Neonatal Abstinence

Syndrome Project

Action Period Call

Ohio Perinatal Quality Collaborative

May 20, 2014

Welcome!

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HOLD!

If you need to step away:

– Use the MUTE button on your phone or

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Time Topic Presenter

3:00 pm Welcome, Agenda Review, roll call Susan Ford

3:10 pm Key Driver Diagram Overview Susan Ford

3:15 pm Review of Pharmacological Bundle

Michele Walsh, MD

3:30 pm Team Sharing & Discussion All Teams

3:40 pm Learning Session Preparation Susan Ford

3:50 pm Next Steps

• Data Update – NAS & VON

• Monthly Progress Report

• Attitude Measurement Survey

Michele Walsh, MD

Susan Ford

Agenda

Roll Call: Please sign in with your hospital affiliation and the

names of your team members on the call in the

Question box

Participating Neonatal Teams

• Akron Children’s Hospital

• Akron Children’s Mahoning Valley

• Akron Children's – St Elizabeth

• Akron Children’s Summa

• Aultman Hospital

• Bethesda North Hospital

• Cincinnati Children’s Hospital

• Cleveland Clinic

• Dayton Children’s Hospital

• Fairview Hospital

• Good Samaritan Hospital

• Hillcrest Hospital

• Mercy Anderson Hospital

• Mercy St. Vincent Medical Center

• MetroHealth Medical Center

• Miami Valley Hospital

• Mount Carmel East Hospital

• Mount Carmel West Hospital

• Nationwide Children’s

• NTW-Doctor’s Hospital

• NTW-Dublin Methodist

• NTW-Grant

• NTW-Mount Carmel St. Ann's

• NTW-Riverside

• Promedica Toledo Children’s

• The Ohio State University Medical

Center - Wexner

• University Hospital - Cincinnati

• UHCMC– Rainbow Babies

and Children’s Hospital

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

How will we accomplish our AIM?

• Develop and implement a standardized process for the

identification, evaluation, treatment and discharge

management of an infant with neonatal abstinence syndrome.

– Standardization of Scoring Tool; improve consistency in use of

Modified Finnegan Tool with D’Apolito video

– Standardization of protocol bundles

– Small tests of change (PDSA’s) towards implementing

standardized protocol into Ohio hospitals

• Create a culture of compassion, understanding, and healing

for the mother infant dyad affected by the problem of neonatal

abstinence syndrome.

– Nurture the Mother-Nurture the Child video

Key Driver:

Intervention:

Pharmacological Bundle

Standardize NAS Treatment Protocol

• Initiate Rx If NAS score > 8 twice. •Stabilization/ Escalation Phase •Wean when stable for 48 hrs by 10% daily.

Source: https://neoadvances.org

Source: http:pyschiatricnews.org

Pharmacologic Treatment Treatment is divided into the following phases:

Initiation, Escalation, Stabilization, Wean

Morphine

• Treatment should be initiated if

an infant has 2 consecutive

scores > 8 OR 1 score > 12.

• Initiation Phase- most infants

can be treated with oral

medication. (**IV morphine and

enteral morphine doses are not

equivalent)

Methadone

• Treatment should be initiated if

an infant has 2 consecutive

scores > 8 OR 1 score > 12

• Initiation Phase- all treatments

are with oral medication

Methadone

PO 0.05mg/kg/dose q6h

Morphine**

PO 0.05mg/kg/dose q3h

IV 0.02 mg/kg/dose q3h

0

5

10

15

20

25

30

35

40

45

50

N=102 N=183 N=187 N=29 N=32 N=14 N=547

A B C D E F Total

Opiate Treatment days

Day of Life of Discharge

Opiate Treatment and Length of Stay

0

5

10

15

20

25

Day of life discharged Days total opiate treatment

Morphine only

Methadone only

Morphine n= 276

Methadone n= 224

Morphine vs Methadone

Treatment is divided into the following phases:

Initiation, Escalation, Stabilization, Wean

Morphine

• Escalation Phase:

• Increase dose every 3 hours until

controlled

• Rescue Dose: If infant has 1 score

of > 12, double the previous dose

given (enteral or IV) x 1 and then

adjust accordingly:

Methadone

• Escalation Phase:

• Increase dose if NAS still > 8 after

3 doses of methadone

• If 3 doses later NAS still > 8

increase to 0.15 mg/kg/dose q6h

Morphine

PO 0.03mg/kg/dose q3h

IV 0.01 mg/kg/dose q3h

Methadone

PO 0.1mg/kg/dose q6h

Treatment is divided into the following phases:

Initiation, Escalation, Stabilization, Wean

Second Drug: Phenobarbital

Consider adding Phenobarbital if:

• Polysubstance exposure (benzodiazepines, barbiturates,

antipsychotics, antidepressants, other sedatives/hypnotics,

tobacco) is suspected/confirmed

• AND CNS findings (tremors, increased muscle tone, etc.)

rather than GI findings predominate on NAS sub scale score

• AND Morphine dose exceeds 0.3 mg/kg/dose with score

remaining > 8 OR Methadone dose exceeds 0.2 mg/kg/dose

• OR unable to wean for 2 consecutive days

Pharmacologic Treatment Treatment is divided into the following phases:

Initiation, Escalation, Stabilization, Wean

• Stabilization:

– All scores remain < 8 for minimum 48 hours.

– 72 hours of stabilization may be used if infant has had to

increase above 0.4 mg/kg dose or if phenobarbital

added.

Morphine AND Methadone Stabilization

Pharmacologic Treatment Treatment is divided into the following phases:

Initiation, Escalation, Stabilization, Wean

Morphine AND Methadone Wean

• Weaning Phase: Once stabilized on same dose for 48 hours, use this dose as

the starting point of the wean. Begin weaning the dose by 10% (of the original

dose when the first wean was started) every 24 hours. Drug may be

discontinued when a single dose is < 0.02 mg/kg/dose. See examples of drug

decreases included in the OCHA Protocol.

• *Ad lib infants*: Infants should be allowed to ad lib feed but kept on q6hr drug

schedule

• Discharge:

– Observe in-house x 48 hours off of Morphine before discharge.

– Observe in-house x 72 hours off of Methadone before discharge.

THIS APPEARSTO BE THE MOST IMPORTANT VARIABLE TO DECREASE LOS

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

0

5

10

15

20

25

30

35

N=77 N=476

No Protocol Protocol

Opiate Treatment Days

Day of Life of Discharge

Impact of Weaning Protocol

Strict wean protocol No specified wean

0

1

2

3

4

5

6

7

8

9

No Protocol Protocol

Total Morphine Dose Given (mg/kg)

Total Morphine Dose Given

(mg/kg)

Strict wean protocol No specified wean

0

1

2

3

4

5

6

No Protocol Protocol

Total Methadone Dose Given (mg/kg)

Total Methadone Dose Given (mg/

kg)

No specified wean Strict wean protocol

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.

Team Discussion/Poll

Which piece of the pharmacological bundle

could you test in your hospital?

Drug/Opiate

Trigger Scores

Escalation

Wean

Discharge

Responses to Monthly Progress Report

Have you changed or adopted to some of the

elements of the OCHA NAS Protocol?

50%: Yes, we have changed and adopted all/some

of the elements.

13%: No, we have not, but plan to do so.

34%: No, we have not, and have no plan to do so.

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.

Storyboard Suggestions

Here are suggestions for items you might include on your storyboard:

Name & location of

NICU

Improvement Team:

names, titles, roles.

Include a picture if

possible

Brief description of

NICU (e.g., community

or population

characteristics, services,

relationship to specific

maternity hospital/s)

• 2 PDSA examples

Creating Your Team Storyboard:

Keep it small!!

• 1 PDSA

• 1 Baby

• 1 Day

PDSA Worksheet https://opqc.net/teams/quality-improvement-resources

PDSA

• Plan: Briefly describe your test. How will you know change is an

improvement? What Key Driver does this test impact?

• Do: Test the change. Was the cycle carried out as planned?

Record data and observations.

• Study: Compare your results to your hypothesis. Did your

results match your predictions.

• Act: Decided to adapt, adopt, or abandon? Explain why.

PDSA Plan:

Describe your test. What Key Driver does it impact?

Do: Test the change. Record data and observations.

Study: Compare your results to

your hypothesis. Did your results match your

predictions?

Act: Will you adapt, adopt or

abandon the test? Explain why.

Register for the Learning Session

The OPQC Summer 2014

Learning Session will be on

Thursday, June 26th in Columbus

Registration link is on our

website: https://opqc.net

Learning Session Details

Where:

The Ohio Union (at OSU)

1739 High Street

Columbus, OH 43210

When:

Thursday, June 26, 2014

Registration opens at 7:30 am

Presentations begin at 9:00 am

Hotel Information:

OPQC has secured group

rates at the following

Columbus hotels:

– Springhill Suites

• $124/night

• Discount code: CCH

– Hyatt Place

• $135/night

• Discount code: OPQC

Data Update

• Data Worksheet and Data Dictionary found

on OPQC website in password area of site:

Member Log In-NAS-Data Collection

• Can begin to submit data electronically on May 28th

• Email and tutorial PPT overview will be sent to Data

Contacts and posted on our website

• PLEASE submit data on at least 10 babies by June 16th

so we will be able to review data at the Learning Session

Next Steps

• VON Infection Data (sustain mode) for April

was due 5/5; 76% of teams submitted that data

• Monthly Progress Report

– Will be sent out 5/27; due 6/5

• Have ALL staff (MD, NNP,RN, Social Workers) complete

Attitude Measurement Survey from May 21 – June 10.

*Could have staff review of the VON Virtual Visit DVD prior

to submission

• NO Action Period Call in June in preparation for the Learning

Session in Columbus on the 26th

• Prepare Storyboard Update to share with other teams at the

Learning Session (template hyperlink here)

The OPQC NAS Project is

funded by The Ohio

Department of Medicaid