Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost.

BACKGROUND AND OBJECTIVE: The incidence and associated costs of neonatal abstinence syndrome (NAS) have recently risen sharply; newborns with NAS occupy 4% of NICU beds. We implemented a coordinated program for NAS including standardized protocols for scoring, medications and weaning, and a calm rooming-in environment, to improve family-centered care and to decrease both length of stay (LOS) and hospital costs. METHODS: In early 2013, a multidisciplinary quality improvement team began consecutive plan-do-study-act (PDSA) cycles. We trained nurses in modified Finnegan scoring, ensured scoring only after on-demand feeds during skin-to-skin care, and standardized physician score interpretation. We provided prenatal family education, increased family involvement in symptom monitoring and nonpharmacologic treatment, and treated otherwise healthy infants on the inpatient pediatric unit instead of in the NICU. We measured outcomes using statistical process control methods. RESULTS: At baseline, 46% of inborn infants at-risk for NAS were treated with morphine; by 2015, this decreased to 27%. Adjunctive use of phenobarbital decreased from 13% to 2% in the same period. Average LOS for morphine-treated newborns decreased from 16.9 to 12.3 days, average hospital costs per treated infant decreased from $19 737 to $8755, and costs per at-risk infant dropped from $11 000 to $5300. Cumulative morphine dose decreased from 13.7 to 6.6 mg per treated newborn. There were no adverse events, and 30-day readmission rates remained stable. CONCLUSIONS: A coordinated, standardized NAS program safely reduced pharmacologic therapy, LOS, and hospital costs. Rooming-in with family and decreased use of NICU beds were central to achieved outcomes.

Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative.

OBJECTIVES: Venous thromboembolism (VTE) prophylaxis for patients at risk is often overlooked in pediatric health care institutions, which provides an opportunity to improve patient care. The objectives of this study were to review our current hospital practice, identify a population at high risk, and formulate institutional guidelines for thromboprophylaxis. METHODS: This was a prospective patient-safety and quality-improvement project performed at a large pediatric tertiary care hospital. We developed criteria for assessing risk and selecting prophylactic intervention through analysis of the age distribution and underlying medical conditions of patients with VTE at our center, literature review of adult recommendations for thromboprophylaxis, and consensus opinion of multiple specialists at our institution. A patient-care policy was developed to assess VTE risk and prescribe the appropriate thromboprophylaxis regimen. The primary outcome measure was compliance with thromboprophylaxis guidelines in patients at risk for VTE. RESULTS: Over the 4-year study period, the observed rate of VTE prophylaxis in patients at risk increased from a baseline of 22% to an average rate of 82%, and there were intermittent improvements up to 100%. CONCLUSIONS: Although some of the details may vary from center to center, many of the discussed principles and practices involved in instituting a VTE-prevention program are applicable to other pediatric institutions. Despite the fact that the risk of VTE in hospitalized children is much lower than that in adults, there are patients in pediatric hospitals who deserve systematic screening and thoughtful application of preventative measures.