Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Quality Improvement Article
  • Published:

Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome

Journal of Perinatology volume 38, pages 1114–1122 (2018)Cite this article

Subjects

Abstract

Objectives

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

Design

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.

Results

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.

Conclusions

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.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1

Similar content being viewed by others

References

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

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

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

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

    Article  CAS  Google Scholar 

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

  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. 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. 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.

    Article  CAS  Google Scholar 

  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. 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. 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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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

Acknowledgements

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.

Funding

Massachusetts Health Policy Commission Neonatal Abstinence Syndrome Innovation Grant.

Author information

Authors and Affiliations

  1. Pediatrics, Boston Medical Center, Boston, MA, USA

    Elisha M. Wachman, Davida M. Schiff, Barbara L. Philipp, Susan Minear, Elizabeth Hutton, Karan Barry, Ginny Combs, Donna Stickney, Jennifer Driscoll, Robin Humphreys, Judith Burke & Hira Shrestha

  2. Pediatrics, Yale University School of Medicine, New Haven, CT, USA

    Matthew Grossman

  3. Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, USA

    Davida M. Schiff

  4. Obstetrics, Boston University School of Medicine, Boston, MA, USA

    Kelley Saia

  5. Boston University School of Public Health, Boston, MA, USA

    FNU Nikita & Crystal Alvarez

  6. Boston University School of Medicine, Boston, MA, USA

    Ahmad Khattab & Angela Nolin

  7. Pharmacy, Boston Medical Center, Boston, MA, USA

    Camilla Farrell

  8. Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA

    Bonny L. Whalen

Authors
  1. Elisha M. Wachman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Matthew Grossman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Davida M. Schiff
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Barbara L. Philipp
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Susan Minear
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Elizabeth Hutton
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Kelley Saia
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. FNU Nikita
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Ahmad Khattab
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Angela Nolin
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Crystal Alvarez
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Karan Barry
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Ginny Combs
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Donna Stickney
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Jennifer Driscoll
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Robin Humphreys
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Judith Burke
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Camilla Farrell
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Hira Shrestha
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Bonny L. Whalen
    View author publications

    You can also search for this author in PubMed Google Scholar

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

Check for updates. 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

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41372-018-0109-8

This article is cited by

Search

Advanced search

Quick links