Maternal Group B Streptococcus Prophylaxis Improvement using an Electronic Medical Record Dynamic Order Set

 

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Abstract

Objective To develop and implement a Group B Streptococcal (GBS) dynamic order set to improve adherence to the American College of Obstetricians and Gynecologists/Centers for Disease Control and Prevention (ACOG/CDC) guidelines.

Study Design A team of information technology and clinical experts developed a dynamic order block. The content was patterned after the CDC “Prevent GBS” mobile app. It was then embedded in the labor and delivery/induction order set and piloted at a single high-volume obstetric unit. Following the pilot and incorporation of the 2019 ACOG update of the CDC guidelines, the order set was rolled out in five additional hospitals within a region of a large health system. Information on GBS prophylaxis performance before and after implementation was available for the pilot site and four of the additional hospitals. Information before implementation was obtained electronically from electronic medical record (EMR) laboratory and pharmacy data and supplemented by manual chart review. Postimplementation data were obtained from discrete order set EMR data elements. Adherence to the guidelines before and after were compared using chi-squared test.

Results There were 7,114 deliveries before implementation and 4,502 after implementation. Preterm delivery occurred in 6.8 and 6.9%, respectively. There was an increase in appropriate treatment of preterm patients (positive and unknown GBS) delivering after implementation (88.7–99.1%, p < 0.001). More patients were reported to have a penicillin allergy before implementation than after implementation (14.7 vs. 11.1%, respectively, p = 0.01). Associated changes in therapy noted after implementation included a nonsignificant decrease in the proportion reporting a high-risk allergy (50.3 vs. 41.9%, p = 0.18), an increase in the appropriate use of clindamycin and vancomycin (64.4 vs. 92.3%, p < 0.001) and a decrease in clindamycin use in those without sensitivity testing.

Conclusion Routine universal use of a dynamic admission labor/induction order set was associated with high and improved adherence to GBS prophylaxis guidelines.

Key Points

• Lapses in GBS prophylaxis are associated with early-onset GBS disease.

• Preterm delivery and penicillin allergic patients are commonly associated with lapses in prophylaxis.

• Dynamic EMR order set use can improve adherence to clinical guidelines.

Publication History

Received: 21 April 2023

Accepted: 18 October 2023

Accepted Manuscript online:
23 October 2023

Article published online:
22 November 2023

© 2023. Thieme. All rights reserved.

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• References

• 1 American College of Obstetricians and Gynecologists. ACOG Committee Opinion #782. Prevention of group B streptococcal early-onset disease in newborns. Obstet Gynecol 2019; 134: e19-e40
  PubMedGoogle Scholar
• 2 Verani JR, McGee L, Schrag SJ. Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease–revised guidelines from CDC, 2010. MMWR Recomm Rep 2010; 59 (RR-10): 1-36
  PubMedGoogle Scholar
• 3 Nanduri SA, Petit S, Smelser C. et al. Epidemiology of invasive early-onset and late-onset group B streptococcal disease in the United States, 2006–2015. JAMA Pediatr 2019; 173 (03) 224-233
  CrossrefPubMedGoogle Scholar
• 4 Verani JR, Spina NL, Lynfield R. et al. Early-onset group B streptococcal disease in the United States: potential for further reduction. Obstet Gynecol 2014; 123 (04) 828-837
  CrossrefPubMedGoogle Scholar
• 5 Briody VA, Albright CM, Has P, Hughes BL. Use of cefazolin for group B streptococci prophylaxis in women reporting a penicillin allergy without anaphylaxis. Obstet Gynecol 2016; 127 (03) 577-583
  CrossrefPubMedGoogle Scholar
• 6 Critchfield AS, Lievense SP, Raker CA, Matteson KA, Group B. Group B streptococcus prophylaxis in patients who report a penicillin allergy: a follow-up study. Am J Obstet Gynecol 2011; 204 (02) 150.e1-150.e8
  CrossrefPubMedGoogle Scholar
• 7 Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016; 25 (12) 986-992
  CrossrefPubMedGoogle Scholar
• 8 Castells M, Khan DA, Phillips EJ. Penicillin allergy. N Engl J Med 2019; 381 (24) 2338-2351
  CrossrefPubMedGoogle Scholar
• 9 Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy; a review. JAMA 2019; 321 (02) 188-199
  CrossrefPubMedGoogle Scholar
• 10 Desravines N, Waldron J, Venkatesh KK, Kwan M, Boggess KA. Outpatient penicillin allergy testing in pregnant women who report an allergy. Obstet Gynecol 2021; 137 (01) 56-61
  CrossrefPubMedGoogle Scholar
• 11 Kwah JH, Burn MS, Liao J, Cate J, Son M. Outpatient penicillin allergy evaluation during pregnancy and associated clinical outcomes. Am J Obstet Gynecol MFM 2022; 4 (05) 100674
  CrossrefPubMedGoogle Scholar
• 12 Macy E. Penicillin skin testing in pregnant women with a history of penicillin allergy and group B streptococcus colonization. Ann Allergy Asthma Immunol 2006; 97 (02) 164-168
  CrossrefPubMedGoogle Scholar
• 13 Philipson EH, Lang DM, Gordon SJ, Burlingame JM, Emery SP, Arroliga ME. Management of group B streptococcus in pregnant women with penicillin allergy. J Reprod Med 2007; 52 (06) 480-484
  PubMedGoogle Scholar
• 14 Cook E, Ramirez M, Turrentine M. Time has come for routine penicillin allergy testing in obstetrics. AJP Rep 2020; 10 (01) e15-e19
  Article in Thieme ConnectPubMedGoogle Scholar
• 15 Albright CM, MacGregor C, Sutton D, Theva M, Hughes BL, Werner EF. Streptococci screening before repeat cesarean delivery. Obstet Gynecol 2017; 129 (01) 111-119
  CrossrefPubMedGoogle Scholar