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