Impact of the implementation of an obstetric sepsis protocol on maternal and neonatal outcomes

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Objective: Maternal sepsis is a leading cause of preventable maternal morbidity and mortality in the United States. We assessed the implementation of a standardized early-goal-directed sepsis care bundle on maternal and neonatal outcomes. This bundle was activated by a set of vital sign criteria in combination with providers' concern for infection and included immediate rapid response team evaluation and standardized orders for fluid resuscitation, antibiotics, and labs. Methods: A retrospective cohort study was performed at a single tertiary care center between January 1, 2012 and December 31, 2018. Individuals were included if they were pregnant or within 6 weeks of delivery with a singleton gestation and had a recorded temperature measurement of >100.4°F (38°C) or <96.8°F (36°C) in addition to a heart rate >100 beats/min or a respiratory rate >20 breaths/min within 30 min of the documented temperature during an inpatient stay or triage visit. Groups were categorized as pre-implementation (January 2012-September 2016) and post-implementation (October 2016-December 2018) of the "code sepsis" protocol. The primary outcome was a composite of maternal sepsis-related outcomes: (1) intensive care unit admission, (2) acute renal failure (defined as a creatinine > 1.1 mg/dL), and (3) maternal death. Multiple secondary outcomes were analyzed. Outcomes were compared across groups using generalized estimating equation models and adjusted for significant characteristics. Results: Overall, 5368 pregnancies met criteria for inclusion: 56% pre-implementation and 44% post-implementation. Post-implementation, 126 code sepsis protocols were activated after providers had clinical concern for infection. An identified infection diagnosis was found in 12.2% of the post-implementation and 12.1% of the pre-implementation group with urinary tract infection being the most common. The primary outcome occurred in 7.0% of the pre-implementation group and 4.6% of the post-implementation group (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.52-0.83; adjusted OR [aOR], 0.64; 95% CI, 0.48-0.83). Stratified analysis by temperature >100.4°F (38°C) or temperature <96.8°F (36°C) revealed an association when criteria were met with hypothermia (OR, 0.55; 95% CI, 0.39-0.78; aOR, 0.48; 95% CI, 0.33-0.70), but not hyperthermia. When activated, the protocol had >92% adherence. Conclusion: Implementation of an early-goal-directed sepsis care pathway led to improved maternal outcomes in an obstetric population with a 36% reduction in the primary outcome.

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