A Quality Improvement Initiative to Improve the Care of Infants Born Exposed to Opioids by Implementing the Eat, Sleep, Console Assessment Tool

Opioid equipotency conversions for hospitalized infants: a systematic review

Hospitalized infants commonly receive opioids to reduce pain and minimize distress during invasive procedures. However, infant neurodevelopment is significantly impacted by cumulative and prolonged opioid exposures. While opioid conversion has been studied extensively in adults, no standardized equipotency opioid conversions exist for hospitalized infants and opioid stewardship efforts are inconsistent. We performed a systematic review to identify opioid dosing conversions commonly used in hospitalized infants <1 year of age, finding fourteen articles which documented or cited a calculation of cumulative opioid exposure. Morphine milligram equivalents (MME) conversion factors varied widely, with nine studies citing conversion equivalent equations commonly used in adults. Efforts to expand safe opioid stewardship to hospitalized infants will require evidence-based consensus for opioid equipotency dose conversions which acknowledge the unique physiology of infants.

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.

Eat, Sleep, Console model for neonatal opioid withdrawal syndrome: a meta-analysis

Background

The rising incidence of drug abuse among pregnant women has rendered neonatal opioid withdrawal syndrome a significant global health concern.

Methods

Databases including PubMed, Web of Science, the Cochrane Library, Embase, Elton B. Stephens. Company (EBSCO), China National Knowledge Infrastructure (CNKI), and Wanfang were searched for comparative studies of the Eat, Sleep, Console model vs. traditional assessment tools for neonatal opioid withdrawal syndrome. Two reviewers conducted literature searches, screened according to the inclusion criteria, extracted data, and independently verified accuracy. All meta-analyses were conducted using Review Manager Version 5.4.

Results

In total, 18 studies involving 4,639 neonates were included in the meta-analysis. The Eat, Sleep, Console model demonstrated superior outcomes in assessing neonatal opioid withdrawal syndrome, significantly reducing the need for pharmacological treatment [risk ratio = 0.44, 95% confidence interval (CI) = 0.34-0.56, P < 0.001], decreasing the length of hospital stay [standard mean difference (SMD) = -2.10, 95% CI = -3.43 to -0.78, P = 0.002], and shortening the duration of opioid treatment (SMD = -1.33, 95% CI = -2.22 to -0.45, P = 0.003) compared to the Finnegan Neonatal Abstinence Scoring System.

Conclusions

The Eat, Sleep, Console model is more effective than the Finnegan Neonatal Abstinence Scoring System in improving the assessment and management of neonatal opioid withdrawal syndrome.

Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal: A Post Hoc Subgroup Analysis of the ESC-NOW Randomized Clinical Trial

Importance

The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown.

Objective

To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool.

Design, Setting, and Participants

This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks' gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024.

Exposure

Opioid treatment for NOWS and the ESC care approach.

Main Outcomes and Measures

For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics.

Results

In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001).

Conclusion and Relevance

When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later.

Trial Registration

ClinicalTrials.gov Identifier: NCT04057820.

Implementation of a Nurse-Driven Eat-Sleep-Console (ESC) Treatment Pathway at a Community Hospital for Treatment of Neonatal Opioid Withdrawal Syndrome in an Effort to Improve Short-term Outcomes

BACKGROUND

The Chandler Regional Medical Center (CRMC) neonatal intensive care unit (NICU) began a phased implementation of Eat-Sleep-Console (ESC) for the management of those at risk for neonatal opioid withdrawal syndrome (NOWS).

PURPOSE

The purpose of this initiative is to track short-term outcomes as well as the program's effect on nursing workflow and job performance rating/satisfaction.

METHODS

A retrospective review of the ESC implementation process at CRMC from the years 2018-2020. The study consisted of 3 epochs: (1) traditional pharmacologic management; (2) parent-led ESC management; and (3) parent/nurse-led ESC management. Length of stay (LOS), treatment pathway assignment, and proportion of infants treated with pharmacologic agents were compared between epochs. In addition, a survey of NICU nursing staff was distributed to measure nurses' perceptions and attitudes towards the ESC program and the management of infants with NOWS.

RESULTS

The proportion of infants treated via ESC increased (0%, 53%, and 100%), with an associated decrease in LOS (18.4, 10.5, and 9.3 days) during each epoch of the study period. Thirty-seven nurses completed the survey, with 94% of nurses reporting being comfortable caring for ESC patients and 89% feeling supported in their ESC nursing assignments, with only 11% stating that caring for ESC patients significantly alters their other nursing care processes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Implementation of an ESC treatment program for infants with NOWS significantly decreased LOS and the proportion of infants treated pharmacologically. This phased implementation process was not associated with self-reported negative nursing perceptions of the program and its treatment goals/outcomes.

Piloting a Mobile Clinical Decision Support Application for Pediatric Clinical Guidelines

Mobile Clinical Decision Support Systems (CDSSs) represent an increasingly utilized technology to promote clinical guideline use. We sought to explore clinician guideline use and access preferences during implementation of a mobile guideline app at a free-standing children's hospital integrating 23 guidelines. Surveys included demographic variables and access preferences among anonymous onboarded clinicians in January 2022. Response rate was 21.8% (57/261) among onboarded users, mostly attending (59.6%) and resident/fellow physicians (21.1%) in inpatient (42.1%) and emergency department (31.6%) settings. Onboarded users accessed guidelines on over half of shifts (68.4%) and quickly (80.7%, <1 minute). Overall, most users reported favorable patterns for adoption of mobile CDSSs as useful adjuncts to existing formats. Users reported more ease of access and frequent guideline usage, particularly for younger clinicians. Guidelines related to antibiotic decision-making or newer disease processes were most useful. Further study is needed on electronic health record incorporation, adherence, and patient outcomes.

Transitioning Care Approach for Neonatal Opioid Withdrawal Syndrome and Neonatal Abstinence Syndrome

The increase in substance use during pregnancy results in a higher incidence of neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS), straining health care and social systems and creating an economic burden. There is a paradigm shift in transitioning the care approach for NAS/NOWS from a medical model of care to a family-centered individualized non-pharmacological care approach with non-pharmacological interventions as the first line of treatment. Supporting families after birth with a nurturing environment and providing them with a toolbox of non-pharmacological interventions prepares them for the transition from hospital to home.

Growing together: Optimization of care through quality improvement for the mother/infant dyad affected by perinatal opioid use

The care of the dyad affected by opioid use disorder (OUD) requires a multi-disciplinary approach that can be challenging for institutions to develop and maintain. However, over the years, many institutions have developed quality improvement (QI) initiatives aimed at improving outcomes for the mother, baby, and family. Over time, QI efforts targeting OUD in the perinatal period have evolved from focusing separately on the mother and baby to efforts addressing care of the dyad and family during pregnancy, delivery, and postpartum. Here, we review recent and impactful QI initiatives that serve as examples of work improving outcomes for this population. Further, we advocate that this work be done through a racial equity lens, given ongoing inequities in the care of particularly non-white populations with substance use disorders. Through QI frameworks, even small interventions can result in meaningful changes to the care of babies and families and improved outcomes.

Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome

A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.

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.

Impact of Clinical Guidelines on Hospital Utilization in Children With Croup

OBJECTIVES

To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission.

METHODS

Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year.

RESULTS

Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant.

CONCLUSIONS

Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.

Neonatal Outcomes after Medications for Opioid Use Disorder during Pregnancy in a State Women's Prison Facility, 2016-2019

OBJECTIVE

Although medications for opioid use disorder improve both maternal and neonatal outcomes, little is known about opioid-exposed infants born during episodes of incarceration. The study sought to examine birth outcomes for infants born with opioid exposure during perinatal incarceration.

METHODS

Participants were identified from clinic rosters in a Southeastern women's prison (2016-2019). Included infants born to pregnant people with opioid use disorder incarcerated in the study facility at the time of delivery. We abstracted hospital length of stay, neonatal opioid withdrawal syndrome (NOWS) severity, and discharge plan from hospital records and report descriptive statistics, analysis of variance F tests, and chi-square tests to compare outcomes by opioid exposure type.

RESULTS

There were 125 infants born after exposure to methadone (n = 34), buprenorphine (n = 15), oxycodone (n = 22), or no opioid medication (n = 54) during prenatal incarceration. Most infants exposed to methadone or buprenorphine had difficulty with eating, sleeping, or consoling (97% and 80%), and 59% and 47% were treated with medication for NOWS, respectively. The majority with prenatal opioid exposure required intervention for NOWS symptoms after their birthing parent was discharged to the prison. The average hospital length of stay was different for infants with no opioid, methadone, buprenorphine, and oxycodone exposure during incarceration (4, 15, 12, and 9 days, respectively, P < 0.001).

CONCLUSIONS

Neonatal hospitalization experiences of infants with perinatal opioid exposures during maternal incarceration mirror those of similarly exposed infants born outside the context of incarceration, except for hospital length of stay. Consideration of avoiding separation of the parent-infant dyad may be needed to improve outcomes for these infants.

Implementation of ESC QI Initiative in Neonatal Unit Setting and Adaptation During the Pandemic

OBJECTIVES

To improve outcomes in infants with neonatal opioid withdrawal syndrome (NOWS) admitted to NICU by implementing a quality improvement (QI) initiative incorporating "eat, sleep, console" (ESC) as a withdrawal evaluation tool and promotion of nonpharmacological interventions. Secondarily, we evaluated the impact of the coronavirus disease 2019 pandemic on QI initiative and outcomes.

METHODS

We included infants born ≥ 36 weeks gestation and admitted to NICU with a primary diagnosis of NOWS between December 2017 and February 2021. (preintervention; December 2017-January 2019, postintervention; February 2019-February 2021). We compared cumulative dose, duration of opioid treatment, and length of stay (LOS) as our primary outcomes.

RESULTS

The average duration of opioid treatment decreased from 18.6 days in the preimplementation cohort (n = 36) to 1.5 days in the first-year postimplementation (n = 44) with a reduction in cumulative opioid dose from 5.8 mg/kg to 0.6 mg/kg and decrease in the proportion of infants treated with opioids from 94.2% to 41.1%. Similarly, the average LOS decreased from 26.6 to 7.6 days. In the second-year postimplementation during the coronavirus disease 2019 pandemic (n = 24), there was an increase in average opioid treatment duration and LOS to 5.1 and 12.3 days respectively, but cumulative opioid dose (0.8 mg/kg) remained significantly lower than the preimplementation cohort.

CONCLUSIONS

ESC-based quality improvement initiative led to a significant decrease in LOS and opioid pharmacotherapy in infants with NOWS in NICU setting. Despite the impact of the pandemic, some of the gains were sustained with adaptation to ESC QI initiative.

Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal

BACKGROUND

Although clinicians have traditionally used the Finnegan Neonatal Abstinence Scoring Tool to assess the severity of neonatal opioid withdrawal, a newer function-based approach - the Eat, Sleep, Console care approach - is increasing in use. Whether the new approach can safely reduce the time until infants are medically ready for discharge when it is applied broadly across diverse sites is unknown.

METHODS

In this cluster-randomized, controlled trial at 26 U.S. hospitals, we enrolled infants with neonatal opioid withdrawal syndrome who had been born at 36 weeks' gestation or more. At a randomly assigned time, hospitals transitioned from usual care that used the Finnegan tool to the Eat, Sleep, Console approach. During a 3-month transition period, staff members at each hospital were trained to use the new approach. The primary outcome was the time from birth until medical readiness for discharge as defined by the trial. Composite safety outcomes that were assessed during the first 3 months of postnatal age included in-hospital safety, unscheduled health care visits, and nonaccidental trauma or death.

RESULTS

A total of 1305 infants were enrolled. In an intention-to-treat analysis that included 837 infants who met the trial definition for medical readiness for discharge, the number of days from birth until readiness for hospital discharge was 8.2 in the Eat, Sleep, Console group and 14.9 in the usual-care group (adjusted mean difference, 6.7 days; 95% confidence interval [CI], 4.7 to 8.8), for a rate ratio of 0.55 (95% CI, 0.46 to 0.65; P<0.001). The incidence of adverse outcomes was similar in the two groups.

CONCLUSIONS

As compared with usual care, use of the Eat, Sleep, Console care approach significantly decreased the number of days until infants with neonatal opioid withdrawal syndrome were medically ready for discharge, without increasing specified adverse outcomes. (Funded by the Helping End Addiction Long-term (HEAL) Initiative of the National Institutes of Health; ESC-NOW ClinicalTrials.gov number, NCT04057820.).

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.

Transfer Timing and the Length of Medication Weaning for Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

Many infants with neonatal opioid withdrawal syndrome (NOWS) from prenatal exposure to opioids require transfer to a pediatric inpatient unit for medication weaning. The purpose of this study is to assess the difference in the duration of medication weaning between infants transferred by day of life (DOL) 14 versus later (DOL 15 and after) to a tertiary care setting for pharmacological and nonpharmacological management of NOWS.

METHODS

This single-site retrospective cohort study uses medical chart data from infants with NOWS transferred to specialized care between May 2016 and June 2021 (n = 87). The primary outcome is length of medication weaning, calculated as the number of days between transfer from the NICU to a tertiary care setting and the cessation of pharmacotherapy.

RESULTS

The majority of the infants in this sample are transferred from acute to tertiary care after DOL 15 (62% versus 38% by DOL 14). The predicted number of days to wean is 14.2 among those infants transferred by DOL 14, whereas the duration of weaning is 6.6 days longer among the later transfer group (20.8 days), adjusting for key covariates. The duration of weaning is also prolonged among infants with greater NOWS symptom severity and with prenatal exposure to psychotropic medications.

CONCLUSIONS

Delayed treatment prolongs NOWS symptoms and increases the burden on the health care system. Earlier referral from NICUs to pediatric inpatient units with environmental supports could reduce prolonged medication exposure and length of hospitalization for infants diagnosed with NOWS.

Addressing drivers of healthcare utilization for neonatal opioid withdrawal syndrome

OBJECTIVE

Aim to reduce healthcare utilization (HU) for infants at risk of neonatal opioid withdrawal syndrome (NOWS) by 30% in 1 year and sustain for 2 years.

STUDY DESIGN

Baseline data from three Level I & II newborn nurseries from January 2016 to June 2018 informed PDSA cycles from August 2018 to December 2021. Shewhart process control charts evaluated length of stay (LOS), pharmacologic treatment (PT) rates, direct cost (DC), process, and balancing measures for special cause variation (SCV).

RESULTS

Two hundred and seventeen infants showed downward SCV in LOS (12.6 to 4.4 days), PT (53% to 17%) and DC ($12593.82 to $5219.17). Onset of the COVID-19 pandemic coincided with reversible SCV. DC varied by provider specialty.

CONCLUSION

Transition from MFNASS to ESC led to decrease in healthcare utilization for infants at risk of NOWS. QI methodology identified persistent drivers of variability, including the COVID-19 pandemic and provider specialty.

Eat Sleep Console for the Management of Neonatal Abstinence Syndrome: A Process and Outcomes Evaluation

INTRODUCTION

This project aimed to evaluate a practice change to Eat Sleep Console (ESC) in the postpartum unit and neonatal intensive care unit of a single Baby-Friendly tertiary hospital.

METHOD

Guided by Donabedian's quality care model, a process and outcomes evaluation of ESC was conducted through a retrospective chart review and the Eat Sleep Console Nurse Questionnaire, which assessed processes of care and knowledge, attitudes and perceptions of nurses.

RESULTS

Improvement in neonatal outcomes, including a decreased number of morphine doses (12.33 vs. 3.17; p = .045), was noted from preintervention to postintervention. Breastfeeding at discharge increased from 38% to 57% but did not reach statistical significance. Thirty-seven nurses (71%) completed the full survey.

DISCUSSION

The use of ESC resulted in positive neonatal outcomes. Nurse-identified areas for improvement resulted in a plan for continued improvement.

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.

Early Weight Loss Percentile Curves and Feeding Practices in Opioid-Exposed Infants

OBJECTIVE

We examined weight loss patterns and feeding practices of infants hospitalized for neonatal opioid withdrawal syndrome (NOWS) managed by the eat, sleep, console approach, which emphasizes nonpharmacologic treatment. Although feeding practices during hospitalization vary widely, weight loss patterns for infants managed under this approach have not yet been described.

METHODS

Of 744 infants with NOWS born from 2014 to 2019 at our institution, 330 met inclusion criteria (≥35 weeks' gestation and no NICU transfer). We examined maximum weight loss and created weight loss percentile curves by delivery type using mixed effects quantile modeling with spline effect for hour of life; 95% confidence intervals (CI) were compared to published early weight loss nomograms.

RESULTS

In the cohort, the mean gestational age was 39.2 weeks, mean birth weight was 3.1 kg, and mean length of stay was 6.5 days; 94.6% did not require pharmacologic treatment. Median percent weight loss was significantly more compared to early weight loss nomograms for both vaginally-delivered infants at 48 hours (6.9% [95% CI: 5.8-8.5] vs 2.9%) and cesarean-delivered infants at 48 hours (6.5% [95% CI: 4.1-9.1] vs 3.7%) and 72 hours (7.2% [95%CI 4.7-9.9] vs 3.5%), all P < .001. Overall, 27.9% lost >10% birth weight.

CONCLUSIONS

We demonstrate weight loss patterns of infants with NOWS managed by the eat, sleep, console approach at a single center. Infants with NOWS lose significantly more weight than nonopioid exposed infants and are at increased risk of morbidity and health care use. Studies to address optimal feeding methods in these infants are warranted.

Impact of Coronavirus Disease-2019 on Hospital Care for Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

To compare prenatal exposures, hospital care processes, and hospitalization outcomes for opioid-exposed newborns before and during the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

In this multicenter retrospective analysis, data were collected from 19 Massachusetts hospitals, including 5 academic and 14 community hospitals. The pre-COVID-19 cohort was defined as births occurring during March 1, 2019-February 28, 2020, and the COVID-19 cohort was defined as births occurring during March 1, 2020-December 31, 2020. Opioid-exposed newborns born at ≥35 weeks of gestation were included. Differences in prenatal substance exposures, hospital care processes, and neonatal opioid withdrawal syndrome (NOWS) outcomes, including pharmacologic treatment for NOWS (PharmTx), length of stay (LOS), and as-needed (prn) treatment failure rates, were evaluated.

RESULTS

There were 663 opioid-exposed newborns in the pre-COVID-19 group and 476 in the COVID-19 group. No between-group differences were seen in prenatal substance exposures or the need for PharmTx. Compared with the pre-COVID-19 group, in the COVID-19 group there was less rooming-in after maternal discharge (53.8% vs 63.0%; P = .001) and less care in the pediatric unit setting (23.5% vs 25.3%; P = .001), longer LOS (adjusted risk ratio, 1.04; 95% CI, 1.01-1.08), and a higher rate of breast milk receipt at discharge (aOR, 2.03; 95% CI, 1.22-3.39). Within the subset of academic centers, more infants failed prn treatment in the COVID-19 group (53.8% vs 26.5%, P = .02; aOR, 3.77; 95% CI, 0.98-14.5).

CONCLUSIONS

Among the hospitals in our collaborative, hospital processes for NOWS, including care setting, rooming-in, and LOS were negatively impacted in the COVID-19 group, particularly in academic medical centers.

Strategies to Successfully Implement an Eat, Sleep, Console Protocol

ABSTRACT

Neonatal opioid withdrawal syndrome is pervasive, reflected in a case rate increase among most demographics in the United States from 4.0 newborns per 1,000 hospitalized births in 2010 to 7.3 newborns per 1,000 hospitalized births in 2017. Historically, assessments have been based on present symptomatology, excluding the mother's input, and increasing the likelihood of pharmacotherapy. The Eat, Sleep, Console approach provides an opportunity for the mother to act as the treatment for her newborn as she performs nonpharmacologic interventions that reduce withdrawal severity. Maternal confidence to help her newborn grows with this level of involvement and mother/infant dyad care improves, as do nurse and mother interactions. Assessments are less subjective and less time-consuming for nurses to conduct than those of the often-used Finnegan tool, and are conducted in collaboration with the mother. Facilities implementing this approach have seen a reduction in newborn hospital length of stay, pharmacotherapy, associated medical costs, and improved breastfeeding rates. Implementing an Eat, Sleep, Console protocol involves a stepwise approach to ensure all stakeholders are effectively prepared for the transition. We present strategies to implement an Eat, Sleep, and Console clinical protocol. A stepwise approach to implementation along with a clinical nursing maternal education protocol exemplar is included. Methods to overcome barriers to implementation and recommendations for further development are discussed.

Neonatal opioid withdrawal syndrome: a review of the science and a look toward the use of buprenorphine for affected infants

Neonates born to mothers taking opioids during pregnancy are at risk for neonatal opioid withdrawal syndrome (NOWS), for which there is no recognized standard approach to care. Nonpharmacologic treatment is typically used as a first-line approach for management, and pharmacologic treatment is added when clinical signs are not responding to nonpharmacologic measures alone. Although morphine and methadone are the most commonly used pharmacotherapies for NOWS, buprenorphine has emerged as a treatment option based on its pharmacologic profile and results from initial single site clinical trials. The objective of this report is to provide an overview of NOWS including a summary of ongoing work in the field and to review the state of the science, knowledge gaps, and practical considerations specific to the use of buprenorphine for the treatment of NOWS as discussed by a panel of experts during a virtual workshop hosted by the National Institutes of Health.

Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals

OBJECTIVES

Investigate disparities by Hispanic ethnicity in the care of opioid exposed newborns (OENs) in Colorado birthing hospitals within a statewide quality improvement collaborative.

METHODS

This study is a secondary analysis of a quality improvement initiative aimed at standardizing hospital-based care of OENs through implementation of the Eat, Sleep, Console Model. We used statistical process control charts to compare time to special cause variation by Hispanic ethnicity for outcomes including infant length of stay, use of pharmacologic therapy, and breastfeeding eligibility and receipt. Only hospitals that delivered both Hispanic and non-Hispanic OENs during the study period were included, documented maternal ethnicity was required for inclusion. We investigated hospital variation in these outcomes among 4 hospitals that cared for Hispanic OENs for most of the study period.

RESULTS

We analyzed 799 mother-OEN dyads, 241 Hispanic and 558 non-Hispanic. Both Hispanic and non-Hispanic OENs experienced decreases in length of stay overall and among those who received postnatal opioids, although Hispanic OENs achieved these decreases 3 annual quarters after non-Hispanic OENs. Pharmacologic therapy use decreased by 55% for Hispanic OENs and 60% for non-Hispanic OENs. Hispanic OENs experienced a 1-quarter delay for this decrease.

CONCLUSIONS

Although this quality improvement initiative resulted in positive outcomes for Hispanic and non-Hispanic OENs, improvement was delayed among Hispanic infants, indicating a need to explore and address care practices of Hispanic mothers and infants affected by opioid use disorders.

The harms of punishing substance use during pregnancy

As rates of substance use have increased in the United States, rates of substance-involved pregnancies have also been on the rise, inspiring new civil policies designed to punish pregnant and parenting individuals who engage in substance use or are living with an untreated substance use disorder. Proponents of punitive civil policies argue that such policies will deter substance use behaviors and/or that substance use during pregnancy deserves punishment for harming the fetus. Current scientific evidence invalidates both claims, offering compelling evidence that punitive civil policies often worsen the harms of substance use for both parent and child. In this commentary, we review this evidence and explain how punitive policies that threaten child removal and the termination of parental rights exacerbate the very problems they are ostensibly designed to reduce. Rather than coercive and punitive responses, families affected by substance use need greater access to affordable, evidence-based treatment as well as services that address the structural and relational concerns underlying substance use. Above all, responses to perinatal substance use in both policy and practice should prioritize keeping families together.

Strategies to Improve the Quality of Team-Based Care for Neonatal Abstinence Syndrome

BACKGROUND

Prioritizing nonpharmacologic care for neonatal abstinence syndrome (NAS) requires a team-based care (TBC) approach to facilitate staff and family engagement. We aimed to identify the important structures and processes of care for TBC of infants with NAS and quality of care outcomes that are meaningful to care team members (including parents).

METHODS

Using a Donabedian framework, we conducted semistructured interviews from May to October 2019 with care team members at 3 community hospitals, including parents, nurses, social workers, physicians, lactation nurses, child protective services, volunteers, and hospital administrators. We used thematic analysis to identify important structures, processes of care, and outcomes.

RESULTS

We interviewed 45 interprofessional care team members: 35 providers and 10 parents. Structures critical to providing TBC included (1) building a comprehensive network of interprofessional team members and (2) creating an NAS specialized unit. Necessary processes of care included (1) prioritizing early involvement of interprofessional team members, (2) emphasizing nonjudgmental incorporation of previous experience with addiction, (3) establishing clear roles and expectations, and (4) maintaining transparency with social services. Lastly, we identified 9 outcomes resulting from these identified structures and processes that are meaningful to care team members to assess the quality of care for infants with NAS.

CONCLUSIONS

In this study, we identify important structures, processes of care, and meaningful outcomes to enhance and evaluate TBC for infants with NAS. Hospitals that adopt and implement these structures and processes have the potential to improve the quality of care for infants, caregivers, and providers who care for these infants.

Economic Evaluation of Interventions for Treatment of Neonatal Opioid Withdrawal Syndrome: A Review

This study assessed the economic evidence on the pharmacological and non-pharmacological management of infants with neonatal opioid withdrawal syndrome (NOWS). Six databases were searched up to October 2020 for peer-reviewed studies. After titles and abstracts were screened, 79 studies remained for full-text review, and finally, 8 studies were eligible for inclusion in the review. The methodological quality of included studies was assessed using the Drummond checklist. The review showed significant limitations in these studies, with one study being rated as good and the remaining seven studies as of poor quality. There are methodological issues that require addressing, including a lack of detail on cost categories, a robust investigation of uncertainty, and extending the time horizon to consider longer-term outcomes beyond the initial birth hospitalization. Despite these limitations, existing evidence suggests non-pharmacological strategies such as rooming-in were associated with a shorter hospital stay and a decreased need for pharmacological treatment, thereby lowering hospitalization costs. The review highlights the paucity of high-quality studies assessing the cost-effectiveness of intervention strategies for NOWS. There is also a lack of evidence on long-term outcomes associated with NOWS and the treatment of NOWS. The inclusion of economic analyses in future studies will provide evidence to inform policymakers on resource allocation decisions for this patient population.

Integrated Review of the Assessment of Newborns With Neonatal Abstinence Syndrome

OBJECTIVE

To critically review and summarize current knowledge regarding the assessment of newborns with neonatal abstinence syndrome (NAS).

DATA SOURCES

We searched the following databases for articles on the assessment of newborns with NAS that were published in English between January 2014 and June 2020: PubMed, CINAHL, and PsycINFO. Keywords and Medical Subject Heading terms used to identify relevant research articles included neonatal abstinence syndrome; Finnegan Scale; eat, sleep, console; epigenetics; genetics; pharmacokinetics; and measurement. We independently reviewed articles for inclusion.

STUDY SELECTION

We retrieved 435 articles through database searches and 17 through manual reference searches; 31 articles are included in the final review. Excluded articles were duplicates, not relevant to NAS, qualitative studies, and/or of low quality.

DATA EXTRACTION

We used the methodology of Whittemore and Knafl to guide this integrative review. We extracted and organized data under the following headings: author, year and country, purpose, study design, participants, measurement, biomarker (if applicable), results, limitations, recommendations, and intervention.

DATA SYNTHESIS

The Finnegan Neonatal Abstinence Scale is the most widely used instrument to measure symptoms of NAS in newborns, although it is very subjective. Recently, there has been a transition from the Finnegan Neonatal Abstinence Scale to the eat, sleep, console method, which consists of structured assessment and intervention and has been shown to decrease length of hospital stay and total opioid treatment dose. Researchers examined biomarkers of NAS, including genetic markers and autonomic nervous system responses, on the variation in incidence and differential severity of NAS. In the included articles, women with opioid use disorder who were treated with naltrexone during pregnancy gave birth to newborns without NAS diagnoses. However, most women who were treated with buprenorphine gave birth to newborns with NAS diagnoses.

CONCLUSION

NAS negatively affects newborns in a multitude of ways, and the objective assessment and measurement of the newborn's response to withdrawal remains understudied and needs further investigation.

Baby STRENGTH: Eat, Sleep, Console for Infants With Neonatal Abstinence Syndrome

BACKGROUND

Traditional medication-based management of neonatal abstinence syndrome (NAS) results in long hospitalizations. Nonpharmacologic treatment and using the Eat, Sleep, Console (ESC) model of care have been shown to decrease lengths of stay (LOSs).

PURPOSE

To determine whether using the ESC model of care to treat infants with opioid withdrawal resulted in decreased LOSs and number of infants receiving morphine when compared with traditional medication management.

METHODS

Retrospective medical review for all patients admitted for NAS 12 months before and 12 months after implementing the ESC model of care. Data collected from electronic health records included demographic data, maternal history, infant LOS, infants receiving morphine, and birth weight/weight on day of life (DOL) 5. Univariate analysis was used to control for demographic data/risk factors. A 2-samples t test was used to compare average LOSs. Chi-square test was used to detect differences in the number of infants receiving morphine. Data were analyzed using SAS 9.4 software.

RESULTS

LOS decreased from mean of 17.7 days to a mean of 5.9 days (P < .0001). The number of infants receiving morphine decreased from 20 (58.9%) to 1 (2.7%) (P < .0001). No statistically significant difference was noted in the percentage of weight loss on DOL 5. Data showed an increase in breastfeeding rates from 41.18% to 64.86% (P = .0456).

IMPLICATIONS FOR PRACTICE

The ESC model of care decreased infant LOS and the number of morphine doses administered for opioid withdrawal symptoms. Maternal breastfeeding rates increased.

IMPLICATIONS FOR RESEARCH

More research is needed to determine long-term neurodevelopmental outcomes of infants managed using ESC principles.

Correlating Scores but Contrasting Outcomes for Eat Sleep Console Versus Modified Finnegan

OBJECTIVES

The Modified Finnegan Neonatal Abstinence Scoring System (M-FNASS) and the newer Eat, Sleep, and Console (ESC) model guide the clinical management of neonatal opioid withdrawal syndrome (NOWS). In this study, we evaluate how the M-FNASS and ESC model directly compare in inpatient practice. We hypothesized that ESC scores would correlate with M-FNASS scores, whereas ESC management would reduce health care use for infants with NOWS.

METHODS

In this retrospective cohort study, we compared management of infants with NOWS admitted to nursery settings. Epoch 1 was managed by using an M-FNASS algorithm. Epoch 2 was scored simultaneously with the M-FNASS and ESC model and managed by using the ESC approach. In the statistical analysis, we compared M-FNASS and ESC scores and outcomes between epochs.

RESULTS

A total of 158 infants provided 2101 scoring instances for analysis. Demographic characteristics were similar between epochs. ESC scores significantly correlated with overall M-FNASS scores and specific M-FNASS domains. Receiver operating characteristic (ROC) curve analysis revealed that an ESC score containing at least 1 "no" was best predicted by an M-FNASS cutoff value of 7.5 (sensitivity 0.84; specificity 0.70; area under the curve = 0.842). Length of stay (median 9.5 vs 5 days; P = .0002) and initiation (53% vs. 33%; P = .018) and duration of pharmacologic treatment (median 11 vs 7 days; P = .0042), as well as length of stay for infants who were pharmacologically treated (median 15 vs 10 days; P = .0002), were significantly reduced with ESC-based management after adjustment for covariates.

CONCLUSIONS

The ESC approach meaningfully correlates with the M-FNASS to detect NOWS. Management with the ESC approach continues to be associated with reduced health care use when compared with an M-FNASS approach, implying that the ESC approach may facilitate higher-value inpatient care.

Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis

The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased substantially in the setting of the opioid epidemic, a major public health problem in the United States. At present, NOWS has commonly used assessment and treatment protocols, but new protocols have questioned old practices. However, because of limited access to opioid use disorder (OUD) treatment and socioeconomic factors, many pregnant (and postpartum) women with OUD do not receive treatment. The pathophysiology of NOWS is not completely understood, although limited research studies have been conducted in humans and animals to better understand its etiology. Moreover, there is evidence that epigenetic and genetic factors play a role in the development of NOWS, but further study is needed. Animal models have suggested that there are deleterious effects of in utero opioid exposure later in life. Clinical research has revealed the harmful long-term sequelae of NOWS, with respect to cognitive function and childhood development. Many psychiatric disorders begin during adolescence, so as infants born with NOWS approach adolescence, additional clinical and molecular studies are warranted to identify biologic and psychosocial risk factors and long-term effects of NOWS. Additionally, access to specialized OUD treatment for pregnant women must be more readily available in the United States, especially in rural areas.

Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome

OBJECTIVES

This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome.

STUDY DESIGN

We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs.

RESULTS

The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates.

CONCLUSIONS

Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts' PNQIN collaborative

OBJECTIVE

To support hospitals in the Massachusetts PNQIN collaborative with adoption of the ESC Neonatal Opioid Withdrawal Syndrome (NOWS) Care Tool© and assess NOWS hospitalization outcomes.

STUDY DESIGN

Statewide QI study where 11 hospitals adopted the ESC NOWS Care Tool©. Outcomes of pharmacotherapy and length of hospital stay (LOS) and were compared in Pre- and Post-ESC implementation cohorts. Statistical Process Control (SPC) charts were used to examine changes over time.

RESULTS

The Post-ESC group had lower rates of pharmacotherapy (OR 0.35, 95% CI 0.26, 0.46) with shorter LOS (RR 0.79, 95% CI 0.76, 0.82). The 30-day NOWS readmission rate was 1.2% in the Pre- and 0.4% in the Post-ESC cohort. SPC charts indicate a shift in pharmacotherapy from 54.8 to 35.0% and LOS from 14.2 to 10.9 days Post-ESC.

CONCLUSIONS

The ESC NOWS Care Tool was successfully implemented across a state collaborative with improvement in NOWS outcomes without short-term adverse effects.

A Core Outcome Set for Neonatal Opioid Withdrawal Syndrome

BACKGROUND

As rates of neonatal opioid withdrawal are increasing, the need for research to evaluate new treatments is growing. Large heterogeneity exists in health outcomes reported in current literature. Our objective is to develop an evidence-informed and consensus-based core outcome set in neonatal opioid withdrawal syndrome (NOWS-COS) for use in studies and clinical practice.

METHODS

An international multidisciplinary steering committee was established. A systematic review and a 3-round Delphi was performed with open-ended and score-based assessments of the importance of each outcome to inform clinical management of neonatal opioid withdrawal. Interviews were conducted with parents and/or caregivers on outcome importance. Finally, a consensus meeting with diverse stakeholders was held to review all data from all sources and establish a core set of outcomes with definitions.

RESULTS

The NOWS-COS was informed by 47 published studies, 41 Delphi participants, and 6 parent interviews. There were 63 outcomes evaluated. Final core outcomes include (1) pharmacologic treatment, (2) total dose of opioid treatment, (3) duration of treatment, (4) adjuvant therapy, (5) feeding difficulties, (6) consolability, (7) time to adequate symptom control, (8) parent-infant bonding, (9) duration of time the neonate spent in the hospital, (10) breastfeeding, (11) weight gain at hospital discharge, (12) readmission to hospital for withdrawal, and (13) neurodevelopment.

CONCLUSIONS

We developed an evidence-informed and consensus-based core outcome set. Implementation of this core outcome set will reduce heterogeneity between studies and facilitate evidence-based decision-making. Future research will disseminate all the findings and pilot test the validity of the NOWS-COS in additional countries and populations to increase generalizability and impact.