Background: An increasing number of the most vulnerable victims of the opioid epidemic are infants afflicted with neonatal abstinence syndrome (NAS), a multi-systemic constellation of symptoms that may be precipitated by illicit or prescribed maternal use of opiates during gestation. Caring for these infants requires monitoring for, and treatment of, withdrawal symptoms that impede the infant’s ability to thrive, and can lead to protracted and resource-intensive hospital stays. This may be due to over-dependence on pharmacologic therapy, underutilization of non-pharmacologic techniques, and reliance on the Finnegan Neonatal Abstinence Scoring System (FNASS), a tool that may not capture an infant’s functional status. Newer care models have successfully reduced length of stay by increasing non-pharmacologic therapies, standardizing pharmacologic treatment, and using the Eat-Sleep-Console (ESC) score, which foregrounds the infant’s functional status. Local problem: Infants are admitted for NAS care in our institution relatively infrequently but suffer a disproportionately protracted length of stay when compared to the national average. Methods/Interventions: This Quality Improvement project aims to reduce the length of stay by 40% for infants with NAS admitted to our institution. We created a NAS-Care Bundle that delivers current, evidence-based NAS care to our patients by (1) increasing the use of non-pharmacologic therapies for treatment of NAS such as soothing, parental engagement, and breast milk feeding; (2) standardizing pharmacologic therapy; (3) reframing symptom scoring (by comparing the ESC with the FNASS); and (4) providing multidisciplinary medical team and family education for caregivers. Figure 1 displays our key driver diagram; Figure 2 displays a run chart of the length of stay in our institution prior to our intervention. Results: Our first PDSA cycle resulted in the development and refinement of a tool comparing the ESC and FNASS scores. Our second PDSA cycle was a multidisciplinary collaboration with child life and nursing professionals that resulted in the creation of a non-pharmacologic resource kit for caregivers. Our third PDSA cycle standardized pharmacologic care by creating an algorithm for medicine initiation, titration, and cessation; delivering an improved formulation of morphine to our unit; and tailoring electronic morphine orders. Our current PDSA cycle provides an innovative QR-code based survey to swiftly capture staff knowledge, attitudes, and practices about NAS (Figure 3). Future planned PDSA cycles include ongoing multidisciplinary staff education; the development of family caregiving tools; engagement with obstetrical colleagues to provide antenatal consultation for mothers whose infants may have NAS; and collaboration with unit social workers and care coordinators to streamline the discharge process for infants whose parents may not obtain custody. Conclusions: NAS carries high morbidity and cost. An NAS-Care Bundle at our institution foregrounded non-pharmacologic therapies, optimized pharmacologic therapy, and continues to collaborate with and educate staff about NAS to reduce our length of stay.
Reducing Length of Stay for Neonatal Abstinence Syndrome: A Quality Improvement Initiative Implementing a Neonatal Abstinence Syndrome Care Bundle
Mike Pollaro, Vicky Reichman, Donna Garey; Reducing Length of Stay for Neonatal Abstinence Syndrome: A Quality Improvement Initiative Implementing a Neonatal Abstinence Syndrome Care Bundle. Pediatrics August 2019; 144 (2_MeetingAbstract): 153. 10.1542/peds.144.2MA2.153
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