Mighty Germ But Tight Plan Can Send The Baby Home
23 February 2016 Last updated:
8 April 2016
Mighty Germ But Tight Plan Can Send The Baby Home
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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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.
- 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.
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.
- 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.
- Sustained - the initiative has been implemented and is sustained in standard business.
- January 2011 – June 2014.
- The Royal Hospital for Women, SESLHD
- 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.
- 2015 NSW Health Innovation Awards Finalist – Harry Collins Award
- 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.
- 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.
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- 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.
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Dr Srinivas Bolisetty
Lead Clinician, Royal Hospital for Women
South Eastern Sydney Local Health District
Phone: 02 9382 6190
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