admission to term nursery
Based on CCHS 2015 “chorio admission” data, this would be
~ $86, ,000/year

4. T.I.M.E. Pathway T = Triple M = Manage E = Early-onset Sepsis
I = Intrauterine Inflammation and/or Infection
M = Manage
E = Early-onset Sepsis

5. Maternal Fever? “Isolated" Fever: “Documented” Fever:
Temperature > 38
Repeated after 30 minutes
Temp < 38
“Documented” Fever:
Temp > 38
Any temperature > 39 – no need to repeat –This is considered a “documented” fever

6. Triple I Clinical Diagnosis
Documented Maternal fever
PLUS ONE OF THE FOLLOWING Clinical Findings:
Fetal Tachycardia (>160 for 10 minutes)
Purulent Discharge from the Cervical OS
“Left shift in WBC”/WBC’s > 15,000

7. Kaiser Permanente Sepsis Risk Score Calculator

8. Kaiser Permanente Sepsis Risk Score Calculator
Clinical Exam Description

9. L&D Nurse Flow Process
Alert to Nurse with initial Newborn Vital sign documentation 30 minutes of life)
Fires alert to Nurse
Provides URL access
Opens Power Form from alert

10. 1. Nurse clicks Sepsis Calculator Link (goes to URL)
If all the necessary information is added to PowerChart, a nurse alert will appear to complete the Sepsis Calculator…Select Sepsis Calc 1st

11. Using Sepsis Calculator
7. Click Calculate
1. Select 0.5/1000 (CDC Incidence)
2. Enter Gestational Age
3. Highest maternal temp. within 24 hrs of delivery
4. ROM Duration
5. GBS status
8. Record these Clinical Recommendations into Cerner Powerform
“Neonatal Sepsis Risk Assessment” 6.
GBS Specific IAP Abx:
Penicillin
Ampicillin
Clindamycin
Erythromycin
Cefazolin
Vancomycin
Broad Spectrum Abx:
Other cephalosporins
Fluoroquinolones
Any extended spectrum β-lactams
Any GBS IAP plus an aminoglycoside
Access Sepsis Calculator via
URL link in PowerChart…

12. 8. Record these Clinical Recommendations into Cerner Powerform
“Neonatal Sepsis Risk Assessment”
Incidence: Always select CDC national. After you click calculate, the information in the Clinical Recommendation column is what is transferred to the Sepsis Form…

13. L&D Nurse Flow Process

14. Peds/DR provider fills out the rest#5
Record newborn 30 min vital signs
2. Record Sepsis Calculator Clinical
Recommendations. *Fill in all that
apply from the calculator
Notify Peds DR team/provider and document who was notified
Complete form
Sign form #1 #2 #3 #4
Peds/DR provider fills out the rest
Fill in Clinical Recommendations from the Sepsis Calculator for Well Appearing & Equivocal. Remember, Newborns assessed with clinical illness will be admitted to NICU

15. Nurse/Pediatric Delivery Room Provider IMPORTANT Points
Peds/DR provider should be at all deliveries if there is a concern for fetal well being.
Peds/DR does not need to be at all deliveries. If the mother only had an isolated fever these babies need a Sepsis Calculator score completed after delivery, notify Peds of the recommendations
Call Peds/DR provider to notify them of mothers with fevers (when able to do so) and also after the Sepsis Calculator score has been completed for the newborn (if Peds not present for delivery).
Call Peds/DR provider if there is concern for newborn instability or vitals abnormality (e.g. tachypnea).
Peds/DR provider should assess all babies with any sign of clinical instability (e.g. tachypnea).

16. Nurse/Pediatric Delivery Room Provider IMPORTANT Points continued …
If the baby appears to be stable and is demonstrating normal transitional physiology (ie: has tachypnea but no distress), he/she may remain with the mother per routine in L&D.
The baby can always be brought to the NICU for OBS if indicated.
“Equivocal” exam babies, by definition require 2-4 hours of persistent symptoms. Therefore, a tachypneic baby at 1 HOL may simply be demonstrating transitional physiology and does not necessarily meet criteria for “equivocal exam”. If concerned, discuss with Peds/DR or Neonatology.
When the mother is ready for transfer to Well Baby floor, only “Well Appearing” babies who do not require NICU admission (per their Sepsis Calculator recommendations) are cleared for co-transfer to Well Baby floor.
Any baby with ongoing transitional physiologic abnormalities, or any sign of distress must go to the NICU.
If a baby goes to NICU for OBS and then has complete resolution of symptoms, clinical discretion can be used to allow this baby to return to Well Baby Floor with mother.
The Peds/DR provider must notify the Well Baby provider or covering provider about the baby’s Sepsis Calculator recommendation and clinical disposition.
Remember: The L&D nurse needs to include the Sepsis Calculator Score in the Mother/Baby report.

17. T.I.M.E. Pathway PowerChart Tags

18. Additions to OBIS for easy access to information…

19. Addition to OBIS Chalkboard to identify the need for Peds…

20. Key Issues to Remember
The goal is to reduce unnecessary admissions to the NICU.
Safety is key to making this a success.
Any Well Baby/Floor newborn with possible signs of distress needs to be discussed with NICU team and the covering well baby doctor.
Don’t delay in transferring a baby who has abnormal vitals or signs of distress to the NICU.

21. Go Live January 24, 2017