Sepsis scoring systems and use of the Sepsis six care bundle in maternity hospitals.

BACKGROUND: This study aimed to assess the predictive power of three different Sepsis Scoring Systems (SSSs), namely maternity Systematic Inflammatory Response Syndrome (mSIRS), quick Sepsis-related Organ Failure Assessment (qSOFA) and Modified Early Warning System (MEWS) in identifying sepsis by comparing them with positive culture. This study also sought to evaluate compliance with using the Sepsis Six Care Bundle (SSCB) operated in an individual health board. METHODS: A retrospective cohort study was conducted in 3 maternity hospitals of a single Scottish health board that admitted 2690 pregnancies in a 12 weeks period in 2016. Data for study was obtained from medical notes, handheld and electronic health records for women who were prescribed antibiotics with a confirmed or suspected diagnosis of sepsis. Data on clinical parameters was used to classify women according to mSIRS, qSOFA and MEWS as having sepsis or not and this was compared to results of positive culture to obtain sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under Receiver Operating Characteristic curve (AUROC) along with their 95% confidence intervals. Data was also obtained on SSCB compliance. RESULTS: A total of 89 women were diagnosed with sepsis, of which 14 had missing data, leaving 75 for final analysis. Sensitivity, specificity, PPV, NPV and AUROC of mSIRS and MEWS were almost similar with AUROC of both being around 50%. Only 33 (37.1%) had identifiable sepsis six sticker displayed on medical notes and only 2 (2.2%) had all elements of SSCB delivered within the recommended one-hour post-diagnosis period. Blood culture and full blood count with other lab tests had been performed for most women (97%) followed by intravenous antibiotics and fluids (93.9%). CONCLUSIONS: mSIRS and MEWS were quite similar in detecting sepsis when compared to positive culture, with their ability to detect sepsis being close to chance. This underlines the need for creating a valid SSS with high sensitivity and specificity for clinical use in obstetric settings. Clinical use of SSCB was limited despite it being a health board policy, although there is considerable possibility of improvement following detailed audits and removal of barriers for implementing SSCB.

An Observational Cohort Study Evaluating Antimicrobial Use in Peripartum Sepsis: A Tendency towards Overdiagnosis?

(1) Background: Sepsis is the leading cause of maternal death in 11-15% of women worldwide. This emphasises the importance of administrating timely and appropriate antibiotic therapy to women with sepsis. We aimed to evaluate the appropriateness of antimicrobial prescribing in women diagnosed with peripartum sepsis. (2) Method: A prospective observational cohort study in a single Scottish health region with 12,233 annual live births. Data were collected on women diagnosed with sepsis in the peripartum period using physical and electronic medical records, drug Kardex® (medication administration) and ward handover records. (3) Results: A sepsis diagnosis was concluded in 89 of the 2690 pregnancy cases reviewed, with a median hospital stay of four days. Good overall adherence to the local guidelines for the empiric antimicrobial treatment of sepsis was observed. Group B Streptococcus was associated with 20.8% of maternal sepsis cases, whilst in 60% of clinical specimens tested no causative pathogen was isolated. (4) Conclusion: The lack of specific and sensitive clinical markers for sepsis, coupled with their inconsistent clinical application to inform diagnosis, hindered effective antimicrobial stewardship. This was further exacerbated by the lack of positive culture isolates from clinical specimens, which meant that patients were often continued on broader-spectrum empiric treatment.

A Qualitative Study Investigating the Barriers to the Implementation of the 'Sepsis Six Care Bundle' in Maternity Wards.

Background: In 2014, the Sepsis Six Care Bundle (SSCB) was introduced into a Scottish health region to improve patient outcomes. Poor compliance was demonstrated with the SSCB across different specialities. This study explored determinants of non-compliance with the SSCB in maternity wards. Methods: In-depth interviews were conducted with midwives in a single Scottish health region. Convenience sampling was used to recruit interviewees. The interviews were digitally recorded, transcribed verbatim, entered into NVivo software, and analysed using thematic analysis. Results: Thirteen face-to-face interviews were completed and lasted an average of 33 min. Three main barriers were identified to SSCB implementation; the difficulty of diagnosing sepsis, the suitability of the SSCB in a maternity setting as part of the pre-conditions phase, and the lack of staff training as part of the pre-implementation phase. Conclusion: The findings emphasize the importance of adapting improvement initiatives with sufficient preparation of staff in the rationale use to the context of care bundles.

Is additional oral phosphate supplementation for preterm infants necessary: an assessment of clinical audit.

UNLABELLED: Adequate phosphate intake is important for the prevention of metabolic bone disease in preterm infants. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition recommends a daily phosphate intake of 184-230 mg/kg/day, which should be met by standard feed volumes of either commercially fortified breast milk or preterm formulae. We sought to investigate whether our local practise of providing supplemental oral phosphate for all infants born before 32 weeks' gestation continues to be necessary. Details of parenteral and milk feeding and both oral and parenteral phosphate supplementation from birth until 8 weeks of age were collected retrospectively from the case notes of 31 preterm infants. Routinely collected biochemical markers of bone mineral status were also recorded. Mean (SD) plasma phosphate concentration was higher when oral phosphate supplementation was given [2.10 (0.38) versus 1.92(0.50) mM/L without supplement (p < 0.001)]. A minimum average phosphate intake of 184 mg/kg/day was achieved by 47 and 77 % of babies in weeks 1 and 2, respectively, and by 84-100 % of infants from week 3. The percentage of plasma phosphate measurements below the minimum target of 1.8 mM/L was greater amongst unsupplemented babies (45 versus 18 %). CONCLUSION: A majority of infants <32 weeks' gestation did not achieve the recommended phosphate intake during the first week of life. Despite achieving the recommended phosphate intake from week 3, many infants did not have plasma phosphate concentrations within the accepted normal range. Additional oral supplementation may help to achieve blood phosphate concentrations within this target range.