ABSTRACTEarly detection of prenatal substance abuse is paramount to providing the best care possible to newborns at risk for developing Neonatal Abstinence Syndrome (NAS), and improving the related care processes(8). Symptoms of NAS can vary in severity and commonly will not present until around the time that a well-newborn would discharge home from the hospital(8). For this reason early detection is vital. The focus of this master’s project is to collaborate with care providers and develop a risk-based screening tool that will be completed by labor and delivery nurses for each of their patients upon admission. The screening tool may assist nurses in identifying patients who have risks factors that correspond with prenatal substance abuse in a significant statistical manner. In the event that a patient has a positive risk-based screen, a drug toxicology test may be ordered to improve early detection. The thorough and prompt detection of these newborns could facilitate early and non-punitive social service interventions, along with appropriate treatment and observation.

PICO QUESTIONFor mothers in the labor and delivery setting, how does a risks assessment screening tool upon admission and drug toxicology testing if

indicated by the screening tool compared to the standard of care (no screening tool) affect timely treatment rates for neonatal abstinence

syndrome?

LITERATURE REVIEWA literature review was completed to explore maternal self-reporting of prenatal drug abuse, risk factors associated with prenatal drug abuse,

and a available drug toxicology testing methods.

• 225,000 infants are exposed to illicit substances prenatally each year(7).

• Incidence of NAS increased 300% from 2000-2009 (1).

• Testing of biomarkers identifies drug use at

more than four times a self-report(2,4,6).

• (late or insufficient prenatal care, admission from a justice center, placental abruption, and

gynecological infection all are statistically significant to prenatal drug abuse(10,11,13).

• umbilical tissue and meconium samples both

provide accurate detection of drug use from 20 weeks gestation(5,6,13).

Development of a Prenatal Substance Abuse Risk-Based Screening Tool to Enhance Interdisciplinary

Care of the At-Risk Neonate at Davis Hospital

Shelbie Richards, MSN, RN

Plan and Implementation:

• Once the tool is developed and resides in the EHR, nursing education will ensue to train the nurses of the new tool, an implementation date, and evaluation plan. A power point will be developed and presented at staff meetings, upon approval of the unit manager.

• A protocol to accompany the screening tool will allow nurses to order drug testing in the event of a positive risk-based screen. Pediatricians will be included in the implementation of the protocol.

• When a drug test is sent, social work will be electronically notified to follow up with the parents to set up and offer resources.

Evaluation

Reports will be generated first weekly and then monthly to determine:

• If the screening tool is being completed on all laboring mothers. The goal will be 100% compliance. When a screening tool is not filled out, the clinical coordinator will follow up to find out why and reeducate as necessary.

• If a drug test was sent for all positive risk-based screens.

• To compare detection rates of prenatal substance abuse before and after implementation of the screening tool.

• To determine how many positive risk-based screen resulted in a positive drug toxicology test to determine accuracy of the screening tool.

THEORETICAL FRAMEWORKOrem’s self-care deficit theory includes three basic assumptions:

• Individuals should be self-reliant and responsible for their care as well as others in their family who need care.

• People are distinct individuals.

• Nursing is a form of action and is an interaction between two or more people.

successfully meeting universal and development self-care requisites is an important component of primary care, prevention, and ill health(9).

CONCLUSIONSThe nationwide increase in drug and opiate abuse has increased the incidence of NAS(1). It is imperative that early detection of prenatal

substance abuse be improved; not only for the appropriate observation for and treatment of NAS in accordance to AAP guidelines, but so that

appropriate social service interventions may be set up prior to hospital discharge. . This is important since 60-80% of newborns diagnosed

with NAS will require pharmacologic treatment(8),

and since parents who abuse drugs are more likely to have associated parental

psychopathology, depression, antisocial personality, and family violence(3,12).).

REFERENCES1. Centers for Diesease Control, Prevention. Vital signs: Prescription painkiller overdoses: A

growing problem, especially among women. http://www.cdc.gov/vitalsigns/pdf/2013-07-vitalsigns.pdf MMWR 2013. Accessed September 27, 2013

2. Eichel, M.M., & Johannemann, T.R. (2014). Implementation of universal maternal drug screening to identify neonatal abstinence syndrome candidates. Newborn and Infant Nursing Reviews, 14(1), 17-22. doi: 10.1053/j.nainr.2013.12.004

3. Fraser, J.A., Barnes, M., Biggs, H.C., & Kain, V.J., (2007). Caring, chaos and the vulnerable family: Experiences in caring for newborns of drug-dependent parents. International Journal of Nursing Studies, 44(8), 1363-1370. doi: 10.1016/j.ijnurstu.2006.06.004.

4. Grekin, E.R., Svikis, D.S., Lam, P., Connors, V., LeBreton, J.M., Steiner, D.L., Ondersma, S.J. (2010). Drug use during pregnancy: Validating the drug abuse screening test against physiological measures. Psychology of Addictive Behaviors, 24(4), 719-723. Doi 10.1037/a0021741.

5. Labardee, R. M., Swartzwelder, J.R., Gebhardt, K. E., Pardi, J.A., Dawsey, A. C., Dixon, R., & Cotton, S.W. (2017). Method performance and clinical workflow outcomes associated with meconium and umbilical cord toxicology testing. Clinical Biochemistry, 50 (18), 1093-1097. doi: 10.1016/j.clinbiochem.2017.09.016.

6. Lange, S., Shield, K., Koren, G., Rehm, J., & Popova, S. (2014). A comparison of the prevalence of prenatal alcohol exposure obtained via maternal self-reports versus meconium testing: A systematic literature review and meta-analysis. BMC Pregnancy and Childbirth, 14(1), 127-138. Doi 10.1186/1471-2393-14-127.

7. MacMullen, N.J., Dulski, L. A., & Blobaum, P. (2014). Evidence-based interventions for neonatal abstinence syndrome. Pediatric Nursing, 40(4), 165-172.

8. McQueen, K., & Murphy-Oikonen, J. (2016). Neonatal abstinence syndrome. The New England Jounal of Medicine, 375(25), 2468-2479. doi: 10.1056/NEJMra1600879

9. Petiprin, A. (2016). Nursing theory. Dorthea E. Orem-nursing theorist. Retrieved November 2, 2018 from: www.nursing-theory.org/nursing-theorists/Dorthea-E-Orem.php

10.Schempf, A. H. (2009). Drug use and limited prenatal care: An examination of responsible barriers. Journal of Obstetrics and Gynecology, 200(4), 412e1- 412e10. doi:10.101016/j.ajog.2008.10.055

11.Wexelblatt, S.L., Ward, L.P., Torok, K., Tisdale, E., Meinzenderr, J.K., Greenberge, J.M. (2015). Universal maternal drug testing in a high-prevalence region of prescription opiate abuse. The Journal of Pediatrics, 166(3), 582-586. Doi 10.1016/j.jpeds.2014.10.004

12.Witt, C.E., Rudd, K. E., Bhatraju, P., Rivara, F.P., Hawes, S.E., & Weiss, N.S. (2017). Neonatal abstinence syndrome and early childhood morbidity and mortality in washington state: A retrospective cohort study. Journal of Perinatology, 37(10), 1124-1129. doi: 10.1038/jp.2017.106

13.Wood, K. E., Sinclair, L.L., Rysgaard, C.D., Strathmann, F.G., McMillin, G.A., & Krasowski, M.D. (2014). Retrospective analysis of the diagnostic yield of newborn drug testing. BMC Pregnancy

and Childbirth, 14(1), 250-259 doi 10.1186/1471-2393-14-250Image in upper right from stockfreeimages.com(2018)

PROJECT METHODOLOGYA screening tool located in the patient’s electronic health record will be completed by labor and delivery nurses during the admission process. The screening tool will list known risk factors that significantly correspond with prenatal substance abuse. If one or more risk factors are present, the labor nurse will be prompted by the charting system to send an umbilical cord tissue segment for drug toxicology testing immediately following delivery. If completed, the intervention will be documented in the delivery summary and it will populate on the newborn’s EHR so that the nursery nurse and pediatrician will see that a drug screen was obtained. If a drug toxicology screen and or a risk based screen is positive, the hospital’s social work team will consult with the newborn’s parents and the rest of the healthcare team caring for the newborn.