1. Neonatal abstinence syndrome management: A quality improvement initiative to educate caregivers, & providers in the outpatient setting
Nguyen J, MD*. Chau K, DO*. Lilly C, MD. Ashmeade TL, MD. Balakrishnan M, MD.
University of South Florida at Tampa General Hospital, Tampa, FL.
BACKGROUND
METHODS
The U.S. incidence of antenatal drug use & Neonatal Abstinence Syndrome (NAS) has increased with >50% of opioid exposed infants developing NAS.
NAS is associated w/prolonged hospital length of stay & increased health care costs.
Outpatient medical management for NAS may decrease health care costs.
Little is known related to:
Parents response to coordinated inpatient & outpatient interventions for NAS
Outpatient healthcare provider level of knowledge & comfort w/NAS management
INTERVENTIONS
Cycle 1:
6/11/13 to 9/19/13
Developed JNFP comprehensive discharge planning
Developed & implemented tools for providers: NAS outpatient management guideline, methadone dose adjustment algorithm, EMR note template
Developed & implemented tools for parents: erasable magnetic tablet for care plan, NAS symptom diary
Standardized methadone concentration & prescription instructions for providers
Developed provider education curriculum (USF Pediatric attendings, residents, nurse practitioners)
Cycle 2:
9/20/13 to 12/11/13
Revised NAS guideline: scheduled minimum 4 follow-up appointments, increased % of weans, encouraged wean at first outpatient appointment
Revised NAS EMR template to improve efficiency
Developed clinic NAS poster for healthcare providers: prompting survey distribution, providing management tips, pharmacy contact information
Placed reminder sticker on NAS symptom diary to bring diary to each appointment
Confirmed 3 local pharmacies consistently stocked prescribed methadone concentration
Cycle 3:
12/12/13 to 4/30/14
TGH’s occupational therapy handouts available in outpatient clinics (e.g. positioning techniques, swaddling instructions, range of motion exercises).
Included consideration of outpatient counseling by mother when deciding social work’s clearance of infant for outpatient methadone management
NAS Outpatient Weaning Algorithm
OBJECTIVES
Use a multi-disciplinary approach in NAS management to improve consistency of care
RESULTS
Primary
Describe our center’s comprehensive outpatient NAS management program
Assess the program’s safety
(defined as <10% requiring hospital readmission)
Achieve healthcare provider compliance w/the program:
1. >75% compliance w/outpatient management
guideline
2. >75% of healthcare providers using EMR
note template
Secondary
Describe duration & cumulative dose of outpatient methadone exposure
>75% of healthcare providers & parents having improved knowledge & attitudes towards NAS
After implementation*
100% of parents responded being comfortable:
1.Caring for & soothing their NAS infant
2. Administering methadone to their infant
3.Understanding the diagnosis of NAS prior to delivery
4. Comfort level in identifying NAS signs & symptoms
5. Finding medical team helpful in providing anticipatory guidance
There was no significant difference in helpfulness of NAS educational materials.
*Parent survey response rates: #1 at pre-implementation: 100% (n=5), #2 at 1st appointment: 73% (n=22), #3 at appointment when methadone discontinued: 40% (n=20)
Input measure
Parent compliance in bringing NAS symptom diary to pediatric appointments
Process
measure
Healthcare provider compliance w/NAS outpatient management guidelines & EMR template
Outcome measure
Duration of outpatient methadone treatment
Cumulative dose methadone exposure
Balancing
Appropriate weight gain (>20 g/day)
Hospital readmissions for NAS management
Total # surveys distributed: 67
Description of input & process measures.
Cycle 1a
(N=97)
Cycle 2a
(N=124)
Cycle 3a
(N=82)
All cyclesa
(N=303)
Outpatient methadone algorithm compliance, n (%)
65(67)
90(73)
58(71)
213(70)
EMR template used, n (%)
76(78)
96(77)
60(73)
232(77)
Infant weight assessment documented in EMR, n (%)
83(86)
109(88)
65(79)
257(87)
NAS symptoms documented in EMR, n (%)
91(94)
120(97)
81(99)
292(96)
Current dose documented in EMR, n (%)
89(92)
112(90)
74(90)
263(87)
NAS symptom diary brought to pediatric clinic appointment, n (%)
43(44)
62(50)
52(63)
157(52)
N: number of appointments in each cycle. aDate of NICU discharge determines which cycle infants are included.
SETTING
TGH is an academic medical center with
~ 5,500 deliveries/year
~70 NICU admits/year for NAS diagnosis
~20 infants/year d/c w/outpatient management
USF/TGH Joint Neonatal Follow-up Program (JNFP) uses methadone for outpatient NAS management
USF/TGH’s NICU NAS infants may be discharged for outpatient management if:
1. Controlled NAS symptoms on methadone
≤0.16 mg/kg/day once daily
2. Cleared by TGH social work
Inclusion criteria: NAS infants discharged from USF/TGH NICU for outpatient methadone management w/USF Pediatric follow-up.
DISCUSSION
A multidisciplinary approach to outpatient NAS management can:
Be safe when a comprehensive management program is implemented
Result in appropriate infant weight gain
Demonstrate healthcare provider compliance w/an outpatient management guideline & EMR template
Improve parent & provider knowledge & attitudes regarding care of a NAS infant
More research is needed to determine the long term effects of cumulative methadone dose exposure & duration of exposure on infant outcomes.
Description of outcome & balancing measures.
Cycle 1a
(N=4)
Cycle 2a
(N=10)
Cycle 3a
(N=6)
All cyclesa
(N=20)
Number of pediatric clinic appointments for NAS, average (range)
8 (4-13)
9 (5-20)
11 (7-13)
10 (4-20)
Total duration of methadone from NICU discharge to time methadone discontinued in cycle, days±SD (range)
58.8±15.2 (40-80)
61.8±27.5 (32-132)
69.7±12.6
(46-86)
63.6±22.1 (32-132)
Average NICU discharge dose of methadone, mg±SD
0.35±0.08
0.39±0.13
0.45±0.08
0.4 ± 0.11
Average dose at methadone discontinuation, mg±SD
0.13±0.04
0.11±0.02
0.11±0.01
0.11±0.03
Average outpatient cumulative methadone dose from NICU discharge to time methadone discontinued in cycle, mg±SD
13.6±5.8
15.6 ± 9.8
16.8±4
15.6±7.8
Weight (g) at first pediatric clinic appointment, average (range)
3370±261
3240±536
3300±458
Average weight gain (g/day) on outpatient methadone management, mg±SD
26±9.4
29.4±9.4
31.8±3.9
29.4±8.4
Hospital readmissions for NAS management 2
N: Number of infants in each cycle. Infants who required hospital readmission & were completely weaned off of methadone during hospital admission or did not wean off of methadone before the end date of cycle 3 were excluded from this data analysis (2 infants). aDate of methadone discontinuation determines which cycle infants are included.
CONTACT: Division of Neonatology, 1 Tampa General Circle, F170, Tampa, FL 33611