Early-Onset Sepsis Risk Calculator Integration Into an Electronic Health Record in the Nursery

Abstract

Background and objectives: An early-onset sepsis (EOS) risk calculator tool to guide evaluation and treatment of infants at risk for sepsis has reduced antibiotic use without increased adverse outcomes. We performed an electronic health record (EHR)-driven quality improvement intervention to increase calculator use for infants admitted to a newborn nursery and reduce antibiotic treatment of infants at low risk for sepsis.

Methods: This 2-phase intervention included programming (1) an EHR form containing calculator fields that were external to the infant's admission note, with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds and (2) discrete data entry elements into the EHR admission form with a hyperlink to the calculator Web site. We used statistical process control to assess weekly entry of risk scores and antibiotic orders and interrupted time series to assess trend of antibiotic orders.

Results: During phase 1 (duration, 14 months), a mean 59% of infants had EOS calculator scores entered. There was wide variability around the mean, with frequent crossing of weekly means beyond the 3σ control lines, indicating special-cause variation. During phase 2 (duration, 2 years), mean frequency of EOS calculator use increased to 85% of infants, and variability around the mean was within the 3σ control lines. The frequency of antibiotic orders decreased from preintervention (7%) to the final 6 months of phase 2 (1%, P < .001).

Conclusions: An EHR-driven quality improvement intervention increased EOS calculator use and reduced antibiotic orders, with no increase in adverse events.

FIGURE 1

EHR form for phase 1 that was external to the nursery admission note and accessed from the sidebar (Risk Assessments). URL to the EOS risk calculator was entered manually into an Internet browser. Providers entered calculator scores manually into the 3 empty fields (rectangles).

FIGURE 2

EHR Smart Form for phase 2, with discrete entry elements programmed into the admission encounter and URL hyperlink to the calculator Web site.

FIGURE 3

Calculator use and antibiotics ordered. A, SPC p-chart: proportion of nursery infants each week who had calculator scores entered into the EHR fields by the provider. The center line in each study phase was the calculated mean of the weekly proportion of infants with calculator used during the phase. The UCL and LCL were 3σ above and below the center line. The breaks in the center lines were determined by the process changes. B, SPC CUSUM chart: proportion of nursery infants each week who had antibiotics ordered within 24 hours after birth.

FIGURE 4

Interrupted time series of the proportion of infants receiving antibiotics each week.