Case Study: UPMC 2025 Achievement Award

Excellence in Care Award—Large Division

Enhancing Standardized Protocols for Early Onset Sepsis in Well Appearing Neonates Across Fifteen Birthing Centers

The Goal

Early-onset sepsis (EOS) is rare but serious; broad screening often results in unnecessary treatment and NICU stays for healthy infants, disrupting bonding and microbiome development. A 2023 review of 15 sites revealed inconsistent practices and overuse due to lack of protocols, prompting a clear need for a more standardized and safer approach.

The Intervention

Using the Breakthrough Series Collaborative (BTS) Model for Improvement, the project took a structured approach to enhancing EOS screening. A multidisciplinary leadership team—clinicians, quality specialists, data analysts, and administrators—led a four-month planning phase to identify gaps, engage stakeholders, train staff, and establish baseline data. An eight-month action phase followed, during which teams implemented strategies, shared lessons learned, and received individualized support to address site-specific needs. In collaboration with the Health Analytics team, a centralized data platform was developed to streamline collection, enhance site autonomy, and enable ongoing feedback. The BTS model fostered continuous learning, collaboration, and quality improvement throughout the process.

Results

The initiative standardized EOS care across birthing sites through evidence-based protocols and provider education, reducing unnecessary antibiotics by 55%, blood tests by 60%, and maternal-infant separation by 16.5%, with no disparities by race or insurance. Tailored support and ongoing data monitoring addressed resistance and workflow challenges, ensuring sustained, system-wide improvement.

 

 

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Topics: Quality Initiatives

Revision Date: 6/23/2025

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