Association of medication-assisted treatment and short acting opioids with newborn head circumference and birth weight.

OBJECTIVE: We compared the association of methadone, buprenorphine, and short-acting opioid exposure with newborn head circumference (HC) and birth weight (BW), and evaluated gestational age (GA) as a mediator. STUDY DESIGN: We included newborns born 2013-2018 identified by neonatal abstinence syndrome diagnosis code (N = 572) and birthday-matched unexposed controls (N = 571). Linear regressions of opioid exposure with HC and BW controlled for tobacco, marijuana, cocaine, gabapentin, cesarean section, Medicaid, and newborn sex, with mediation analysis by GA. RESULT: Methadone was associated with 0.81 cm lower HC (95% CI = -1.22, -0.40) and 0.23 kg lower BW (95% CI = -0.35, -0.10) with approximately 24% and 41% mediated by GA, respectively. Buprenorphine and short acting opioids were not associated with HC or BW. CONCLUSION: Methadone exposed newborns have smaller HC and lower BW not fully attributable to younger GA, suggesting a direct effect of methadone on intrauterine growth. Exploration of potential developmental consequences of this is urgently needed.

Decreasing Unplanned Extubations in the Neonatal ICU.

BACKGROUND: Unplanned extubation (UE) is a preventable adverse event and may lead to additional complications such as cardiovascular resuscitation or respiratory compromise in a critically ill neonate during an emergent re-intubation. A quality improvement project to reduce unplanned endotracheal tube dislodgement would reduce these morbidities. We aimed to reduce UEs in the NICU to 1 UE/100 ventilator days by October 2018. METHODS: As of the baseline period (March 2017 to November 2017), our level 4 NICU had 950 annual admissions and a baseline rate of 9.9 UEs/100 ventilator days. We formed an inter-professional task force consisting of a neonatologist, 2 respiratory therapists, and the NICU nurse educator. We tracked all of our UE events and required the staff involved to file an electronic safety report. PDSA (plan-do-study-act) cycles consisted of staff attitude survey, development of a data collection tool, protocol of 2 staff members for all transfers of intubated patients, staff education around securement device, and daily retaping of endotracheal tubes to securement device. UE events and ventilator days were extracted from a respiratory database and the electornic medical record. RESULTS: A special cause variation was noted via control chart rules for the mean UE rate from a baseline of 9.9 UEs/100 ventilator days in the baseline period compared to a post-intervention mean of 1.6 UEs/100 ventilator days for the period of August 2018 to March 2019). During the intervention phase of the project (December 2017 to July 2018), a special cause variation was noted with a UE rate of 5/100 ventilator days. CONCLUSIONS: Development of a quality improvement project by a multidisciplinary taskforce, along with several PDSA cycles including education and staff awareness, reduced the UE rate by 84% in a level 4 NICU. Ongoing surveillance, education, and review of UE cases will be key to maintaining UE events at a goal of 1 UE/100 ventilator days.

Improving Care for Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVE: Care for neonatal abstinence syndrome (NAS), a postnatal drug withdrawal syndrome, remains variable. We designed and implemented a multicenter quality improvement collaborative for infants with NAS. Our objective was to determine if the collaborative was effective in standardizing hospital policies and improving patient outcomes. METHODS: From 2012 to 2014, data were collected through serial cross-sectional audits of participating centers. Hospitals assessed institutional policies and patient-level data for infants with NAS requiring pharmacotherapy, including length of pharmacologic treatment and length of hospital stay (LOS). Models were fit, clustered according to hospital, to evaluate changes in patient outcomes over time. RESULTS: Among 199 participating centers, the mean number of NAS-focused guidelines increased from 3.7 to 5.1 of a possible 6 (P < .001), with improvements noted in all measured domains. Among infants cared for at participating centers, decreases occurred in median (interquartile range) length of pharmacologic treatment, from 16 days (10 to 27 days) to 15 days (10 to 24 days; P = .02), and LOS from 21 days (14 to 33 days) to 19 days (15 to 28 days; P = .002). In addition, there was a statistically significant decrease in the proportion of infants discharged on medication for NAS, from 39.7% to 26.5% (P = .02). After adjusting for potential confounders, standardized NAS scoring process was associated with shorter LOS (-3.3 days,95% confidence interval, -4.9 to -1.4). CONCLUSIONS: Involvement in a multicenter, multistate quality improvement collaborative focused on infants requiring pharmacologic treatment for NAS was associated with increases in standardizing hospital patient care policies and decreases in health care utilization.