Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome



To improve Neonatal Abstinence Syndrome (NAS) inpatient outcomes through a comprehensive quality improvement (QI) program.


Inclusion criteria were opioid-exposed infants ≥36 weeks. QI methodology including stakeholder interviews and plan-do-study-act (PDSA) cycles were utilized. We compared pre- and post-intervention NAS outcomes after a QI initiative that included: A non-pharmacologic care bundle, function-based assessments consisting of symptom prioritization and then the “Eat, Sleep, Console” (ESC) Tool; and a switch to methadone for pharmacologic treatment.


Pharmacologic treatment decreased from 87.1 to 40.0%; adjunctive agent use from 33.6 to 2.4%; hospitalization length from a mean 17.4 to 11.3 days, and opioid treatment days from 16.2 to 12.7 (p < 0.001 for all). Total hospital charges decreased from $31,825 to $20,668 per infant. Parental presence increased from 55.6 to 75.8% (p < 0.0001). No adverse events were noted.


A comprehensive QI program focused on non-pharmacologic care, function-based assessments, and methadone resulted in significant sustained improvements in NAS outcomes. These findings have important implications for establishing potentially better practices for opioid-exposed newborns.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1


  1. 1.

    Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated healthcare expenditures—United States, 2000−2009. JAMA. 2012;307:1934–40.

    CAS  Article  Google Scholar 

  2. 2.

    Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015;35:667.

    CAS  Article  Google Scholar 

  3. 3.

    Milliren CE, Gupta M, Graham DA, Melvin P, Jorina M, Ozonoff A. Hospital variation in neonatal abstinence syndrome incidence, treatment modalities, resource use, and costs across pediatric hospitals in the United States, 2013 to 2016. Hosp Pediatr. 2018;8:15–20.

    Article  Google Scholar 

  4. 4.

    Massachusetts Department of Public Health. 2017. Data brief: an assessment of opioid-related overdoses in Massachusetts 2011−2015 [Homepage on the Internet]. http://www.mass.gov/eohhs/docs/dph/stop-addiction/data-brief-chapter-55-aug-2017.pdf (Accessed August 2017).

  5. 5.

    Hudak ML, Tan RC. From the American Academy of Pediatrics: Neonatal drug withdrawal. Pediatrics. 2012;129:e540–560.

    Article  Google Scholar 

  6. 6.

    Kraft WK, Adeniyi-Jones SC, Chervoneva I, Greenspan JS, Abatemarco D, Kaltenbach K, et al. Buprenorphine for the treatment of the neonatal abstinence syndrome. N Engl J Med. 2017;376:2341–8.

    CAS  Article  Google Scholar 

  7. 7.

    Brown MS, Hayes MJ, Thornton LM. Methadone versus morphine for treatment of neonatal abstinence syndrome: a prospective randomized clinical trial. J Perinatol. 2015;35:278–83.

    CAS  Article  Google Scholar 

  8. 8.

    Tolia VN, Patrick SW, Bennett MM, Murthy K, Sousa J, Smith PB, et al. Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. N Engl J Med. 2015;372:2118–26.

    Article  Google Scholar 

  9. 9.

    Sarkar S, Donn SM. Management of neonatal abstinence syndrome in neonatal intensive care units: a national survey. J Perinatol. 2006;26:15–17.

    CAS  Article  Google Scholar 

  10. 10.

    Mehta A, Forbes KD, Kuppala VS. Neonatal abstinence syndrome management from prenatal counseling to post-discharge follow-up care: results of a national survey. Hosp Pediatr. 2013;3:317–23.

    Article  Google Scholar 

  11. 11.

    Bogen DL, Whalen BL, Kair LR, Vining M, King BA. Wide variation found in care of opioid-exposed newborns. Acad Pediatr. 2017;17:374–80.

    Article  Google Scholar 

  12. 12.

    Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2:141–58.

    CAS  Google Scholar 

  13. 13.

    Jones HE, Seashore C, Johnson E, Horton E, O’Grady KE, Andringa K, et al. Psychometric assessment of the Neonatal Abstinence Scoring System and the MOTHER NAS Scale. Am J Addict. 2016;25:370–3.

    Article  Google Scholar 

  14. 14.

    Grossman M, Berkwitt A, Osborn R, Xu Y, Esserman DA, Shapiro ED. et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139:e20163360

    Article  Google Scholar 

  15. 15.

    Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hosp Pediatr. 2018;8:1–6.

    Article  Google Scholar 

  16. 16.

    Holmes AV, Atwood EC, Whalen B, Beliveau J, Jarvis JD, Matulis J. et al. Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost. Pediatrics. 2016;137:e20152929

    Article  Google Scholar 

  17. 17.

    Bagley SM, Wachman EM, Holland E, Brogly SB. Review of the assessment and management of neonatal abstinence syndrome. Addict Sci Clin Pract. 2014;9:19.

    Article  Google Scholar 

  18. 18.

    Howard MB, Schiff MD, Penwill N, Si W, Rai A, Wolfgang T, et al. Impact of parental presence at infants’ bedside on neonatal abstinence syndrome. Hosp Pediatr. 2017;7:63–69.

    Google Scholar 

  19. 19.

    MacMillan KD, Rendon CP, Verma K, Riblet N, Washer DB, Holmes AV. Rooming-in for neonatal abstinence syndrome: a systematic review and meta-analysis. JAMA Pediatrics. Feb. 5. https://doi.org/10.1001/jamapediatrics.2017.5195 [Epub ahead of print].

    Article  Google Scholar 

  20. 20.

    Neo Advances [homepage on the Internet]. Karen D’Apilito. Available from: https://www.neoadvances.com/index.html.

  21. 21.

    Clinical Trials.Gov: improving outcomes in neonatal abstinence syndrome [homepage on the Internet]. First posted October 2013, updated December 2017. Available from: https://clinicaltrials.gov/ct2/show/NCT01958476.

  22. 22.

    Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23:290–8.

    Article  Google Scholar 

  23. 23.

    Wachman EM, Newby PK, Vreeland J, Byun J, Bonzagni A, Bauchner H, et al. The relationship between maternal opioid agonists and psychiatric medications on length of hospitalization for neonatal abstinence syndrome. J Addict Med. 2011;5:293–9.

    CAS  Article  Google Scholar 

  24. 24.

    Jones HE, Heil SH, Tuten M, Chisolm MS, Foster JM, O’Grady KE, et al. Cigarette smoking in opioiddependent pregnant women: neonatal and maternal outcomes. Drug Alcohol Depend. 2013;131:271–7.

    Article  Google Scholar 

  25. 25.

    Patrick SW, Dudley J, Martin PR, Harrell FE, Warren MD, Hartmann KE, et al. Prescription opioid epidemic and infant outcomes. Pediatrics. 2015;135:842–50.

    Article  Google Scholar 

  26. 26.

    Hall ES, Meinzen-Derr J, Wexelblatt SL. Cohort analysis of a pharmacokinetic-modeled methadone weaning optimization for neonatal abstinence syndrome. J Pediatr. 2015;167:1221–5.e1.

    CAS  Article  Google Scholar 

  27. 27.

    Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. BMJ Qual Saf. 2003;12:458–64.

    CAS  Article  Google Scholar 

  28. 28.

    Saia K, Bagley SM, Wachman EM, Patel PP, Nadas MD, Brogly SB. Prenatal treatment for opioid dependency: observations from a large inner-city clinic. Addict Sci Clin Pract. 2017;12:5.

    Article  Google Scholar 

Download references


This study was funded by the Massachusetts Health Policy Commission and the Boston Medical Center Department of Pediatrics. We would like to acknowledge Kathryn MacMillan, Victoria Flanagan, William Edwards, Sheila-Jane Lewis, Rachel Hoch, Rishitha Bollam, Nicole Desai, Kate Mitchell, Nicole Penwill, Rachel Morgan, Cathleen Dehn, Kristine Smith, Jordana Price, Michelle Sia, Tirah Samura, the entire Project RESPECT team, all pediatric nurses from the BMC inpatient units, Mary Beth Howard, Macy Reed, CALM volunteers, Zoe Thomas, Leonie Hoyo, Maria D’Amico, Nina Gummadi, and Cassie Duran.


Massachusetts Health Policy Commission Neonatal Abstinence Syndrome Innovation Grant.

Author information



Corresponding author

Correspondence to Elisha M. Wachman.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wachman, E.M., Grossman, M., Schiff, D.M. et al. Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome. J Perinatol 38, 1114–1122 (2018). https://doi.org/10.1038/s41372-018-0109-8

Download citation

Further reading