Ohio Perinatal Quality Collaborative Improves Care of Neonatal Narcotic Abstinence Syndrome Michele C
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Ohio Perinatal Quality Collaborative Michele C. Walsh, MD, MSEpi,a, b Moira Crowley, MD, a, b Scott Wexelblatt, MD, c, d Susan Ford, RN, MSN,a ImprovesPierce Kuhnell, BS,e Heather C. CareKaplan, MD, MS, ofc, d Richard Neonatal McClead, MD, f, g Maurizio Macaluso, MD, PhD, c, d c, d NarcoticCarole Lannon, MD, MPH, forAbstinence the Ohio Perinatal Quality Collaborative Syndrome OBJECTIVES: ’ abstract Neonatal abstinence syndrome (NAS) after an infant s in-utero exposure to opioids has increased dramatically in incidence. No treatment standards exist, leading to substantial variations in practice, degree of METHODS: opioid exposure, and hospital length of stay. The Ohio Perinatal Quality Collaborative conducted an extensive aDivision of Neonatology and Department of Pediatrics, multi-modal quality improvement initiative with the goal to (1) standardize Rainbow Babies & Children’s Hospital, Cleveland, Ohio; identification, nonpharmacologic and pharmacologic treatment in level-2 bDepartment of Pediatrics, Case Western Reserve University, Cleveland, Ohio; cAnderson Center for Health and 3 NICUs in Ohio, (2) reduce the use of and length of treatment with Systems Excellence and eDivision of Biostatistics and opioids, and (3) reduce hospital length of stay in pharmacologically treated Epidemiology, Cincinnati Children’s Medical Center, RESULTS: d newborns with NAS. Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; fDepartment of Pediatrics, Fifty-two of 54 (96%) Ohio NICUs participated in the collaborative. Nationwide Children’s Hospital, Columbus, Ohio; and gDepartment of Pediatrics, Ohio State University, Columbus, Compliance with the nonpharmacologic bundle improved from 37% to Ohio 59%, and the pharmacologic bundle improved from 59% to 68%. Forty- Dr Walsh helped conceptualize this work, eight percent of the 3266 opioid-exposed infants received pharmacologic was a leader in the implementation of the treatment of symptoms of NAS, and this rate did not change significantly policies described, was the primary writer across the time period. Regardless of the opioid used to pharmacologically of the manuscript, and critically revised the treat infants with NAS, the length of treatment decreased from 13.4 to 12.0 manuscript; Drs Crowley, Wexelblatt, and Kaplan CONCLUSIONS: helped conceptualize this work, were leaders days, and length of stay decreased from 18.3 to 17 days. in the implementation of the policies described, Standardized approaches to the identification and and revised the manuscript; Ms Ford helped conceptualize this work and was a leader in the nonpharmacologic and pharmacologic care were associated with a implementation of the policies described; Mr reduced length of opioid exposure and hospital stay in a large statewide Kuhnell conducted the original analyses; Dr McClead collaborative. Other states and institutions treating opioid-exposed infants helped conceptualize this work, was a leader in the implementation of the policies described, and may benefit from the adoption of these practices. revised the manuscript; Dr Macaluso contributed to the design of the analyses and revisions to the manuscript; Dr Lannon helped conceptualize this ’ Neonatal abstinence syndrome (NAS) increased from 1.20 to 3.39 per 1000 work, was a leader in the implementation of policies described, and critically revised the manuscript; after an infant s in-utero exposure to births. All racial and ethnic groups – and all authors have approved the final manuscript are affected. The increase is described opioids has increased1, 2 dramatically 5 7 as submitted and agree to be accountable for all in incidence. In 2011, 1.1% of both nationally and internationally. aspects of the work. pregnant women in the United States A standardized protocol for the DOI: https:// doi. org/ 10. 1542/ peds. 2017- 0900 misused opioids, including3 pain treatment of NAS does not exist. Accepted for publication Dec 4, 2017 relievers and heroin. Up to 12.9% Nonpharmacologic measures, of women were dispensed an opioid including swaddling, skin-to-skin 4 To cite: Walsh MC, Crowley M, Wexelblatt S, et al. during pregnancy. Between 2000 care, and reduced stimulation are Ohio Perinatal Quality Collaborative Improves and 2010, maternal antepartum recommended and are intuitively Care of Neonatal Narcotic Abstinence Syndrome. opioid use increased from 1.19 to 5.63 appealing, despite lacking evidence Pediatrics. 2018;141(4):e20170900 per 1000 hospital births annually. of efficacy. Pharmacologic support Correspondingly, the diagnosis of NAS with opioids, including morphine, Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 4, April 2018:e20170900 QUALITY REPORT Interventions: Care – methadone, and buprenorphine, Data from the first 3 months of the is often used; yet, none of these initiative (January 2014 March A key driver diagram (Fig 1) medications has been shown 2014) were used as the baseline. The summarizes our theory for conclusively to be superior. Few project protocol was considered QI improvement. Our aim was to reduce studies of secondary agents including and not human subjects research ’ the length of opioid exposure and phenobarbital and clonidine exist. by the institutional review board of duration of hospitalization by using In animal models, all narcotics the Cincinnati Children s Hospital a multifactorial approach, which alter neuronal connections in the Medical Center. All participating included the following: developing brain; thus, reducing the NICUs received documents to review total opioid exposure of infants while with their institutional review board 1. Prenatal identification: counseling still humanely treating withdrawal and legal departments to confirm of opioid-exposed women in symptoms is desirable. the status of not human subjects partnership with obstetricians, Ohioresearch Perinatal. Quality Collaborative neonatologists, and addiction We previously reported the treatment specialists; development of an optimized pharmacologic protocol. The protocol 2. Improved recognition and support includes standardized guidelines for The Ohio Perinatal Quality of narcotic-exposed women and scoring NAS, triggers for initiation Collaborative (OPQC) is a state-based their infants: enhanced staff understanding of substance abuse of treatment, and a8, 9stringent network of Ohio perinatal clinicians, weaning protocol. We found that hospitals, professional organizations, as a chronic illness and of trauma- protocol use with stringent weaning and state agencies with a mission to informed care, encouraged guidelines reduced the duration reduce preterm births and improve partnering with the substance- of opioid exposure and length of outcomes for infants. Participating exposed mother, and training in nonjudgmental care. Training hospital8, 9 stay, regardless of the opioid hospitals and clinicians are was completed by using a video used. supported by a central staff with QI “ created by the Vermont Oxford expertise and an administrative and ” In a pilot group of hospitals, we 7 Network on NAS entitled Nurture NICUdata managementParticipants infrastructure.and Patient 10 supplemented the standardized the Mother-Nurture the Child Population pharmacologic protocol with an and through panels of in-recovery optimized nonpharmacologic care mothers of infants with NAS who bundle. The nonpharmacologic shared their personal stories at bundle emphasized compassionate All level-2 and 3 Ohio NICUs and collaborative learning sessions. trauma-informed care for the their affiliated level-1 units were We encouraged care in the lowest ’ mother-infant dyad, keeping mother eligible. Level-1 units were typically acuity setting, together with and infant together, and standardized aggregated with their level-2 or 3 the infant s mother and family, scoring of NAS symptoms by hospital counterpart, although 2 promoting breastfeeding for “ ” nurses trained to a standard of high level-1 nurseries with a large volume those in a recovery program. We reliability. This report describes a of infants with NAS submitted data selected the FIR Square program quality improvement (QI) initiative independently. Twenty-six of 26 in British Columbia, 11Canada, as the to spread the NAS pharmacologic and (100%) level-3 NICUs, 26 of 28 model for ideal care ; nonpharmacologic care bundles to all (93%) level-2 NICUs, and 2 level-1 3. Attained high reliability on NAS level-2 and 3 NICUs in Ohio. The aim units participated. Units formed scoring: used a standardized for this project was to reduce length multidisciplinary teams with a ’ program (modified Finnegan of stay by 20% among term infants physician, nurse, social worker, – Scoring System; D Apolito training with NAS by June 2015 through dietician, and consulting addiction 12 14 ≥ ’ videos) ; identification and compassionate specialist. Infants were included treatment of withdrawal. if they were born 37 weeks 4. Optimized nonpharmacologic METHODS gestation, had evidence of in utero treatment (see key driver opioid exposure, and were cared for diagram) by promoting maternal ’ Study Design in a participating center. Data were involvement, breastfeeding if collected on those with symptoms mother s addiction specialist and pharmacologic treatment. We judged mother stabilized, We conducted a multisite QI excluded infants with symptoms of swaddling, skin-to-skin care, and initiative. The intervention began in NAS related