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  • Quality Improvement Article
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A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts’ PNQIN collaborative

Abstract

Objective

To support hospitals in the Massachusetts PNQIN collaborative with adoption of the ESC Neonatal Opioid Withdrawal Syndrome (NOWS) Care Tool© and assess NOWS hospitalization outcomes.

Study design

Statewide QI study where 11 hospitals adopted the ESC NOWS Care Tool©. Outcomes of pharmacotherapy and length of hospital stay (LOS) and were compared in Pre- and Post-ESC implementation cohorts. Statistical Process Control (SPC) charts were used to examine changes over time.

Results

The Post-ESC group had lower rates of pharmacotherapy (OR 0.35, 95% CI 0.26, 0.46) with shorter LOS (RR 0.79, 95% CI 0.76, 0.82). The 30-day NOWS readmission rate was 1.2% in the Pre- and 0.4% in the Post-ESC cohort. SPC charts indicate a shift in pharmacotherapy from 54.8 to 35.0% and LOS from 14.2 to 10.9 days Post-ESC.

Conclusions

The ESC NOWS Care Tool was successfully implemented across a state collaborative with improvement in NOWS outcomes without short-term adverse effects.

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Fig. 1: Percent of opioid-exposed newborns ≥35 weeks receiving pharmacotherapy, Pre- and Post-ESC implementation.
Fig. 2: Length of hospital stay (LOS) for opioid-exposed newborns ≥35 weeks, Pre- and Post-ESC implementation.

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References

  1. Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and costs of neonatal abstinence syndrome among infants with medicaid: 2004–2014. Pediatrics 2018;141. https://doi.org/10.1542/peds.2017-3520.

  2. 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  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  4. 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  PubMed  Google Scholar 

  5. 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  PubMed  Google Scholar 

  6. 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  PubMed  Google Scholar 

  7. Snowden JN, Akshatha A, Annett RD, Crawford MM, Das A, Devlin LA, et al. The ACT NOW clinical practice survey: gaps in the care of infants with neonatal opioid withdrawal syndrome. Hosp Pediatr. 2019;9:585–92.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Schiff DM, Grossman MR. Beyond the Finnegan scoring system: novel assessment and diagnostic techniques for the opioid-exposed infant. Semin Fetal Neonatal Med. 2019;24:115–20.

    Article  PubMed  PubMed Central  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  10. 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  PubMed  Google Scholar 

  11. Grossman MR, Berkwitt AK, Osborn RR, 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. https://doi.org/10.1542/peds.2016-3360.

  12. 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  PubMed  Google Scholar 

  13. Wachman EM, Grossman M, Schiff DM, Philipp BL, Minear S, Hutton E, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. J Perinatol. 2018;38:1114–22.

    Article  PubMed  Google Scholar 

  14. Whalen BL, Grossman MR, Whatley C. Inter- and intra-rater reliability of the Eating, Sleeping, Consoling (ESC) Care Tool for Neonatal Abstinence Syndrome (NAS). In: Proceedings from the 2018 Annual Meeting of the Pediatric Academic Societies; May 5–8, 2018; Toronto, Canada.

  15. Whalen BL, MacMillan KD, Flanagan VA, Picarillo A. NNEPQIN NAS initiative: implementation of the eat, sleep, console care tool across a regional neonatal quality improvement network. In: Proceedings from the 2019 Annual Meeting of the Pediatric Academic Societies; April 27–30, 2019; Baltimore, MD.

  16. Achilles JS, Castaneda-Lovato J. A quality improvement initiative to improve the care of infants born exposed to opioids by implementing the eat, sleep, console assessment tool. Hosp Pediatr. 2019;9:624–31.

    Article  PubMed  Google Scholar 

  17. Blount T, Painter A, Freeman E, Grossman M, Sutton AG. Reduction in length of stay and morphine use for NAS with the “eat, sleep, console” method. Hosp Pediatr. 2019;9:615–23.

    Article  PubMed  Google Scholar 

  18. Parlaman J, Deodhar P, Sanders V, Jerome J, McDaniel C. Improving care for infants with neonatal abstinence syndrome: a multicenter, community hospital-based study. Hosp Pediatr. 2019;9:608–14.

    Article  PubMed  Google Scholar 

  19. Dodds D, Koch K, Buitrago-Mogollon T, Horstmann S. Successful implementation of the eat sleep console model of care for infants with NAS in a community hospital. Hosp Pediatr. 2019;9:632–8.

    Article  PubMed  Google Scholar 

  20. MacMillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Volpe Holmes A. Association of rooming-in with outcomes for neonatal abstinence syndrome: a systematic review and meta-analysis. JAMA Pediatr. 2018;172:345–51.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wachman EM, Schiff DM, Silverstein M. Neonatal abstinence syndrome: advances in diagnosis and treatment. JAMA. 2018;319:1362–74.

    Article  PubMed  Google Scholar 

  22. Howard MB, Schiff DM, 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.

    PubMed  Google Scholar 

  23. Massachusetts Perinatal Neonatal Quality Improvement Network (PNQIN) Perinatal Opioid Project. http://www.pnqinma.org/perinatal-opioid-project. Accessed 16 March 2020.

  24. Kilo CM. A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement’s Breakthrough Series. Qual Manag Health Care. 1998;6:1–13.

    Article  CAS  PubMed  Google Scholar 

  25. Gupta M, Kaplan HC. Using statistical process control to drive improvement in neonatal care: a practical introduction to control charts. Clin Perinatol. 2017;44:627–44.

    Article  PubMed  Google Scholar 

  26. Baby Friendly USA. http://www.babyfriendlyusa.org. Accessed 16 March 2020.

  27. Wachman EM, Warden AH, Thomas Z, Thomas-Lewis JA, Shrestha H, Nikita FNU, et al. Impact of psychiatric medication co-exposure on Neonatal Abstinence Syndrome severity. Drug Alcohol Depend. 2018;192:45–50.

    Article  PubMed  Google Scholar 

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Acknowledgements

We would like to acknowledge the Massachusetts PNQIN perinatal opioid project leadership team, the ESC leadership team, and ESC NOWS Care Tool creators (Bonny Whalen, Elisha Wachman, Kathryn MacMillan, Susan Minear, Matthew Grossman). We would like to thank the numerous people at each hospital who participated in the multi-disciplinary teams needed to implement the ESC NOWS Care Tool.

Funding

This study was supported by grant funding from the Massachusetts Health Policy Commission and the Massachusetts Department of Public Health (CDC Grant no. NU58DP006371).

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Authors

Contributions

All authors reviewed and edited the manuscript, and approved the final submitted version. EMW wrote the first draft of the manuscript, developed the concept for the project and led the project; MG supervised the project, helped develop the concept, and provided key resources and data coordination; MH was a key project lead involved in site, conference, data collection coordination; PM performed the data analysis, table and figure creation; EMW, JM, SM, KDLM, and BLW created the ESC Care Tool training materials, led workshops and webinars, and provided site support; BCI wrote portions of the first draft of the manuscript and assisted with data collection; EMW, JM, RS, DB, AW, TM, RG, SJ, and DRG were site leads who supervised implementation and data collection at their hospitals; HD and FH provided overall project leadership and resources.

Corresponding author

Correspondence to Elisha M. Wachman.

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The authors declare that they have no conflict of interest.

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Wachman, E.M., Houghton, M., Melvin, P. et al. A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts’ PNQIN collaborative. J Perinatol 40, 1560–1569 (2020). https://doi.org/10.1038/s41372-020-0733-y

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