One of the goals of practice guideline is to unify the timing of nursery discharge. We speculated that an effectively instituted guideline would reduce variability in length of stay (LOS). A guideline for the management of term neonates with sepsis ruled-out was instituted by a disease management system(DM) in three major metropolitan areas.

Methods: Patients managed by DM were evaluated if they were greater than 35 weeks gestation and met eligibility for the asymptomatic neonatal sepsis clinical management guideline. This guideline suggested serial complete blood counts for the first 24 hours in infants at risk, and treatment for 48 hours pending a decision for prolonged course. We evaluated infants who were classified as sepsis ruled-out. Under this guideline there would be no need for LOS of 5-6 days based on the sepsis evaluation alone. Patients were subdivided by LOS into 2-4 days (implying guideline adherence) and 5-6 days. The guideline was approved by regional physician advisory boards. Infants with a diagnosis indicating eligibility were identified, and the pre-guideline population (2/1/97-6/30/97) was compared with the post-guideline population(7/1/97-11/30/97) using a chi-square analysis.

Results: There were 202 infants pre-guideline and 210 infants post-guideline and LOS did not differ (mean ± SD 3.9 ± 1.3 pre-guideline Vs 3.8 ± 1.2 post-guideline days). Of these infants, 66% of eligible infants pre-guideline had LOS 2-3 days Vs 72% post-guideline (p=ns).

Conclusions: These data suggest that this guideline for the management of infants with sepsis ruled-out failed to decrease LOS in the first several months following this model of implementation. There was a trend towards decreasing variability in discharge LOS (34% pre-guideline Vs 28% post-guideline infants discharged out of LOS range consistent with guidelines). Despite these guidelines approximately one quarter of infants continue to be discharged out of this range. This suggests that other factors may be contributing to LOS in this population, or that adherence to this guideline was not immediate or universal.