A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts' PNQIN collaborative.

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.

Management of Newborns with Prenatal Opioid Exposure: One Institution's Journey.

The prevalence of newborns with neonatal abstinence syndrome (NAS) is rising sharply. To respond to this crisis, our institution re-examined our policies and procedures regarding our approach to the management of newborns with prenatal opioid exposure. Our 6-pronged approach included: (1) a commitment to nonpharmacologic care as first-line treatment; (2) a simplified function-based approach to observation of the infant (Eat-Sleep-Console); (3) improved prenatal education to prepare parents for the newborn's postnatal course; (4) a cuddler program; (5) strategies to help parents remain at the bedside; and (6) change from morphine to methadone for infants who require medication for NAS. Our obstetrics collaborators and outpatient pediatric colleagues have partnered with us to prepare mothers for delivery by strengthening them in their recovery prenatally and helping them maintain their recovery after discharge. Among many improvements, our changes resulted in a decrease in medication treatment for NAS (from 87% to 40%), a decrease in the need for adjuvant medication (from 34% to 2%), and a decrease in length of hospital stay (from 18 days to 10 days). The 3 most significant factors that have contributed to our success have been: (1) a committed champion leader; (2) a strong collaborative multidisciplinary team; and (3) a quality improvement approach that facilitates implementation of ideas easily and provides timely feedback to guide further change. Although we have seen notable improvements with our new approach, emerging data from our outpatient colleagues indicate that much more is needed to help improve the long-term health of these dyads.

Standard Fixed-Schedule Methadone Taper Versus Symptom-Triggered Methadone Approach for Treatment of Neonatal Opioid Withdrawal Syndrome.

OBJECTIVES: We compared hospitalization outcomes in infants with neonatal opioid withdrawal syndrome (NOWS) treated with a novel symptom-triggered methadone approach (STMA) versus a fixed-schedule methadone taper (FSMT). METHODS: This was a single-center quality-improvement study of infants pharmacologically treated for NOWS. Outcomes were compared over time by using statistical process control charts and between the baseline FSMT (July 2016-November 2017) and intervention STMA (December 2017-May 2018) groups, including median hospital length of stay (LOS), methadone treatment days, total milligrams of methadone, and need for adjunctive agents. RESULTS: There were 48 infants in the FSMT group and 28 in the STMA group. Infants treated with STMA had a median LOS of 10.5 days (interquartile range [IQR] 10.5) versus 17.0 days (IQR 3.9; P = .003) in the FSMT group, with a 9.2-day difference in methadone treatment days (2.5 [IQR 9.0] vs 11.7 [IQR 4.0]; P = .0001), meeting criteria for statistical process control special cause variation. The average number of symptom-triggered doses was 2.1 (SD 1.0). Six infants in the STMA group were converted to FSMT after failing a trial of STMA. Infants successfully treated with the STMA (N = 22) had a median LOS of 10.0 days (IQR 4.0) compared with 17.0 (IQR 3.9) in the baseline FSMT group (P < .0001). CONCLUSIONS: STMA was associated with a significant reduction in median LOS and amount of methadone treatment. A symptom-triggered approach to NOWS may reduce LOS and medication exposure.

Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome.

OBJECTIVES: To improve Neonatal Abstinence Syndrome (NAS) inpatient outcomes through a comprehensive quality improvement (QI) program. DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.

Revision of Breastfeeding Guidelines in the Setting of Maternal Opioid Use Disorder: One Institution's Experience.

Breastfeeding is recommended for women with opioid use disorder who are treated with methadone or buprenorphine. Infants with neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure have unique challenges related to breastfeeding but also have significant benefits including improved NAS symptoms with a decreased need for pharmacotherapy. Poor understanding of substance use disorder and treatment, lack of evidence-based recommendations, and vague guidelines from national academies create controversy about breastfeeding eligibility for these women. Defining breastfeeding guidelines is often difficult, particularly in large institutions with multiple providers caring for the mother-infant dyad. Based on the available evidence and review of our institutional data, we revised our breastfeeding guidelines for mothers with opioid use disorder. The aims of our new guidelines are (a) to safely promote breastfeeding in all mothers with opioid use disorder who are in recovery, (b) to improve NAS outcomes through use of breastfeeding as a key nonpharmacologic treatment modality, and (c) to improve staff communication and consistency on the subject of breastfeeding in this patient population.