Neonatal Abstinence
Syndrome Project
Action Period Call
Ohio Perinatal Quality Collaborative
May 20, 2014
Welcome!
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Time Topic Presenter
3:00 pm Welcome, Agenda Review, roll call Susan Ford
3:10 pm Key Driver Diagram Overview Susan Ford
3:15 pm Review of Pharmacological Bundle
Michele Walsh, MD
3:30 pm Team Sharing & Discussion All Teams
3:40 pm Learning Session Preparation Susan Ford
3:50 pm Next Steps
• Data Update – NAS & VON
• Monthly Progress Report
• Attitude Measurement Survey
Michele Walsh, MD
Susan Ford
Agenda
Roll Call: Please sign in with your hospital affiliation and the
names of your team members on the call in the
Question box
Participating Neonatal Teams
• Akron Children’s Hospital
• Akron Children’s Mahoning Valley
• Akron Children's – St Elizabeth
• Akron Children’s Summa
• Aultman Hospital
• Bethesda North Hospital
• Cincinnati Children’s Hospital
• Cleveland Clinic
• Dayton Children’s Hospital
• Fairview Hospital
• Good Samaritan Hospital
• Hillcrest Hospital
• Mercy Anderson Hospital
• Mercy St. Vincent Medical Center
• MetroHealth Medical Center
• Miami Valley Hospital
• Mount Carmel East Hospital
• Mount Carmel West Hospital
• Nationwide Children’s
• NTW-Doctor’s Hospital
• NTW-Dublin Methodist
• NTW-Grant
• NTW-Mount Carmel St. Ann's
• NTW-Riverside
• Promedica Toledo Children’s
• The Ohio State University Medical
Center - Wexner
• University Hospital - Cincinnati
• UHCMC– Rainbow Babies
and Children’s Hospital
Key Driver Diagram Project Name: OPQC Neonatal NAS Leader: Walsh
SMART AIM
KEY DRIVERS INTERVENTIONS
By increasing identification of and
compassionate withdrawal treatment for full-term infants born with
Neonatal Abstinence Syndrome (NAS), we will reduce length of stay by 20% across participating sites by June 30, 2015.
Improve recognition and non-judgmental support for Narcotic
addicted women and infants
Connect with outpatient support and treatment program prior to discharge
Standardize NAS Treatment Protocol
Optimize Non-Pharmacologic Rx Bundle
• Initiate Rx If NAS score > 8 twice. •Stabilization/ Escalation Phase •Wean when stable for 48 hrs by 10% daily.
•Swaddling, low stimulation. •Encourage kangaroo care •Feed on demand- MBM if appropriate or lactose free, 22 cal formula
•All MD and RN staff to view “Nurture the Mother- Nurture the Child” •Monthly education on addiction care
Attain high reliability in NAS scoring by nursing staff
Partner with Families to Establish Safety Plan for Infant
Fulltime RN staff at Level 2 and 3 to complete D’Apolito NAS scoring training video and achieve 90% reliability.
• Establish agreement with outpatient program and/or Mental Health •Utilize Early Intervention Services
Collaborate with DHS/ CPS to ensure infant safety.
Prenatal Identification of Mom Implement Optimal Med Rx Program
Engage families in Safety Planning. Partner with other stakeholders to
influence policy and primary prevention.
Provide primary prevention materials to sites.
To reduce the number of moms and babies with narcotic exposure, and
reduce the need for treatment of NAS.
GLOBAL AIM
How will we accomplish our AIM?
• Develop and implement a standardized process for the
identification, evaluation, treatment and discharge
management of an infant with neonatal abstinence syndrome.
– Standardization of Scoring Tool; improve consistency in use of
Modified Finnegan Tool with D’Apolito video
– Standardization of protocol bundles
– Small tests of change (PDSA’s) towards implementing
standardized protocol into Ohio hospitals
• Create a culture of compassion, understanding, and healing
for the mother infant dyad affected by the problem of neonatal
abstinence syndrome.
– Nurture the Mother-Nurture the Child video
Key Driver:
Intervention:
Pharmacological Bundle
Standardize NAS Treatment Protocol
• Initiate Rx If NAS score > 8 twice. •Stabilization/ Escalation Phase •Wean when stable for 48 hrs by 10% daily.
Source: https://neoadvances.org
Source: http:pyschiatricnews.org
Pharmacologic Treatment Treatment is divided into the following phases:
Initiation, Escalation, Stabilization, Wean
Morphine
• Treatment should be initiated if
an infant has 2 consecutive
scores > 8 OR 1 score > 12.
• Initiation Phase- most infants
can be treated with oral
medication. (**IV morphine and
enteral morphine doses are not
equivalent)
Methadone
• Treatment should be initiated if
an infant has 2 consecutive
scores > 8 OR 1 score > 12
• Initiation Phase- all treatments
are with oral medication
Methadone
PO 0.05mg/kg/dose q6h
Morphine**
PO 0.05mg/kg/dose q3h
IV 0.02 mg/kg/dose q3h
0
5
10
15
20
25
30
35
40
45
50
N=102 N=183 N=187 N=29 N=32 N=14 N=547
A B C D E F Total
Opiate Treatment days
Day of Life of Discharge
Opiate Treatment and Length of Stay
0
5
10
15
20
25
Day of life discharged Days total opiate treatment
Morphine only
Methadone only
Morphine n= 276
Methadone n= 224
Morphine vs Methadone
Treatment is divided into the following phases:
Initiation, Escalation, Stabilization, Wean
Morphine
• Escalation Phase:
• Increase dose every 3 hours until
controlled
• Rescue Dose: If infant has 1 score
of > 12, double the previous dose
given (enteral or IV) x 1 and then
adjust accordingly:
Methadone
• Escalation Phase:
• Increase dose if NAS still > 8 after
3 doses of methadone
• If 3 doses later NAS still > 8
increase to 0.15 mg/kg/dose q6h
Morphine
PO 0.03mg/kg/dose q3h
IV 0.01 mg/kg/dose q3h
Methadone
PO 0.1mg/kg/dose q6h
Treatment is divided into the following phases:
Initiation, Escalation, Stabilization, Wean
Second Drug: Phenobarbital
Consider adding Phenobarbital if:
• Polysubstance exposure (benzodiazepines, barbiturates,
antipsychotics, antidepressants, other sedatives/hypnotics,
tobacco) is suspected/confirmed
• AND CNS findings (tremors, increased muscle tone, etc.)
rather than GI findings predominate on NAS sub scale score
• AND Morphine dose exceeds 0.3 mg/kg/dose with score
remaining > 8 OR Methadone dose exceeds 0.2 mg/kg/dose
• OR unable to wean for 2 consecutive days
Pharmacologic Treatment Treatment is divided into the following phases:
Initiation, Escalation, Stabilization, Wean
• Stabilization:
– All scores remain < 8 for minimum 48 hours.
– 72 hours of stabilization may be used if infant has had to
increase above 0.4 mg/kg dose or if phenobarbital
added.
Morphine AND Methadone Stabilization
Pharmacologic Treatment Treatment is divided into the following phases:
Initiation, Escalation, Stabilization, Wean
Morphine AND Methadone Wean
• Weaning Phase: Once stabilized on same dose for 48 hours, use this dose as
the starting point of the wean. Begin weaning the dose by 10% (of the original
dose when the first wean was started) every 24 hours. Drug may be
discontinued when a single dose is < 0.02 mg/kg/dose. See examples of drug
decreases included in the OCHA Protocol.
• *Ad lib infants*: Infants should be allowed to ad lib feed but kept on q6hr drug
schedule
• Discharge:
– Observe in-house x 48 hours off of Morphine before discharge.
– Observe in-house x 72 hours off of Methadone before discharge.
THIS APPEARSTO BE THE MOST IMPORTANT VARIABLE TO DECREASE LOS
Impact of Ohio Weaning Protocol
Pilot Hospital 1
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Consecutive Patients
Tre
atm
en
t (D
ays)
New Protocol
0
5
10
15
20
25
30
35
N=77 N=476
No Protocol Protocol
Opiate Treatment Days
Day of Life of Discharge
Impact of Weaning Protocol
Strict wean protocol No specified wean
0
1
2
3
4
5
6
7
8
9
No Protocol Protocol
Total Morphine Dose Given (mg/kg)
Total Morphine Dose Given
(mg/kg)
Strict wean protocol No specified wean
0
1
2
3
4
5
6
No Protocol Protocol
Total Methadone Dose Given (mg/kg)
Total Methadone Dose Given (mg/
kg)
No specified wean Strict wean protocol
Questions for Dr. Walsh? Please click on the raised hand icon on the right of your screen to
ask a question OR type it into the chat box.
Team Discussion/Poll
Which piece of the pharmacological bundle
could you test in your hospital?
Drug/Opiate
Trigger Scores
Escalation
Wean
Discharge
Responses to Monthly Progress Report
Have you changed or adopted to some of the
elements of the OCHA NAS Protocol?
50%: Yes, we have changed and adopted all/some
of the elements.
13%: No, we have not, but plan to do so.
34%: No, we have not, and have no plan to do so.
Additional Questions? Please click on the raised hand icon on the right of your screen to
ask a question OR type it into the chat box.
Storyboard Suggestions
Here are suggestions for items you might include on your storyboard:
Name & location of
NICU
Improvement Team:
names, titles, roles.
Include a picture if
possible
Brief description of
NICU (e.g., community
or population
characteristics, services,
relationship to specific
maternity hospital/s)
• 2 PDSA examples
Creating Your Team Storyboard:
Keep it small!!
• 1 PDSA
• 1 Baby
• 1 Day
PDSA Worksheet https://opqc.net/teams/quality-improvement-resources
PDSA
• Plan: Briefly describe your test. How will you know change is an
improvement? What Key Driver does this test impact?
• Do: Test the change. Was the cycle carried out as planned?
Record data and observations.
• Study: Compare your results to your hypothesis. Did your
results match your predictions.
• Act: Decided to adapt, adopt, or abandon? Explain why.
PDSA Plan:
Describe your test. What Key Driver does it impact?
Do: Test the change. Record data and observations.
Study: Compare your results to
your hypothesis. Did your results match your
predictions?
Act: Will you adapt, adopt or
abandon the test? Explain why.
Register for the Learning Session
The OPQC Summer 2014
Learning Session will be on
Thursday, June 26th in Columbus
Registration link is on our
website: https://opqc.net
Learning Session Details
Where:
The Ohio Union (at OSU)
1739 High Street
Columbus, OH 43210
When:
Thursday, June 26, 2014
Registration opens at 7:30 am
Presentations begin at 9:00 am
Hotel Information:
OPQC has secured group
rates at the following
Columbus hotels:
– Springhill Suites
• $124/night
• Discount code: CCH
– Hyatt Place
• $135/night
• Discount code: OPQC
Data Update
• Data Worksheet and Data Dictionary found
on OPQC website in password area of site:
Member Log In-NAS-Data Collection
• Can begin to submit data electronically on May 28th
• Email and tutorial PPT overview will be sent to Data
Contacts and posted on our website
• PLEASE submit data on at least 10 babies by June 16th
so we will be able to review data at the Learning Session
Next Steps
• VON Infection Data (sustain mode) for April
was due 5/5; 76% of teams submitted that data
• Monthly Progress Report
– Will be sent out 5/27; due 6/5
• Have ALL staff (MD, NNP,RN, Social Workers) complete
Attitude Measurement Survey from May 21 – June 10.
*Could have staff review of the VON Virtual Visit DVD prior
to submission
• NO Action Period Call in June in preparation for the Learning
Session in Columbus on the 26th
• Prepare Storyboard Update to share with other teams at the
Learning Session (template hyperlink here)
The OPQC NAS Project is
funded by The Ohio
Department of Medicaid