Quality Improvement Article | Published:

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.

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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.

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Conflict of interest

The authors declare that they have no conflict of interest.

Correspondence to Elisha M. Wachman.

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Further reading

  • Neonatal abstinence syndrome

    • Mara G. Coyle
    • , Susan B. Brogly
    • , Mahmoud S. Ahmed
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Fig. 1