Project Console: a quality improvement initiative for neonatal abstinence syndrome in a children's hospital level IV neonatal intensive care unit

Independent Impact of Eat, Sleep, Console Assessment on Neonatal Opioid Withdrawal Syndrome

Compared with the Finnegan Neonatal Abstinence Scoring System (FNASS), the Eat, Sleep, Console (ESC) approach reduces pharmacotherapy and length of stay (LOS) for neonatal opioid withdrawal syndrome (NOWS) infants. The independent outcome contribution of ESC is unknown as the approach combines ESC assessment with additional management changes. Our objective was to evaluate ESC assessment's independent impact on outcomes compared with FNASS. We conducted a retrospective cohort study of in utero opioid-exposed infants ≥35 weeks gestation managed with FNASS versus ESC. Outcomes included pharmacotherapy initiation, LOS, length of pharmacotherapy, and emergency department visit/readmissions. Among 151 FNASS and 100 ESC managed infants, pharmacotherapy initiation (P = .47), LOS for all infants (P = .49), and LOS for pharmacologically treated infants (P = .68) were similar. Length of pharmacotherapy did not differ (P = .84). Emergency department evaluation/NOWS readmission was equally rare (P = .65). Using equivalent models of care, comparison of ESC and FNASS assessment tools showed no difference in NOWS outcomes.

Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome: An Ecological View of Non-Pharmacologic Interventions for Feeding Success

The number of infants diagnosed with neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) has increased. The expression of NAS/NOWS symptoms differs and typically begins within the first few days of life, considered a critical period for feeding skill establishment, nourishment, and attachment. Non-pharmacologic interventions may be deployed to reduce or eliminate the need for replacement opioids while targeting outcomes like feeding dysfunction. Critical care providers can benefit from a structured examination of disordered feeding experiences to inform their selection of non-pharmacologic interventions. This structure can be provided using the Ecology of Human Performance model.

Improving Outcomes in Infants With Neonatal Abstinence Syndrome With the Eat, Sleep, Console Method

BACKGROUND

Neonatal abstinence syndrome (NAS) is a significant public health concern. A quality improvement project was executed in a neonatal intensive care unit at a large urban hospital. The aim was to address the prolonged hospitalization of infants and exposure to medications to treat NAS.

PURPOSE

The goal was to determine whether the eat, sleep, console (ESC) method decreases the length of stay (LOS) and morphine usage when compared with the Finnegan Neonatal Abstinence Scoring System (FNASS).

METHODS

The inclusion criteria were 36 weeks' or longer gestation and exposure to opiates in utero. The FNASS method was replaced by the ESC method with a refocus on nonpharmacologic care. Data were collected for 6 months during implementation of the ESC method and compared with the 6 months prior to implementation.

RESULTS

The results of the project include: the average LOS decreased from 25.9 days to 13.7 days, a 47% reduction; the rate of scheduled morphine initiation decreased from 58% to 7%, an 88% reduction; as-needed morphine initiation decreased from 33% to 7%, a 79% reduction; and the rate of adjunctive medication initiation decreased from 17% to 0%, a 100% reduction.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The outcomes of LOS and rate of morphine usage were significantly improved when using the ESC method when compared with the FNASS at this facility. The results support future implications including expanding the ESC program to the well newborn population at this facility and other similar units. Further research needs to be done on long-term neurodevelopmental outcomes.

SSSH: Responsive soothing bassinet feasibility study for infants with congenital heart disease after cardiac surgery

PURPOSE

For infants with congenital heart disease (CHD) requiring surgery, prolonged hospital stays, intermittent caregiver visitation, and constrained unit staffing ratios present barriers to adequately address post-operative stressors and associated need to retain cognitive and physiological reserves. Similar patients requiring high-engagement interventions, such as hospitalized infants with neonatal abstinence syndrome, have found success in utilizing responsive bassinets to soothe infants and save floor nurses' time. However, it remains unclear if such technology can be leveraged in the CHD population given their complex hemodynamics, feeding intolerance, and monitoring requirements.

METHODS

This multidisciplinary feasibility study evaluated responsive bassinet use in a cohort of infants with CHD <6 months of age in a medical-surgical unit at a midwestern children's hospital. Specifically assessing 1) implementation requirements, challenges, and potential of utilizing the device, together with 2) ability to perform bedside monitoring (monitoring) and 3) measuring physiologic trends during use.

RESULTS

Between 11/2020-1/2022, nine infants utilized a responsive bassinet over 599 h (mean 13, range 4-26 days per infant). No increase in monitoring alarms and accurate vital signs monitoring during bassinet activity were noted with appropriate physiologic responses for infants with single ventricle and biventricular surgeries.

CONCLUSIONS

Feasibility of introducing new technology into care, and successful use of its functionality for soothing was found to be plausible for infants with CHD.

PRACTICE IMPLICATIONS

After cardiac surgery, infants with CHD have need for interventions to reduce stress. Use of a soothing bassinet has the potential to aid in doing so without interference with monitoring requirements.

Implementation of the Eat, Sleep, and Console Model of Care: A Quality Improvement Project

A Southeastern, 741-bed acute care, Magnet designated teaching hospital and level III B NICU identified assessment and treatment concerns for Neonatal Opioid Withdrawal Syndrome (NOWS). In March 2020, a quality improvement project led to a multidisciplinary team formation to determine the effectiveness of the Eat, Sleep, Console (ESC) model of care in reducing the length of treatment (LOT) and length of stay (LOS) for neonates experiencing NOWS rather than use of the Finnegan Neonatal Abstinence Syndrome Scoring tool. The results concluded a decrease in the average LOT from 19.2 to 2.5 days and the average LOS from 23.9 to 9.3 days for those admitted directly into the ESC model of care on postpartum vs previous direct admission to the NICU. A group samples t-test showed there was a statistically significant decrease in LOS for ESC patients (p < .001) and LOT for ESC patients (p <001).

Using Quality Improvement to Improve Value and Reduce Waste

Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.

Challenging Cases in Statistical Process Control for Quality Improvement in Neonatal Intensive Care

Effective quality improvement (QI) depends on rigorous analysis of time-series data through methods such as statistical process control (SPC). As use of SPC has become more prevalent in health care, QI practitioners must also be aware of situations that warrant special attention and potential modifications to common SPC charts, which include skewed continuous data, autocorrelation, small persistent changes in performance, confounders, and workload or productivity measures. This article reviews these situations and provides examples of SPC approaches for each.

Using the Eat Sleep Console Model to Promote Optimal Care and Outcomes for Infants With Neonatal Abstinence Syndrome: A Nurse-Driven, Multidisciplinary Initiative

BACKGROUND

A nurse led a team of providers in a quality improvement (QI) project to positively impact inpatient care and outcomes for infants with neonatal abstinence syndrome (NAS). The Eat Sleep Console (ESC) model was implemented to promote rooming-in and family-centered care as part of a nonpharmacological treatment approach.

PURPOSE

To compare the ESC model with the traditional Finnegan treatment approach to describe differences in infants' pharmacotherapy use (morphine), length of stay (LOS), weight loss, consumption of mother's own milk by any feeding method within 24 hours of discharge, Neonatal Intensive Care Unit (NICU) use, and Pediatric Unit utilization.

METHODS

The QI project was conducted at a single hospital site with more than 1700 deliveries per year in the Midwestern United States. A comparative effectiveness study design was used to evaluate the ESC model.

RESULTS

The ESC model impacted care and outcomes for infants with NAS, contributing to a significant reduction in morphine treatment, decrease in LOS among morphine-treated infants, increase in weight loss in infants who did not require morphine treatment, less NICU use, and greater Pediatric Unit utilization. A nonsignificant increase was found in the number of infants who consumed their mother's own milk by any feeding method in the 24-hour period prior to discharge.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Results may be helpful for hospitals striving to optimize care for infants exposed to opioids, using assessments of eating, sleeping, and consoling to guide individualized treatment decisions and to reduce morphine use.