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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



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.


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.


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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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.


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 and Affiliations



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.

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Correspondence to Elisha M. Wachman.

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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).

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