Creating a Neonatal Antibiotic Stewardship QI Team

Any of the toolkit elements can be implemented as a stand-alone measure in your center. However, for hospitals that would like to create a sustainable culture change around antibiotic stewardship, it will be valuable to implement these measures as part of a more global quality improvement effort.

The Centers for Disease Control and Prevention outlines seven Core Elements of Hospital Antibiotic Stewardship Programs:

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First, assemble a multidisciplinary team that includes representatives from each stakeholder group involved with the delivery of antibiotics to neonates in your hospital. It is important to set a regular meeting schedule with this team. Meetings should be at least monthly and possibly more frequent at the outset.

Team members might include:

  • Senior Leaders (CNO, CMO, CEO)
  • Providers (MD, NP/PA)
  • Pharmacists
  • L&D Nursing Staff
  • Nursery Nursing Staff
  • Nurse Managers
  • EMR IT Staff
  • Lab/Microbiology Technician(s)
  • Families

Implementation Guidance

Several CASC Steering Committee members established a Quality Improvement Team at their own hospitals, and have developed numerous resources with suggestions for how others might implement the same practices.

  • Develop a Project Charter to identify strengths, strategize solutions to challenges, and unify your team around common, actionable goals.

Project Charter Template

Project Charter with Sample Answers

  • The Core Elements of Hospital Antibiotic Stewardship Programs Antibiotic Stewardship Program Assessment Tool can help you complete the Project Charter, and reassess progress over time.

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  • Refer to the Key Drivers of a successful neonatal antibiotic stewardship quality improvement project to identify specific interventions to test with your team

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Still not sure how to get started? The Pediatric Infectious Diseases Society’s How To Guide: Starting an (ASP) is a great resource for setting up your own Antibiotic Stewardship Program. In addition to the resources included in this toolkit, you may wish to visit the Perinatal Quality Collaborative of North Carolina and Illinois Perinatal Quality Collaborative antibiotic stewardship web pages to learn about other AS QI program models.


Data collection

Why should my QI team collect data?

Strategic data collection is essential for ensuring your quality improvements are making a difference. Your data can be used to target key areas of improvement, and to communicate successes to your administration or other stakeholders. This data will also help you make sure that your interventions are having the intended effect and leading to improvement.

Suggested approach

Partner with the pharmacy department, which may have an easy way to collect the measures you want to track. Many hospital pharmacies already collect this data.

Establish a baseline from the past 6-12 months to gauge current AUR

  • Because of normal variations, it’s most accurate to have a longer baseline (10-12 months), especially if you have a low delivery volume.
  • Sometimes even just preparing to do a QI project results in changes. It might be best to set your “year” of baseline data to end 1-2 months before the QI project begins.

Track your hospital’s AUR on an Annotated Run Chart each month

  • Annotations show which interventions had the biggest impact on your AUR
  • Keep tracking this data after you’ve seen a change until you are confident you have sustained improvement (up to a year after you reach your goal)

Conduct case reviews for all infants with positive blood culture in the first seven days of life to ensure procedural changes do not inadvertently increase risks.


Data collection resources

This sample run chart shows the importance of building improvements into hospital systems to sustain success.

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A steady rise in maternal mortality rates and disparities in infant mortality have increased the spotlight on the quality of care delivered by hospitals and their staff. Together, we can address these issues, improve outcomes and reduce preventable deaths in our state.

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