RESEARCH ARTICLE

Successful Implementation of the Eat SleepConsole Model of Care for Infants With NASin a Community HospitalDouglas Dodds, MD, Kayla Koch, MD, Talia Buitrago-Mogollon, MHA, CPHQ, Sara Horstmann, MD

A B S T R A C TBACKGROUND: Opioid use across the United States is increasing. The concomitant rise in theincidence of neonatal abstinence syndrome (NAS) has made care of infants with this disease processa top priority for pediatric centers across the country. There is growing evidence that the Eat SleepConsole (ESC) model of care is superior to the established Finnegan Neonatal Abstinence ScoringSystem model.

OBJECTIVES: We aimed to improve the care of infants with NAS by transitioning from theFinnegan Neonatal Abstinence Scoring System model to the ESC model of care. Our goal wasto decrease the average length of stay from 11.77 to 5.94 days without having an increase inreadmissions.

METHODS: A multidisciplinary team was created. Education about NAS and ESC was created anddistributed. Patients were admitted to the inpatient unit, and outcomes were observed. Standardquality improvement methodology was used for this intervention.

RESULTS: After implementation of the ESC care model, average length of stay decreased to5.94 days, with 0 patients readmitted or transferred for NAS-related complications. We saw a 48%reduction in average variable cost per patient. In addition to these reductions and savings, total perpatient morphine exposure was reduced from 2.25 to 0.45 mg/kg, a 79% reduction in use.

CONCLUSIONS: The ESC model of care was successfully implemented at our institution withresultant cost savings, decreased length of stay, and decreased medication use. Our work furthersupports the adoption of this new model of care for infants with NAS.

Jeff Gordon Children’sCenter, Atrium Health

Levine Children’s Hospital,Concord, North Carolina

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2019-0086Copyright © 2019 by the American Academy of Pediatrics

Address correspondence to Douglas Dodds, MD, Department of Pediatrics, Jeff Gordon Children’s Center, Atrium Health Levine Children’sHospital, Atrium Health-Cabarrus NorthEast, 920 Church St N, Concord, NC 28025. E-mail: douglas.dodds@atriumhealth.org

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Supported by Atrium Health-Cabarrus. Intervention supplies were obtained through a grant from the NorthEast Foundation.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Data sharing statement: Deidentified individual participant data will not be made available.

Drs Dodds, Koch, and Horstmann conceptualized and designed the study and drafted the initial manuscript; Mrs Buitrago-Mogolloncreated run and control charts, provided initial analyses, and reviewed and revised the manuscript; and all authors approved the finalmanuscript as submitted.

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The incidence of neonatal abstinencesyndrome (NAS) has quintupled over thelast decade.1,2 NAS results from the rapiddiscontinuation of opioids, which causesdisturbances in neurologic, autonomic,gastrointestinal, and musculoskeletalsystem function.3 Treatment of NAS variesconsiderably across the country.4,5 The mostused care model is the Finnegan NeonatalAbstinence Scoring System (FNASS). TheFNASS is a scoring tool based largelyon subjective clinical criteria. Patientsoften require prolonged hospital stays,pharmacologic interventions, and have highhealth care costs.1,6,7 These factors, whenjoined with increasing numbers of patientswith NAS, stretch the care limits of NICUs,special care nurseries, and newbornnurseries across the United States,producing upward inflection on the valuecurve of national and local health caresystems.

Recent care improvements generatedcompelling data suggesting that using amodel of care that is more functional in itsassessment and treatment of infants withNAS improves quality of care and positively

affects the average length of stay (ALOS),medication use, breastfeeding, and cost perstay. Authors of several studies reportreduced ALOS, cost, and NICU admissionrates after adopting a rooming-in model ofcare.8–10 Howard et al11 reported similardecreases in length of stay (LOS),withdrawal severity, and need forpharmacologic intervention with increasedparental presence and involvement. Authorsof other studies report breastfeeding’sassociation with decreased need forpharmacologic treatment and reducedLOS.12 In 2014–2015, Grossman et al13–15

developed and introduced the Eat SleepConsole (ESC) model of care with significantreductions in ALOS, pharmacologicintervention, and average cost ofhospitalization. In their work, Grossmanet al13–15 also described increases inbreastfeeding rates in the interventioncohort. This model relies less on subjectiveassessments and provides a simplifiedapproach to assessing and caring forinfants and families coping with NAS. Thefocus with the ESC model is the functionalwell-being of the child, and it enhances the

care of the patient by usingnonpharmacological treatment, improvedbreastfeeding support, and caregiver-centered education and social support.

With .700 at-risk deliveries each yearwithin our health care system and an ALOSfor NAS of 11.77 days, the need forimprovement was evident. We sought to findan improved model of care and a moreappropriate setting for care. For our study,the ESC care model was adopted andadapted to the pediatric hospital medicineinpatient service at a 28-bed communitychildren’s hospital with 3286 yearlyadmissions located within a 457-bed generalhospital that is part of a large multisitehealth care system. We chose this setting toprovide a less stimulating, more holistic,and caregiver-centered environment wherecaregivers can stay and provide continuouscare at the newborn’s bedside. This site alsoprovided access to vital collaborativeservices of the NICU, maternal fetalmedicine, psychiatry, and casemanagement. With these benefits in mind,our aim was to transition care of infantswith NAS from an FNASS model to the ESC

FIGURE 1 Key driver diagram. The aim was to improve the care for children with NAS within Atrium Health.

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model of care and to follow our progressusing the Model for Improvement as ourquality improvement (QI) methodology.16 Ouroutcome measures were to reduce ALOS by50% and decrease cost per stay by 15%. Ourprocess measures were a 90% use rate ofthe ESC assessment tool and increase inbreastfeeding rate of 30%. Our balancingmeasure was a readmission rate of ,10%.

METHODS

This intervention was conducted at achildren’s hospital within a hospital that ispart of a major health care system. Thehospital has a busy newborn service, NICU,and inpatient service and is a regionalreferral base. The practice at the time ofthe study was for infants born exposedto opioids, either through prenatalidentification or at delivery, to be observedfor 5 days in the newborn nursery andscored by using the FNASS. Infants with2 FNASS scores $8 or 1 score $12 werethen moved from the newborn nursery tothe NICU where an FNASS-based protocolwas followed. After implementation, the5-day observation period and assessmentof severity remained the same. However,infants were screened by medical socialwork for inclusion and then transferred toeither the inpatient ward or the NICU fortreatment on the basis of the screeningresults. Our inclusion criteria for the ESCgroup were as follows: gestational age$37 weeks, availability of bedsidecaretaker, and no comorbid illnessesrequiring specialized care. Infants notmeeting $1 of these criteria weretransferred to the NICU for treatment.

For this planned intervention, amultidisciplinary team was created. Thisteam included representatives frompediatric hospital medicine, the Center forAdvancing Pediatric Excellence (QI Center),neonatology, nursing (pediatrics, NICU,newborn nursery), administration, casemanagement, volunteer services, child life,obstetrics, behavioral health, familymedicine, and the local health department.Monthly meetings were held to sustainengagement and assess progress.Institutional review board oversight wasapplied for, and the project received exemptstatus as a quality initiative. The Model for

Improvement and rapid plan-do-study-actcycles were used to drive change. A keydriver diagram was created (Fig 1). Data

were collected on infants admitted to thehospital in the year (January 2017 to March2018) before project initiation for

FIGURE 2 ESC scoring form and treatment pathway. NG, Nasogastric; PO, Per Os; RN, registered nurse.

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comparison. These data included detaileddemographic information, in utero drugexposure, individual hospital course, LOS,allocated variable cost per stay, need formedication, frequency of medicationadministered, and any associatedcomplications. We analyzed all infantswho were transferred to the NICU for NAScare in the preimplementation phase.Postimplementation analysis wasperformed on infants admitted to theinpatient pediatric unit for treatment ofNAS. Infants exposed to various illicit drugsas well as prescription opioids, selectiveserotonin reuptake inhibitors, alcohol, andnicotine were included.

Our first intervention was changing thelocation of care for qualifying infantsidentified to have symptoms of NAS fromany nursery to the inpatient unit. Thisallowed for rooming-in and increasedcaregiver involvement at the bedside. Apackage of tools was created to streamlinethe process of caring for these infants. Thisincluded a social work screening tool,admission checklist, discharge checklist,inborn transfer checklist, and outborntransfer checklist. We also developed aprocess for outpatient developmentalfollow-up and continued behavioral healthintervention for the family. Inpatient floornursing staff were educated on the FNASS.Initially this system was followed, andtreatment was based on the preexisting NASprotocol.

The second intervention was to change fromthe FNASS model to the ESC model of care.Educational materials were created on theESC model, and nursing and providers wereeducated. A flow map for treatment wascreated with the scoring system (Fig 2).The ESC scoring tool was created andapproved by the hospital system formscommittee (Fig 2). For the first month ofimplementation, FNASS and ESC scoringwere done concurrently for every patient.This allowed familiarity with each tool todevelop for each scorer. After the firstmonth, the ESC scoring tool was usedexclusively. In accordance with the ESCmodel, infants were assessed on theirability to breastfeed or bottle-feedeffectively, to sleep undisturbed for.1 hour

in between feeds, and to console within10 minutes if distressed. A score of $2 wasconsidered effectively managed withdrawal.A score of #1 was indicative of withdrawalrequiring medication. Nonpharmacologicaltreatment was administered, and ifineffective, morphine 0.1 mg/kg per dosewas administered. Each score wasindependent and drove treatment decisionsonly for that given time of evaluation. Threeconsecutive scores of 0 triggeredconsideration of nasogastric tubeplacement for feeds and addition ofclonidine 1 mg/kg per dose every 6 hours.During this time, extensive education onnonpharmacological interventions such asvertical rocking, swaddling, singing, cooingas well as mamaRoo swings and thePacifier-Activated Lullaby System were madeavailable to nursing staff and caregivers(Fig 2). Parental (or identified caregiver)presence was strongly encouraged, andvolunteers were used when caregivers wereunavailable.

Monthly data collection occurred for infantsadmitted for NAS through manual chartaudits from April 2018 to February 2019.Outcome measures included ALOS, allocatedvariable cost per stay, and total morphineuse. These measures were evaluated byusing statistical process control (SPC)charts. Change concepts were annotated onSPC charts, and results were analyzed by

using standard SPC rules to identify thepresence of special cause variation and2-sample t test with unequal variance toattain significance of improvement. Theprocess measures were use of the ESCassessment tool, which was a proxy foradherence to the ESC method, andbreastfeeding rates. Our balancingmeasure was readmission rate.

RESULTS

There were 82 infants included in this study,with 49 from the baseline period (January2017–March 2018) and 33 from thepostimplementation period (April2018–February 2019). Eight patients wereexcluded from the postimplementationperiod analysis, with 5 excluded because ofcaregiver unavailability, 2 because ofprematurity, and 1 because of comorbiddisease requiring specialized care.Demographic characteristics of the includedinfants are presented in Table 1. There wasno significant difference between the2 groups. Several patients were missingdata on race and ethnicity and thus couldnot be included in this statisticalcomparison.

The ESC model was followed for 90% of thepostimplementation patients. The remaining10% were scored with the FNASS, whichoccurred in the first month of datacollection posttransition after an

TABLE 1 Characteristics and Outcomes of Newborns

Newborn Characteristics Baseline (N 5 49) Postimplementation (N 5 33) P

Excluded 0 8

Boys, n (%) 21 (44) 10 (29) .17

Race, n (%) .15

White 43 (90) 13 (76)

Person of color 5 (10) 4 (24)

Birth wt, kg 2.91 6 0.48 2.84 6 0.48 .52

Polypharmacy, n (%) 26 (54) 17 (50) .72

Exposed to opioids, n 48 31

Outcomes

Use of ESC scoring tool, n (%) 0 (0) 12, n 5 13 (92%) ,.0001

ALOS, d 11.77 6 9.62 5.94 6 2.98 .0003

Morphine use 2.25 mg/kg 6 3.45 0.45 mg/kg 6 0.78 .001

Required morphine, n (%) 23 (48) 8 (24) .03

Total dose, mg/kg 2 0.45

Breastfeeding rate, % 45 45 0.99

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educational communication breakdownoccurred causing this break in protocol.None of these infants required initiationof morphine therapy. These infants wereincluded in our analysis. Our measuresof ALOS, average variable cost per patient,

and morphine use revealed special causevariation (8 data points below the mean)resulting in a downward shift of the meanafter the main 2 interventions (mother andinfant rooming-in and starting ESC protocol)(Fig 3). The 2-sample t test with unequal

variance revealed a decreased ALOS from11.77 to 5.94 days, a 50% reduction (P 5.0003). Average variable cost per staydecreased by 48%, and the cumulativeamount of morphine used per stay (totalamount of morphine given during the

FIGURE 3 X-bar charts. Means differ between t test and SPC charts because of different data groups. Means in SPC charts represent normalversus special cause variation and means on t test represent pre- and postintervention periods. A, LOS per patient (days). B, Totalmorphine administered per patient (mg/kg). LCL, lower control limit; UCL, upper control limit.

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hospital stay divided by birth weight)decreased from 2.25 to 0.45 mg/kg, a 79%reduction (P 5 .001) (Table 1).Breastfeeding rates were not impacted. Noadverse events were reported in studyparticipants. Two infants requiredreadmission for non–NAS-related illnesses.

All 8 excluded infants were scored andtreated with the FNASS-based protocol inthe NICU. For the 5 infants who wereexcluded because of caregiver unavailability,the ALOS was 22 days. The averagecumulative amount of morphine perkilograms used for these 5 infants was3.1 mg/kg.

DISCUSSION

Transition from the FNASS to the ESC modelof care at our institution was successful.While achieving these successes, quality andsafety of care was maintained. There wereno other efforts aimed at decreasing theLOS for patients with NAS at the time of thisstudy, and we are confident that ourinterventions gave rise to the changesobserved. Grossman et al13–15 describedsimilar results at their institution whendeveloping the ESC model. Our study wasimplemented at a smaller, nonacademiccommunity-based children’s hospital withina larger health care system.

The major strength of this QI initiative wasthe adoption of an interdisciplinarycollaborative view of the disease process.Viewing the mother-infant dyad as a singleentity allowed a shift in care from a patient-centered to a caregiver-centered caremodel. Allowing caregivers to room in withinfants and providing a quiet and nurturingenvironment are major reasons for theproject’s success. Opioid use disorderstigma softened as the caregiver becamethe primary care provider for the infant anda therapeutic, trustful relationshipdeveloped between the hospital staff andthe caregiver. Another strength was theregularity with which the multidisciplinaryteam met to discuss the study andinterventions. We were able to addressconcerns and unexpected barriers quicklyand effectively, thus maintaining atreatment environment conducive topositive results throughout the study period.Strengthening of the local care system

occurred as community, government, andhealth system programs were identified togenerate a continuum of care beginning atthe first prenatal visit and extending to theentry of the dyad into primary care.Financial support of the program by thehospital foundation solidified itscommitment to the community to findcreative and effective ways to stem theeffects of opioid use disorder. This early anddramatic success led to expansion of theprogram to other system sites. Thesuccess has also led to strengthening ofinterdepartmental collaborative efforts andexploration of other novel strategies forcare delivery.

Limitations of the study include the fact thatwe did not control for exposure to anysubstances, including nicotine. We chose notto limit our patient population to thoseexposed only to opioids so as not tomarkedly limit the number of patients whocould be included. Also, our ESC screeningtool is not validated. A final limitation isthat we only included patients enrolled inour program in the postimplementationevaluation. We believe our poorimprovement in breastfeeding rate wasinfluenced by not recommendingbreastfeeding to mothers expressing adesire to actively use marijuana in thepostpartum time period. This was inaccordance with the current approachproposed by the American Academy ofPediatrics in 2018.

With the initial program success,implementation of the ESC model of careacross our health care system has begun.We expect to have full implementationacross all sites caring for newborns by2020. We continue to monitor for changes inALOS, average variable cost per patient, andmorphine use.

Plans include the development of a prenataleducation package for expectant mothers tobetter prepare them for the postpartumhospital experience. Targeted interventionsto increase breastfeeding rates andskin-to-skin time for infants are planned.Long-term goals include strengtheningthe collaborative efforts between keystakeholders to improve access to maternalmedication-assisted treatment using

buprenorphine, to improve infantdevelopmental follow-up, and to beginlongitudinal well care for the infant-caretaker dyad.

CONCLUSIONS

The ESC model of care for children withNAS was successfully implemented at acommunity, nonacademic children’s hospitalwithin a larger health care system with areduced LOS of 5.94 days (a 50% reduction),reduced morphine use per stay to 0.45 mg/kg(a 79% reduction), and average variablecost savings of 48% per case. We believethese results support adopting the ESCmodel of care for infants and caretakers toimprove their care quality and experiencewhile favorably bending the health carevalue curve.

Acknowledgments

We thank Chris Westveer, RhondaBlasingame, Brandi Atwell, Melissa Martin,Brianna Blankenbicker, Alisa Rogers, ShelleyStanley, Andrew Heling, Rob Silver, KatherineBarrier, Richard Smits, Lara Pons, MollyEllsperman, and Sarah Mabus for theircontributions to the success of thisintervention.

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DOI: 10.1542/hpeds.2019-0086 originally published online July 24, 2019; 2019;9;632Hospital Pediatrics 

Douglas Dodds, Kayla Koch, Talia Buitrago-Mogollon and Sara HorstmannWith NAS in a Community Hospital

Successful Implementation of the Eat Sleep Console Model of Care for Infants

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DOI: 10.1542/hpeds.2019-0086 originally published online July 24, 2019; 2019;9;632Hospital Pediatrics 

Douglas Dodds, Kayla Koch, Talia Buitrago-Mogollon and Sara HorstmannWith NAS in a Community Hospital

Successful Implementation of the Eat Sleep Console Model of Care for Infants

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