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Mighty Germ But Tight Plan Can Send The Baby Home

Royal Hospital for Women
Project Added:
23 February 2016
Last updated:
8 April 2016

Mighty Germ But Tight Plan Can Send The Baby Home

Summary

The Royal Hospital for Women conducted an audit to measure the success of an early discharge policy that was implemented in January 2011.

This project was a finalist in the Harry Collins Award category of the 2015 NSW Health Awards.
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Aim

To determine the impact of an early discharge policy on the incidence of early onset Group B streptococcus (GBS) infection in infants born at more than 35 weeks gestation.

Benefits

  • Supports the early discharge of babies at risk of GBS .
  • Improves collaboration between hospital staff and families.
  • Increases awareness of GBS and empowers parents to monitor their newborns.
  • Allows the parent’s wishes to be taken into consideration when developing an early discharge plan.
  • Reduces length of stay and subsequent costs to families and the healthcare system.

Background

In Australia, GBS is the leading type of infection in newborn infants. Women are screened for GBS in pregnancy and if positive, given intravenous antibiotics in labour to prevent the infection in their newborn. Currently, the USA Center for Disease Control and Prevention recommends a 48-hour observation of these infants in hospital, even after antibiotic prophylaxis.

As the incidence of GBS sepsis is low at the Royal Hospital for Women, particularly after adequate intrapartum prohylaxis, it was determined that otherwise well infants could be monitored at home by well-informed parents.

In January 2011, the Royal Hospital for Women changed its policy to allow early discharge of otherwise well newborns who were born at more than 35 weeks gestation and whose mothers were GBS positive but had received adequate antibiotic prohylaxis. Under this policy, these newborns could be discharged within 48 hours of birth, provided that parents were able to monitor their baby using an observation chart and information sheets provided by the hospital.

An audit was undertaken to assess the results of this project three years after implementation, as the low incidence of GBS meant that a longer trial period was required to obtain an adequate sample size.

Implementation

  • The policy was developed by a collaborative, multidisciplinary team from neonatal, maternity and maternal-foetal medicine.
  • The policy was designed for infants born at more than 35 weeks gestation who were otherwise well and whose mothers were GBS positive, but had received adequate antibiotic prohylaxis.
  • Eligible parents were able to take their newborn home within 48 hours of birth, with a midwife following up on home care.
  • Parents were provided with information sheets and infant observation sheets developed by the multidisciplinary team, to monitor their newborn for 24 hours after birth.

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

  • January 2011 – June 2014.

Implementation site

  • The Royal Hospital for Women, SESLHD

Results

  • Of 13858 live births at more than 35 weeks gestation, 10424 (75.2%) were screened for GBS .
  • The mean maternal age of those who were screened was 32 years, mean newborn gestational age was 39 weeks and the mean birthweight was 3.4 kg.
  • A total of 2135 (15.4%) mothers who were screened received GBS prophylaxis and 8289 (59.8%) did not receive GBS prophylaxis.
  • The median length of stay of three days was similar in infants from all groups: those that were not screened; those that were screened and received GBS prophylaxis; and those that had negative GBS screens and did not receive GBS prophylaxis.
  • There were three cases of GBS sepsis diagnosed during the project—an incidence rate of 0.2 cases per 1,000 live births. All cases occurred in mothers who had negative GBS screens and did not receive prophylaxis.
  • Of all infants in the GBS prophylaxis group, 704 (33%) were discharged safely at less than 48 hours of age. This figure was similar to other infants who were not at risk of GBS sepsis. Under the old policy, all 704 mother-infant pairs would have stayed in the hospital for at least 48 hours for observation.
  • Of all live births (13858), 2135 neonates were identified as at-risk infants but received adequate intrapartum prophylaxis. None of the 2135 infants who received intrapartum antibiotic prophylaxis developed GBS sepsis and all cases of GBS sepsis occurred in infants who didn’t receive GBS prophylaxis.
  • Based on 2013-14 Activity Based Funding, the average cost per an encounter of an uncomplicated vaginal delivery in SESLHD based on the average length of stay of 2.37 days was $4641. With an estimated 20% of patients covered by private health insurance, reducing the length of stay by one day in these infants can save a minimum of $335 to a maximum of $1950 per bed per day.
  • The policy and audit shows these otherwise well newborn infants can be sent home safely under the close monitoring of their parents, with proper parental education, information and a back-up safety plan of midwives doing regular home visits for the first 7-10 days of life.

Awards

  • 2015 NSW Health Innovation Awards Finalist – Harry Collins Award

Lessons learnt

  • A prospective data collection on follow-up and outcome of these infants up to 3 months of age would have provided information on any of these infants developing late infection after 7 days of life.
  • More formal education needs to be provided to women during the antenatal period about the risk of early onset and late GBS infection, which can occur in children up to three months of age.

Further reading

  • Stoll BJ, Hansen NI, Sanchez PJ, et al. Early onset neonatal sepsis: the burden of group B Streptococcal and E. coli disease continues. Pediatrics 2011; 127: 817-26.
  • Daley AJ, Isaacs D, Australasian Study Group for Neonatal Infections. Ten-year study on the effect of intrapartum antibiotic prophylaxis on early onset group B streptococcal and Escherichia coli neonatal sepsis in Australasia. The Pediatric Infectious Disease Journal 2004; 23: 630-4.
  • Isaacs D, Royle JA, Australasian Study Group for Neonatal Infections. Intrapartum antibiotics and early onset neonatal sepsis caused by group B Streptococcus and by other organisms in Australia. The Pediatric Infectious Disease Journal 1999; 18: 524-8.
  • Angstetra D, Ferguson J, Giles WB. Institution of universal screening for Group B streptococcus (GBS) from a risk management protocol results in reduction of early-onset GBS disease in a tertiary obstetric unit. The Australian & New Zealand Journal of Obstetrics & Gynaecology 2007; 47: 378-82.
  • Jeffery HE, McIntosh ED. Antepartum screening and non-selective intrapartum chemoprophylaxis for group B streptococcus. The Australian & New Zealand Journal of Obstetrics & Gynaecology 1994; 34: 14-9.
  • Verani JR, McGee L, Schrag SJ. Prevention of perinatal group B streptococcal disease: revised guidelines from CDC, 2010. Morbidity and Mortality Weekly Report (MMWR), Centers for Disease Control and Prevention 2010; 59(RR10); 1-32.
  • American Academy of Pediatrics. Recommendations for the prevention of perinatal group B streptococcal (GBS) disease. Pediatrics 2011; 128: 611-6.
  • Berger MB, Xu X, Williams JA et al. Early hospital discharge of infants born to group B streptococci-positive mothers: a decision analysis. BJOG : An International Journal of Obstetrics and Gynaecology 2012; 119: 439-48.
  • Mohle-Boetani JC, Lieu TA, Ray GT et al. Preventing neonatal group B streptococcal disease: cost-effectiveness in a health maintenance organization and the impact of delayed hospital discharge for newborns who received intrapartum antibiotics. Pediatrics 1999; 103: 703-10.
  • Bromberger P, Lawrence JM, Braun D et al. The influence of intrapartum antibiotics on the clinical spectrum of early-onset group B streptococcal infection in term infants. Pediatrics 2000; 106: 244-50.
  • Barcaite E, Bartusevicius A, Tameliene R et al. Prevalence of maternal group B streptococcal colonisation in European countries. Acta Obstetricia et Gynecologica Scandinavica 2008; 87: 260-71.
  • Ohlsson A, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization. The Cochrane Database of Systematic Reviews 2014; 6: CD007467.
  • Jeffery HE, Moses LM. Eight-year outcome of universal screening and intrapartum antibiotics for maternal group B streptococcal carriers. Pediatrics 1998; 101: E2.
  • Schrag SJ, Zywicki S, Farley MM et al. Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis. The New England Journal of Medicine 2000; 342: 15-20.
  • 15. Phares CR, Lynfield R, Farley MM et al. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. The Journal of the American Medical Association 2008; 299: 2056-65.
  • Van Dyke MK, Phares CR, Lynfield R et al. Evaluation of universal antenatal screening for group B streptococcus. The New England Journal of Medicine 2009; 360: 2626-36.

Contact

Dr Srinivas Bolisetty
Lead Clinician, Royal Hospital for Women
South Eastern Sydney Local Health District
Phone: 02 9382 6190
srinivas.bolisetty@health.nsw.gov.au

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