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Neonatal Teams
NAS Project Level II Spread
Kick Off Action Period Call
Ohio Perinatal Quality Collaborative
April 8, 2014
Welcome!
Please don’t put us on
HOLD!
If you need to step away:
– Use the MUTE button on your phone or
– You can use *6 to place the call on MUTE
and *6 to come off of MUTE
Time Topic Presenter
3:00 pm Welcome, introductions and review of Agenda Susan Ford, RN
3:10 pm Setting the Stage –
• review of OPQC progress to date
Susan Ford, RN
3:15 pm Overview of NAS Project
Michele Walsh, MD
3:35 pm Understanding of Addiction as a Chronic Illness
Krisanna Deppen, MD
4:10 pm Learning Network Activities & Process
• Benefits of a Collaborative
• Forming a team
• Action Period Calls & Learning Session
• Systems Inventory & Baseline Data
Sandy Fuller, M.Ed.
Susan Ford, RN
4:20 pm Next Steps/Q & A Susan Ford, RN
Agenda
Objectives for today’s call:
• Review progress of OPQC to date
• Describe Addiction as a Chronic Illness
• Provide an overview of the NAS initiative
• Describe the Learning Network Activities for
the NAS Collaborative
Roll Call:
Please sign in with your hospital
affiliation and the names of your team
members on the call
Participating Neonatal Teams
• Adena Health System
• Atrium Medical Center
• Blanchard Valley Hospital
• Elyria Memorial Healthcare
• Fort Hamilton Hospital
• Genesis Healthcare
• Good Samaritan - Dayton
• Kettering Medical Center
• Licking Memorial
• Lima Memorial
• Marion General Hospital
• MedCentral Health System
• Mercy Health West
• Mercy Hospital Fairfield
• Mercy Medical Center - Canton
• Mercy Regional Medical - Lorain
• ProMedica Bay Park
• Soin Medical Center
• Southern Ohio Medical Center
• Southview Medical Center
• Springfield Regional Medical Center
• St Rita’s Medical Center
• The Christ Hospital
• TriPoint Medical Center
• Trumbull Memorial Hospital
• Upper Valley Medical Center
Welcome from OPQC
Michele Walsh, MD,
Neonatal Clinical Lead
Carole Lannon, MD,
Quality Improvement Lead
Moira Crowley, MD,
Neonatal Faculty
Heather Kaplan, MD,
Neonatal & QI Faculty
Rick McClead, MD,
Neonatal Faculty
Scott Wexelblatt, MD,
Neonatal Faculty
Leslie Clarke, RN, MS, MBA
Nurse Liaison
Susan Ford RN, BSN
BEACON QI Coordinator
Sandra Fuller, MEd.,
Director, State QI Manager
Raj Narang, MBA
Senior Project Specialist
Kate Haralson, MPH,
Project Specialist
Stephanie Buckler,
Project Coordinator
What is OPQC?
The Ohio Perinatal Quality Collaborative
• Statewide perinatal improvement collaborative
• 2007: Conceived by OPQC - ODH and ODJFS
– All agreed Neonatologists AND Obstetricians needed
to be involved
• 2008: Startup Grant $$ from US DHHS CMS
– now with state and federal funding
• 2008: Initial projects chosen by the sites
– 24 level III NICUs NICU acquired infection (BSI)
– 20 large OB hospitals Scheduled birth < 39 weeks
Goal:
Through collaborative use of improvement science methods, reduce preterm births and improve outcomes
of preterm newborns in Ohio as quickly as possible.
Reducing prematurity-related poor
outcomes for babies in Ohio:
What is the goal for OPQC?
10
The number of very premature infants born in Ohio fills
27 school buses every year.
Ohio Perinatal Quality Collaborative Criteria for Choosing Projects
39 Weeks
Antenatal Steroids
Blood Stream Infection
Breast Milk = Medicine • MgSO4 Neuro Rx
• LBW Hypothermia
• Late Preterm 34-36
Opioid Dependence
Progesterone
Prematurity related
Variation in practice
Existing benchmark
Measurable outcome
Population impact
Prior success
Participant enthusiasm
Public enthusiasm March of Dimes
Ohio ACOG & AAP
CDC
The Ohio Perinatal Quality Collaborative
Obstetrics
Neonatal
39-Week Scheduled Deliveries without medical
indication
Steroids for women at risk for
preterm birth
(240/7 - 33 6/7)
Done Transition to BC Surveillance
Increase Birth Data Accuracy & Online modules
Spread to all maternity
hospitals in Ohio
2014: Progesterone to Reduce Preterm
Birth Risk
Blood Stream Infections:
High reliability of line
maintenance bundle
Use of human milk
in infants 22-29 weeks
GA
2014:
Neonatal Abstinence Syndrome
OCHA NAS in 6 CH’s
Together We Saved Enough Babies to Fill TWO School Buses!
The OPQC Neo BSI Project •Prevented 600 Infections •Saved 75 Babies’ Lives
Overview of NAS
• Why are we doing an NAS initiative
• What do we aim to accomplish
• Highlights of success from the Ohio
Children’s Hospital Association (OCHA) pilot
Region Jan
12
Jun
12
Jan
13
Akron
Athens
Cincinnati
Cleveland
Columbus
Dayton
Toledo
Youngstown
The Heroin Epidemic:
Death toll from drug continues to soar in Cuyahoga County
Sept 13, 2013
•Surpassed deaths due to MVA and
homicide.
Ohio Substance Abuse Monitoring
Network, June 2013
National Problem
• 1 death every 3
minutes
• 1 NAS baby born
every 5 minutes
Date of download: 11/6/2012 Copyright © 2012 American Medical
Association. All rights reserved.
From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009
JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951
Date of download: 11/6/2012 Copyright © 2012 American Medical
Association. All rights reserved.
From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States,
2000-2009
JAMA. 2012;307(18):1934-1940.
OPQC NAS AIM Statement
• 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
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
• Longitudinal cohort of term infants with narcotic abstinence syndrome.
• Admitted to 6 Ohio Children’s Hospitals and affiliates Jan 2012- June 2013.
• Determine the “potentially better practice” for narcotic abstinence treatment.
• Identify variation and areas for future research.
Overview of OCHA NAS Project
Mean Range
Maternal Age, y 27 y 17-44
Maternal Race
White, Non-Hispanic (%)
92%
Single 84%
Insurance,
Public
None
80%
10%
2
2
Descriptors: 660 neonates (2012- 2013)
N= 660
Prenatal Care 89%
Pregnancy Complications 85%
Sexually Transmitted Disease 7%
HIV 0
Hep C 26%
Hep B 1%
2
3
Perinatal Descriptors
Poly Exposures (Data from 80 umbilical cord samples)
82% Exposed to tobacco
• Average cotinine level by cord analysis 135 ng
• Maximum = 270
• Average US Adult Smoker= 100 ng
10% Exposed to SSRI or Benzodiazepine
• Known withdrawal syndromes
2
5
Multiple Simultaneous Withdrawals
Characteristic Mean
Birthweight (kg) 2.97 (Ohio mean = 3.3kg)
Gestational Age (wk) 38.2
Male (%) 52%
2
6
Infant Characteristics
Infant Treatment
Characteristic Symptoms Started (hours; Mean) 46
Treatment Length (days; Mean) 18.5
Hospital Stay (days; Mean) 22.2
Number of Drugs Used (Mean) 1.5
Drugs used Morphine Methadone
50% 49%
0
2
4
6
8
10
12
A B C D E F
Center
Tota
l Op
iate
Do
se (
mg/
kg)
Total Opiate Exposure by Site
Non-Pharmacologic Swaddle, Comfort, MBM or Consider low lactose 22 Calorie
Initiate NAS score > 8 q3h two times
> 12 one time
Drug: Morphine/ Methadone
0.05 mg/kg PO
Escalate If ≥ 12, increase dose
Stabilize No increase for 48 hrs
Wean 10% of max dose daily
Discharge 48 hours off drug 2
9
Ohio Potentially Better Protocol
3
0
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
• Trauma Informed Care
• Use Staff Training Tool:
– Nurture the Mother Nurture the Child
– DVD and Facilitators Guide
– OPQC has purchased for all teams
• Video Tape of Dr. Ron Abrahams talk
will be archived on OPQC website and
content can be uploaded to center online
learning systems.
Improve Non Judgmental Support
Improve Consistency in
Modified Finnegan Scoring • All sites use same tool
• Train RN staff to 90% reliability
in scoring using D’Apolito
Training System
• In Pilot work, we were able to see drop in
max score when training completed
• OPQC will provide to teams via site license
Non Pharmacologic Bundle • Vermont Oxford Network staff training tools (VON Virtual Visit
DVD and Workbook) to improve our non-pharmacologic care
• Consider site of care? Is NICU needed? Might couplet care with Mom be better?
• Soothing techniques
• Prenatal counseling of Mothers on what to expect, and how they can sooth their baby.
• Feedings: Mom’s milk on demand** ? Low Lactose ? Higher calorie in first days?
Pharmacologic Bundle • Currently no convincing evidence of superiority
of morphine or methadone.
• Each site agree on primary drug.
• Standardize: Initiation,
Escalation,
Stabilization,
Weaning
• What is second line drug and criteria for starting
• Discharge 48 hours off drug.
• May need to adapt to local context.
• May turn out to be better drug
• Reports of long QT syndrome
• If choose this drug, recommend babies be on CR monitor.
Methadone
Discharge • Discharge 48 hours when off medicine.
• Enhance awareness of community resources
to support Mom and Baby in recovery and parenting.
• Assessment of home safety.
• Strengths based approach.
• Does DHS need to be involved? Must one refer?
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.
Understanding Addiction as a
Chronic Illness
Krisanna Deppen, MD
Family Medicine, Addiction Medicine
Grant Medical Center-OhioHealth
KRISANNA DEPPEN, MD
FAMILY MEDICINE, ADDICTION MEDICINE
GRANT MEDICAL CENTER-OHIOHEALTH
COLUMBUS, OH
“IF THESE MOMS REALLY CARED
ABOUT THEIR BABIES, THEY
WOULD JUST QUIT”
• Those who can quit, often do
• Addiction has multiple effects on the brain
• Addiction is similar to other chronic
medical illnesses
~SAMHSA NATIONAL SURVEY ON DRUG USE AND
HEALTH, OFFICE OF APPLIED STUDIES, 2002 AND
2003
• Addiction
• A primary chronic, neurobiologic disease, with
genetic, psychosocial, and environmental factors
influencing its development and manifestations
• Neurobiology of addiction
• Role of dopamine
• The neurobiology of addiction
encompasses more than the neurochemistry of
reward
• Frontal cortex-altered impulse control, altered
judgment, and the dysfunctional pursuit of rewards
(Volkow, 2007)
44
“METHADONE (OR
BUPRENORPHINE) IS JUST
ANOTHER ADDICTION”
• Dependence is different than addiction
• Legal, safe, monitored dose
• Studies on improved outcomes on methadone
DEPENDENCE IS DIFFERENT THAN
ADDICTION
• Physical dependence
• Tolerance and withdrawal can develop with
appropriate use of prescription medications (pain or
addiction treatment)
• Addiction
• Characterized by behaviors that include one or more
of the following: impaired control over drug use,
continued use despite harm, and craving (“3 C’s”)
BUPRENORPHINE
• Trade names Suboxone (buprenorphine/naloxone), Zubsolv (buprenorphine/naloxone), Subutex (buprenorphine only)
• Partial opioid agonist/antagonist
• Risk of precipitating withdrawal (Must wait until patient is in mild to moderate opioid withdrawal prior to giving this medication the first time)
• Can be prescribed in office with special license (8 hour CME)
47
METHADONE
• Full opioid agonist
• Long half-life
• Must be prescribed for addiction treatment from a methadone clinic (opioid treatment program)
48
OPIOID MAINTENANCE THERAPY
(SPECIFICALLY METHADONE)
• Began in 1967 by Dole and Nyswander
• Improved outcomes
• Decreased mortality, reduced illicit drug use, reduced
seroconversion of HIV, decreased criminal activity,
increased socially productive activities (Martin 2009)
• Only 10-20% of patients who discontinue maintenance
therapy are able to remain abstinent (Nosyk 2012)
• PET scans suggest that methadone maintenance at least
partly normalizes cerebral glucose metabolism, as
compared with patients withdrawn from methadone and
in sustained remission (Galynker 2000)
“MAINTENANCE THERAPY
IS HELPFUL FOR MOM, BUT
THIS CAN’T BE GOOD FOR
THE BABY.”
• Improved maternal outcomes
• Improved obstetrical outcomes
• Improved neonatal outcomes
Maternal improvements • Decreased risk of relapse
• Improved prenatal care
• Higher likelihood of abstinence from
concomitant drug use
• Untreated heroin use in pregnancy
linked to growth restriction, placental
abruption, fetal demise, preterm labor (ACOG, 2012. Minnes, 2011)
Fetal improvements • Higher birth weights
• Higher gestational age (Peles, 2012)
“THESE MOMS ARE SO
MUCH WORK, THIS ISN’T
WORTH IT.”
• Improving care of these families is valuable to
infant care and development
• Improving care is valuable to the substance
using family
• Improving care may be valuable to your staff
• Improving care could be valuable to you
Benefits of Improved Care for Infants
and Families
Infants • After delivery, long-term outcomes
improved with safe, sober
environment to grow up in
• Facilitated by early bonding
Mother/families • Recovery from addiction is life-
changing
• Recovery occurs at similar rates to
treatment of many other chronic,
medical diseases
•Delivery of infant affected by drug use
could be a teachable moment
IMPORTANCE TO MEDICAL PROVIDERS
• Providing substance-using families a different experience
of the health care system may help facilitate better
bonding and care for infants
• Creating an environment where moms are welcome, can
create a better environment for us to work in
• Understanding addiction and learning skills to
communicate effectively with these families could lessen
caregiver burnout/stress
IMPROVING COMMUNICATION SKILLS:
INTRO TO MOTIVATIONAL INTERVIEWING
• “Motivational interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” (Miller & Rollnick, 2009)
• Five components of motivational interviewing
• Express empathy
• Develop discrepancy
• Support self-efficacy
• Roll with resistance
• Eliciting change talk and commitment language
CONCLUSION
• Addiction is a chronic and treatable disease
• Opioid maintenance therapy with methadone or
buprenorphine may play an important role in treatment of
pregnant women struggling with addiction
• Opioid maintenance therapy improves outcomes for both
pregnant women and their infants
• Providing non-judgmental, compassionate care can be
rewarding and beneficial for the patients and the
providers
Questions for Dr. Deppen Please click on the raised hand icon on the right of your screen to
ask a question OR type it into the chat box.
Learning Network Activities
• Benefits of a Collaborative
• Forming a team
• Systems Inventory & Baseline Data
• Action Period Calls & Learning Session
Learning Network Activities
• 3 prework webinars – April, May and June
to prepare you for participation
• Face to Face Learning Sessions – the first
one is June 26th
• Testing changes in your setting
• Monthly Action Period calls
• Data submission
• Monthly narrative reports
Action Period Calls and
Learning Session:
• Kick Off Call – April 8, 2014
• Prework Call #2 – May 13, 2014
• Prework Call #3 – June 3, 2014
• Learning Session - June 26, 2014
Columbus
Benefits of a Collaborative
• Learning from your colleagues and Level
III hospitals that started NAS work in
January
• Access to experts in the field of addiction
medicine
• Learning a Quality Improvement
Methodology that you can apply to other
projects
• All Teach, All Learn!
Team Sharing and Learning
Harvard School of Education http://socrativegarden.wordpress.com/2011/08/04/1-2-3-word-cloud/
Forming Your Team
Role Responsibility
Key Contact
Team Leader.: Primary contact or first point of contact for your team if questions arise for
which contacting the entire team would be unnecessary. Key Contact will receive and
complete survey information and will relay certain critical messages back to your team.
Lead
Neonatologist
Physician Leader or Champion: Responsible for endorsing best clinical practices and
supporting the work and mission of OPQC within their unit.
*Necessary to identify for MOC requirements.
Key Data
Contact
Submits monthly data. Primary contact or first point of contact for data questions and
clarifications when data is being collected and submitted to OPQC.
Neonatal
Nurse
A NICU nurse who is part of the care team and can work to be an advocate for the NAS
Project within their site.
QI or Admin
Manager
IF NEEDED: Management level administrator/QI Department. Responsible for supporting
activities of the project and problem solving operational barriers.
NICU Social
Worker
This team member serves as a key leader in establishing a child safety plan and brings
knowledge of available community resources to support the family in recovery.
Maternal
Addiction MD This Specialist would be an ideal addition to the NAS Project Team, IF available to the NICU.
Systems Inventory for NAS Project
Clinic Systems Inventory Tool
NICU Name: ____________________________________
Date of Inventory (mm/dd/yyyy): __ __ / __ __ / 2 0 __ __
Instructions: The purpose of this tool is to 1) help the OPQC Central Project Team
understand what processes teams currently have in place to provide a standardized
treatment protocol for infants with Neonatal Abstinence Syndrome and 2) help your
team assess the systems in place that support recognition and non-judgmental support
for narcotic-addicted women and infants. We understand that there is likely to be
variation in the use and/or implementation of these processes among participating
teams.
It is recommended that the entire project team complete this tool together.
Thank you for taking time to complete this. Your responses will be confidential.
Systems Inventory for NAS Project
Systems Inventory for NAS Project
Systems Inventory for NAS Project
Systems Inventory for NAS Project
Baseline Data
Baseline Data Collection:
• Between January and December 2013, for early term and full
term infants >37 weeks, what is the average length of stay for
NAS patients at your center as measured by ICD-9 code 779.5?
______days
• Or, if that data is not easily obtainable, what is the average
length of stay for the last 10 infants at your center diagnosed with
maternal NAS AND treated pharmacologically? ______days
OCHA Protocol Your NICU’s Protocol
Scoring Tool Modified Finnegan
1.
Have the nurses been trained in the
reliable use of the scoring system?
2.
Drug Morphine or Methadone 3.
Trigger Score >8 x 2 scores
Score >12 x 1 score
4.
Initiating
Dose/Drug
5.
Escalating
Dose/Drug
6.
Hold Hold for 48 hours 7.
Wean Wean by 10% every 24 hours 8.
Discharge D/C 48 hours off treatment 9.
Unit Protocol Comparison Table
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.
Save the Date!
The OPQC Summer 2014
Learning Session will be on
Thursday, June 26th in Columbus.
Please mark your calendars!
Next Steps
• Complete and submit Systems Inventory and
Baseline Data as a team by 4/30; (hyperlink and
paperwork will be sent to the team Key Contact)
• Next Action Period Call: May 13, 2014
• Follow us on Twitter: @OhioPQC
• Send us your preferred shipping/mailing
address for both the D’Apolito Scoring Tool
and VON “Nurture the Mother – Nurture the
Child” Virtual Visit DVD’s: opqc@cchmc.org
Resources • OPQC web site: https://opqc.net
• OPQC email: opqc@cchmc.org
• Twitter account: @OhioPQC
• Susan Ford, RN
• BEACON Quality Improvement Coordinator
– susan.ford@UHhospitals.org
• Kate Haralson, MPH
• Project Specialist
– opqc@cchmc.org
The OPQC NAS Project is
funded by The Ohio
Department of Medicaid
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