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Parker LA. Use of Donor Human Milk in Populations Other than Preterm Very Low Birthweight Infants: Where Are We Now? J Perinat Neonatal Nurs 2024; 38:238-240. [PMID: 39074319 DOI: 10.1097/jpn.0000000000000854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
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DiPietro B, Silcox K, Rost J, Woods LS, Edwards EM, Buus-Frank ME, Horbar JD, Hudak ML. Improving Outcomes through a Neonatal Abstinence Syndrome Collaborative in Maryland. Am J Perinatol 2024; 41:e22-e29. [PMID: 35381608 DOI: 10.1055/a-1817-5522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES A statewide Maryland Perinatal Neonatal Quality Collaborative, facilitated by the Maryland Patient Safety Center (MPSC), identified the three specific, measurable, attainable, relevant, and time-limited (SMART) aims to improve outcomes of neonatal abstinence syndrome (NAS) care as follows: (1) to reduce hospital length of stay (LOS), (2) to reduce interhospital transfers, and (3) to reduce 30-day readmission rates of infants with NAS. STUDY DESIGN The Maryland collaborative developed a bundle of best practices for care of infants with NAS. MPSC partnered with Vermont Oxford Network (VON) to utilize the VON NAS toolkit and provided its standardized NAS educational curriculum to address the three objectives for participating birthing hospitals. Efforts began in quarter 4 (Q4) of 2016 and continued for 2 years. Thirty-one of Maryland's 32 delivery hospitals (97%) participated in the 2-year collaborative. Additionally, one specialty pediatric hospital with an NAS unit participated in the group learnings. Participating facilities implemented components of the MPSC NAS bundle and provided their staff caring for infants with NAS and their mothers access to the VON standardized educational curriculum. MPSC partnered with VON to conduct two audits of implementation of policies and procedures in Q1 of 2016 and Q3 of 2018. The Maryland Department of Health supplied quarterly aggregate hospital information on LOS, interhospital transfers, and 30-day readmissions of infants with a discharge diagnosis of the International Classification of Disease, 10th Revision (ICD-10), P96.1. RESULTS Among term infants with NAS with total hospital stay greater than 5 days, we observed a nonsignificant reduction in both mean and median LOS of 1.5 days. In this same group, the rate of interhospital transfers fell significantly from 20.1% in 2016 to 13.8 and 11.0% in 2017 and 2018, respectively. CONCLUSION The best practice bundle created by the Maryland collaborative was associated with a reduction in the percentage of infants with NAS who required interhospital transfer, thereby reducing family disruption. KEY POINTS · A state NAS collaborative engaged 97% of delivery hospitals in education and standardization of care.. · The collaborative witnessed a 1.5-day decrease in length of stay, similar to that observed in other state collaboratives.. · The unique outcome of our collaborative was a 50% decrease in the rate of interhospital transfer..
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Affiliation(s)
| | - Kristin Silcox
- Maryland Department of Health,Prevention and Health Promotion Administration, Maternal and Child Health Bureau, Baltimore, Maryland
| | - James Rost
- Adventist Healthcare White Oak Medical Center, Silver Spring, Maryland
| | - Lee S Woods
- Maryland Department of Health,Prevention and Health Promotion Administration, Maternal and Child Health Bureau, Baltimore, Maryland
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner MD College of Medicine, University of Vermont, Burlington, Vermont
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, Vermont
| | - Madge E Buus-Frank
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH and The Children's Hospital at Dartmouth, Lebanon, New Hampshire
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner MD College of Medicine, University of Vermont, Burlington, Vermont
| | - Mark L Hudak
- Division of Neonatology, Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
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Shuman CJ, Choberka D, Morgan ME, Boyd CJ. ArtSpective™ for Perinatal Substance Use: Feasibility of an Arts-Based Intervention Addressing Stigma. J Addict Nurs 2024; 35:43-50. [PMID: 38829993 DOI: 10.1097/jan.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE The purpose of this proof-of-concept pilot study was to test the initial feasibility and limited efficacy of ArtSpective™ for perinatal substance use (PSU), a novel, arts-based intervention designed to decrease stigmatizing attitudes toward PSU. METHODS Using a pre-post mixed methods quasi-experimental design, ArtSpective™ for PSU was pilot tested for proof of concept among a convenience sample of 11 undergraduate and graduate students with experience in maternal-infant nursing from a Midwestern U.S. nursing school. As a proof-of-concept pilot study, we evaluated feasibility (acceptability, demand, and implementation) and limited efficacy. Participants completed presurveys and postsurveys that included satisfaction items, demographic items, and an adapted version of the Attitudes About Drug Use in Pregnancy Scale and participated in a focus group. Focus group data were analyzed using constant comparative methods, and survey data were analyzed using descriptive statistics and Wilcoxon signed rank tests. RESULTS Participants reported high demand and satisfaction with the intervention and provided recommendations to improve scalability. ArtSpective™ demonstrated significant improvement in stigma toward PSU (pre vs. post: p = .003; d = .633). CONCLUSION ArtSpective™ for PSU demonstrated initial feasibility and limited efficacy for improving nurse attitudes toward PSU. Efforts are needed to further test this novel intervention, adapt it to augment existing educational interventions, and improve its scalability.
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Czynski A, Laptook A, Das A, Smith B, Simon A, Greenberg R, Annett R, Lee J, Snowden J, Pedroza C, Lester B, Eggleston B, Bremer D, McGowan E. Pragmatic, randomized, blinded trial to shorten pharmacologic treatment of newborns with neonatal opioid withdrawal syndrome (NOWS). Trials 2023; 24:466. [PMID: 37480087 PMCID: PMC10362592 DOI: 10.1186/s13063-023-07378-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/16/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND The incidence of maternal opioid use in the USA has increased substantially since 2000. As a consequence of opioid use during pregnancy, the incidence of neonatal opioid withdrawal syndrome (NOWS) has increased fivefold between 2002 and 2012. Pharmacological therapy is indicated when signs of NOWS cannot be controlled, and the objective of pharmacological therapy is to control NOWS signs. Once pharmacologic therapy has started, there is great variability in strategies to wean infants. An important rationale for studying weaning of pharmacological treatment for NOWS is that weaning represents the longest time interval of drug treatment. Stopping medications too early may not completely treat NOWS symptoms. METHODS This will be a pragmatic, randomized, blinded trial of opioid weaning to determine whether more rapid weaning, compared to slow wean, will reduce the number of days of opioid treatment in infants receiving morphine or methadone as the primary treatment for NOWS. DISCUSSION The proposed study is a pragmatic trial to determine whether a rapid-weaning intervention reduces the number of days of opioid treatment, compared to a slow-weaning intervention, and we powered the proposed study to detect a 2-day difference in the length of treatment. Hospitals will be able to use either morphine or methadone with the knowledge that we may find a positive treatment effect for both, one, or neither drugs. TRIAL REGISTRATION NCT04214834. Registered January 2, 2020.
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Affiliation(s)
- Adam Czynski
- Connecticut Children's Medical Center, Hartford, USA.
| | - Abbot Laptook
- Brown University/Women & Infants Hospital of Rhode Island, Providence, USA
| | - Abhik Das
- RTI International, Research Triangle Park, USA
| | - Brian Smith
- Duke Clinical Research Institute, Durham, USA
| | - Alan Simon
- National Institutes of Health, Bethesda, USA
| | | | | | | | | | | | - Barry Lester
- Brown University/Women & Infants Hospital of Rhode Island, Providence, USA
| | | | | | - Elisabeth McGowan
- Brown University/Women & Infants Hospital of Rhode Island, Providence, USA
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Gupta M, Provost LP, Kaplan HC. Challenging Cases in Statistical Process Control for Quality Improvement in Neonatal Intensive Care. Clin Perinatol 2023; 50:321-341. [PMID: 37201984 DOI: 10.1016/j.clp.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
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.
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Affiliation(s)
- Munish Gupta
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Lloyd P Provost
- Associates in Process Improvement, 2000 Red Hawk Road, Wimberly, TX 78676, USA
| | - Heather C Kaplan
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Maltz RM, McClinchie MG, Boyle BM, McNicol M, Morris GA, Crawford EC, Moses J, Kim SC. Biosimilars for Pediatric Patients With Inflammatory Bowel Disease: Pediatric Gastroenterology Clinical Practice Survey. J Pediatr Gastroenterol Nutr 2023; 76:616-621. [PMID: 36827968 DOI: 10.1097/mpg.0000000000003750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Biosimilars are biological agents that have been demonstrated to have similar safety and efficacy profiles as the originator. The objective of this study was to evaluate the perspectives of pediatric gastroenterologists in the United States (U.S.) toward biosimilar use and to explore factors that impact their comfort level with prescribing infliximab biosimilars. METHODS A cross-sectional survey was developed and distributed to pediatric gastroenterology physicians from the U.S. via a listserv (Pediatric gastroenterology Bulletin Board). Respondent's demographics were recorded. Using a 6-point Likert scale, the survey assessed the respondent's perceptions toward biosimilars and initiating switches from the originator to biosimilar agent along with factors impacting provider's comfort level. Fischer exact tests were used to detect statistically significant differences in responses for hypotheses of interest. RESULTS One hundred thirty-nine pediatric gastroenterologists completed the online survey (response rate 5.4%). Eighty-seven percent of respondents reported being comfortable prescribing infliximab biosimilars to anti-tumor necrosis factor naive patients, and 69% reported being comfortable doing a one-time switch if the patient was in clinical remission. Factors that negatively impacted a respondent's comfort level included respondents not practicing at an ImproveCareNow (ICN) center and managing less than 50 patients with inflammatory bowel diseases (IBD). CONCLUSIONS Nearly 90% of pediatric gastroenterologists felt comfortable prescribing an infliximab biosimilar, and 70% felt comfortable with a one-time switch to the biosimilar if the patient was in clinical remission. Involvement in ICN a learning health system and caring for higher numbers of patients with IBD was associated with increased provider comfort with biosimilar use.
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Affiliation(s)
- Ross M Maltz
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
- the Department of Pediatrics, The Ohio State Wexner Medical Center, Columbus, OH
| | - Madeline G McClinchie
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Brendan M Boyle
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
- the Department of Pediatrics, The Ohio State Wexner Medical Center, Columbus, OH
| | - Megan McNicol
- the Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH
| | - Grant A Morris
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Geisinger Janet Weis Children's Hospital, Danville, PA
| | - Erin C Crawford
- the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan Moses
- the Division of Gastroenterology, Hepatology, and Nutrition, UH Rainbow Babies & Children's, Cleveland, OH
| | - Sandra C Kim
- the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
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Arbour M, Fico P, Floyd B, Morton S, Hampton P, Murphy Sims J, Atwood S, Sege R. Sustaining and scaling a clinic-based approach to address health-related social needs. FRONTIERS IN HEALTH SERVICES 2023; 3:1040992. [PMID: 36926501 PMCID: PMC10012656 DOI: 10.3389/frhs.2023.1040992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023]
Abstract
Objective Scaling evidence-based interventions (EBIs) from pilot phase remains a pressing challenge in efforts to address health-related social needs (HRSN) and improve population health. This study describes an innovative approach to sustaining and further spreading DULCE (Developmental Understanding and Legal Collaboration for Everyone), a universal EBI that supports pediatric clinics to implement the American Academy of Pediatrics' Bright Futures™ guidelines for infants' well-child visits (WCVs) and introduces a new quality measure of families' HRSN resource use. Methods Between August 2018 and December 2019, seven teams in four communities in three states implemented DULCE: four teams that had been implementing DULCE since 2016 and three new teams. Teams received monthly data reports and individualized continuous quality improvement (CQI) coaching for six months, followed by lighter-touch support via quarterly group calls (peer-to-peer learning and coaching). Run charts were used to study outcome (percent of infants that received all WCVs on time) and process measures (percent of families screened for HRSN and connected to resources). Results Integrating three new sites was associated with an initial regression of outcome: 41% of infants received all WCVs on time, followed by improvement to 48%. Process performance was sustained or improved: among 989 participating families, 84% (831) received 1-month WCVs on time; 96% (946) were screened for seven HRSN, 54% (508) had HRSN, and 87% (444) used HRSN resources. Conclusion An innovative, lighter-touch CQI approach to a second phase of scale-up resulted in sustainment or improvements in most processes and outcomes. Outcomes-oriented CQI measures (family receipt of resources) are an important addition to more traditional process-oriented indicators.
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Affiliation(s)
- MaryCatherine Arbour
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Placidina Fico
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Baraka Floyd
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, United States
| | | | - Patsy Hampton
- Center for the Study of Social Policy, Washington, D.C., United States
| | - Jennifer Murphy Sims
- Early Intervention Services, UCSF Benioff Children's Hospital, Oakland, CA, United States
| | - Sidney Atwood
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Robert Sege
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States
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Bolen SD, Beverly EA, Khoury S, Regan S, Wright JT, Koroukian S, Wexler R, Rao G, Hargraves D, Bricker D, Solomon GD, Holliday M, Gardner-Buckshaw S, Dworkin L, Perzynski AT, Littman E, Nevar A, Swiatkowski SM, Applegate M, Konstan MW. Forming Cardi-OH: A Statewide Collaborative to Improve Cardiovascular Health in Ohio. Cureus 2022; 14:e28381. [PMID: 36171829 PMCID: PMC9508792 DOI: 10.7759/cureus.28381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/05/2022] Open
Abstract
Background Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach. Methodology With funding from the Ohio Department of Medicaid’s Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio’s Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio. Results Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation. Conclusions The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.
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Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit. CHILDREN 2022; 9:children9081180. [PMID: 36010071 PMCID: PMC9406401 DOI: 10.3390/children9081180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022]
Abstract
Background: Unplanned extubations (UEs) occur frequently in the neonatal intensive care unit (NICU). These events can be associated with serious short-term and long-term morbidities and increased healthcare costs. Most quality improvement (QI) initiatives focused on UE prevention have concentrated efforts within individual NICUs. Methods: We formed a regional QI collaborative involving the four regional perinatal center (RPC) NICUs in upstate New York to reduce UEs. The collaborative promoted shared learning and targeted interventions specific to UE classification at each center. Results: There were 1167 UEs overall during the four-year project. Following implementation of one or more PDSA cycles, the combined UE rate decreased by 32% from 3.7 to 2.5 per 100 ventilator days across the collaborative. A special cause variation was observed for the subtype of UEs involving removed endotracheal tubes (rETTs), but not for dislodged endotracheal tubes (dETTs). The center-specific UE rates varied; only two centers observed significant improvement. Conclusions: A collaborative approach promoted knowledge sharing and fostered an overall improvement, although the individual centers’ successes varied. Frequent communication and shared learning experiences benefited all the participants, but local care practices and varying degrees of QI experience affected each center’s ability to successfully implement potentially better practices to prevent UEs.
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Neonatal abstinence syndrome and mother's own milk at discharge. J Perinatol 2022; 42:1044-1050. [PMID: 35725804 DOI: 10.1038/s41372-022-01430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 06/01/2022] [Accepted: 06/08/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe factors impacting receipt of mother's own milk (MOM) at discharge among California infants diagnosed with neonatal abstinence syndrome (NAS). STUDY DESIGN Cohort study of the California Perinatal Quality Care Collaborative's Maternal Substance Exposure Database for infants with NAS and gestational age ≥ 34 weeks from 2019 to 2020. RESULT 245 infants with NAS were identified. Variables with an increased likelihood of being discharged on MOM included maternal medication assisted treatment (p = 0.001), use of maternal addiction services (p < 0.001), receiving donor human milk (p = 0.001), being treated in the well baby unit (p < 0.001), rooming-in (p < 0.001), and kangaroo care (p < 0.001). Among infants with NAS for whom MOM was recommended (n = 84), rooming-in was the only factor associated with being discharged on MOM (p = 0.002); receiving formula was the only inversely associated factor (p < 0.001). CONCLUSION Results suggest supporting the mother-infant dyad and using non-pharmacologic treatment methods, such as rooming-in, increase receipt of MOM at discharge.
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Diop H, Cui X, Nielsen T, Peacock-Chambers E, Gupta M. Length of Stay Among Infants with Neonatal Abstinence Syndrome and Risk of Hospital Readmission. Matern Child Health J 2022; 26:2020-2029. [PMID: 35907127 DOI: 10.1007/s10995-022-03481-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database. METHODS Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn. RESULTS Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p < 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories. CONCLUSIONS Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.
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Affiliation(s)
- Hafsatou Diop
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA.
| | - Xiaohui Cui
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA
| | - Timothy Nielsen
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA
| | | | - Munish Gupta
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Developments in Nursing Practice to Address Substance Use in the Perinatal Period. J Obstet Gynecol Neonatal Nurs 2022; 51:361-376. [PMID: 35568096 DOI: 10.1016/j.jogn.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 12/30/2022] Open
Abstract
Since 1972, the year of the inaugural issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing, substance use during pregnancy has remained a public health concern in the United States. This concern is currently exacerbated by factors such as the opioid and stimulant use crisis and widening health and social inequities for many women and families. The purposes of this historical commentary are to describe trends in the perception of women with substance use disorder and their infants and related sociolegal implications and to trace the evolution of related nursing practice and research during the past 50 years. We provide recommendations and priorities for practice and research, including further integration of support for the mother-infant dyad, cross-sectoral collaborations, and equity-oriented practices and policies.
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Hemodynamic Quality Improvement Bundle to Reduce the Use of Inotropes in Extreme Preterm Neonates. Paediatr Drugs 2022; 24:259-267. [PMID: 35469390 DOI: 10.1007/s40272-022-00502-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND We evaluated the effect of the quality improvement (QI) bundle on the rate of inotrope use and associated morbidities. METHODS We included inborn preterm neonates born at < 29 weeks admitted to level III NICU. We implemented a QI bundle focusing on the first 72 h from birth which included delayed cord clamping, avoidance of routine echocardiography, the addition of clinical criteria to the definition of hypotension, factoring iatrogenic causes of hypotension, and standardization of respiratory management. The rate of inotropes use was compared before and after implementing the care bundle. Incidence of cystic periventricular leukomalacia (cPVL) was used as a balancing measure. RESULTS QI bundle implementation was associated with significant reduction in overall use of inotropes (24 vs 7%, p < 0.001), dopamine (18 vs 5%, p < 0.001), and dobutamine (17 vs 4%, p < 0.001). Rate of acute brain injury decreased significantly: acute brain injury of any grade (34 vs 20%, p < 0.001) and severe brain injury (15 vs 6%, p < 0.001). There was no difference in the incidence of cPVL (0.8 vs 1.4%, p = 0.66). Associations remained significant after adjusting for confounding factors. CONCLUSIONS A quality improvement bundled approach resulted in a reduction in inotropes use and associated brain morbidities in premature babies.
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Devlin LA, Young LW, Kraft WK, Wachman EM, Czynski A, Merhar SL, Winhusen T, Jones HE, Poindexter BB, Wakschlag LS, Salisbury AL, Matthews AG, Davis JM. Neonatal opioid withdrawal syndrome: a review of the science and a look toward the use of buprenorphine for affected infants. J Perinatol 2022; 42:300-306. [PMID: 34556799 PMCID: PMC8459143 DOI: 10.1038/s41372-021-01206-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/17/2021] [Accepted: 09/03/2021] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Lori A Devlin
- Department of Pediatrics, Division of Neonatal Medicine, University of Louisville School of Medicine, Louisville, KY, USA.
| | - Leslie W Young
- Department of Pediatrics, The Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA
| | - Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elisha M Wachman
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
| | - Adam Czynski
- Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Stephanie L Merhar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - T Winhusen
- Department of Psychiatry and Behavioral Neuroscience, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brenda B Poindexter
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lauren S Wakschlag
- Department of Medical Social Sciences, Feinberg School of Medicine & Institute for Innovations in Developmental Sciences, Northwestern University, Evanston, IL, USA
| | - Amy L Salisbury
- Virginia Commonwealth University School of Nursing, Richmond, VA, USA
| | | | - Jonathan M Davis
- Department of Pediatrics and the Tufts Clinical and Translational Science Institute, Tufts University School of Medicine, Boston, MA, USA
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Shukla S, Hanna I, Cortez J, Mansour M, Eiges A, Sharma P, Aderhold A, Meyers J, VanRavestein J, Hudak ML. Increasing usage of mother's own milk in neonates at risk of neonatal abstinence syndrome: MOM-NAS quality improvement initiative. J Perinatol 2021; 41:2684-2689. [PMID: 34531531 DOI: 10.1038/s41372-021-01209-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/26/2021] [Accepted: 09/09/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To increase the usage rate of mothers' own milk (MOM) among neonates with prenatal opioid exposure from a baseline average of 47% to an average of 75% over two years. STUDY DESIGN Between October 2018 and December 2020, we implemented various Plan-Do-Study-Act cycles that involved engaging providers in postpartum counseling for mothers with opioid dependence, using electronic medical records to track the rate of counseling, providing NAS educational materials to parents, and establishing a rooming-in unit. Our outcome measure was the provision of MOM to eligible neonates, while our process measure was the rate of postpartum counseling. RESULTS During this initiative, we witnessed a special cause variation with an increase in the usage rate of MOM from a baseline of 47% to a 27-month average of 85% by December 2020. CONCLUSION A series of quality improvement efforts resulted in increased usage of MOM among infants at risk of NAS.
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Affiliation(s)
- Samarth Shukla
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA. .,Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA.
| | - Issa Hanna
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Josef Cortez
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA.,Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Marwa Mansour
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Alexia Eiges
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Priya Sharma
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ashley Aderhold
- Department of Women's and Children's Nursing Services, University of Florida Health, Jacksonville, FL, USA
| | - Jennifer Meyers
- Department of Women's and Children's Nursing Services, University of Florida Health, Jacksonville, FL, USA
| | - Jenny VanRavestein
- Department of Women's and Children's Nursing Services, University of Florida Health, Jacksonville, FL, USA
| | - Mark L Hudak
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA.,Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA
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16
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Weikel BW, Palau MA, Hwang SS. Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals. Hosp Pediatr 2021; 11:1190-1198. [PMID: 34649934 DOI: 10.1542/hpeds.2021-005824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Blair W Weikel
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mauricio A Palau
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Sunah S Hwang
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado.,Section of Neonatology, Children's Hospital Colorado, Aurora, Colorado
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17
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Quality Improvement Initiative to Improve Healthcare Providers' Attitudes towards Mothers with Opioid Use Disorder. Pediatr Qual Saf 2021; 6:e453. [PMID: 34476305 PMCID: PMC8389895 DOI: 10.1097/pq9.0000000000000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/03/2021] [Indexed: 12/01/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Individuals with opioid use disorder often report feelings of shame and describe feeling judged negatively. These feelings are especially true for pregnant women with opioid use disorder. The Ohio Perinatal Quality Collaborative conducted a multimodal quality improvement initiative for infants born with Neonatal Abstinence Syndrome (NAS). An important component of the project was focused on improving staff attitudes toward mothers of infants with NAS. Methods: The Ohio Perinatal Quality Collaborative implemented an education program for healthcare providers at 39 participating hospital units regarding opioid use as a chronic disease and principles of nonjudgmental, trauma-informed care. Healthcare providers partnered with the mother of infants with NAS in the care of the infant and connected with local community resources. This work was a subcomponent of an overall multimodal quality improvement project. Healthcare provider attitudes were measured with the “Attitude Measurement: Brief Scales” questionnaire anonymously, at 3 different time points throughout the project. Attitude change was measured by pretraining and posttraining scores. ANOVA methods were used to compare individual items and a summary score across the 3 surveys. Results: Summary scores improved significantly from 18.99 at baseline (January–March 2014) to 19.94 (P < 0.0001) in February 2015 and were maintained at 20.05 in July 2016. Conclusions: A nonjudgmental attitude toward mothers of infants with NAS is an important component of compassionate care. Improving healthcare provider attitudes can benefit a mother of an infant with NAS and help preserve the mother–infant dyad.
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18
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Alsaleem M, Dusin J, Akangire G. Effect of Low Lactose Formula on the Short-Term Outcomes of Neonatal Abstinence Syndrome: A Systematic Review. Glob Pediatr Health 2021; 8:2333794X211035258. [PMID: 34368403 PMCID: PMC8312188 DOI: 10.1177/2333794x211035258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022] Open
Abstract
The use of low lactose formula (LLF) in term and near-term infants in infants with neonatal abstinence syndrome (NAS) has been increasing recently. However, the clinical evidence of such use is limited. Our aim in this paper was to systematically review the current literature about the use of LLF in infants with NAS. We searched PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Database of Systematic Reviews for articles published between 2015 and 2020. Only randomized controlled trials, prospective, and retrospective studies. The risk of bias was assessed by using published tools appropriate for the study type. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Forty-one titles and/or abstracts were screened independently by 2 reviewers (MA and GA). After an indepth review, 4 studies answered the study question (1 randomized controlled trial (RCT), 2 retrospective studies, and 1 quality improvement study). A meta-analysis could not be completed due to the study type difference and how the outcomes were reported. The studies found no benefit to feeding LLF to infants with NAS regarding short-term outcomes (length of stay, duration, and need for pharmacological therapy and growth). Certainty in the evidence is low. In conclusion we found no beneficial effects regarding the need for pharmacological therapy, duration of pharmacological treatment, length of hospital stay, and growth of using LLF compared to the standard formula in infants with NAS.
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Affiliation(s)
- Mahdi Alsaleem
- University of Kansas Medical Center, Wichita, KS, USA.,Children's Mercy Hospital, Kansas City, MO, USA
| | | | - Gangaram Akangire
- Children's Mercy Hospital, Kansas City, MO, USA.,University of Missouri-Kansas City, Kansas City, MO, USA.,Kansas University Medical Center, Kansas City, KS, USA
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19
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Leyenaar JK, Schaefer AP, Wasserman JR, Moen EL, O’Malley AJ, Goodman DC. Infant Mortality Associated With Prenatal Opioid Exposure. JAMA Pediatr 2021; 175:706-714. [PMID: 33843963 PMCID: PMC8042571 DOI: 10.1001/jamapediatrics.2020.6364] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Knowledge of health outcomes among opioid-exposed infants is limited, particularly for those not diagnosed with neonatal opioid withdrawal syndrome (NOWS). OBJECTIVES To describe infant mortality among opioid-exposed infants and identify how mortality risk differs in opioid-exposed infants with and without a diagnosis of NOWS compared with infants without opioid exposure. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of maternal-infant dyads was conducted, linking health care claims with vital records for births from January 1, 2010, to December 31, 2014, with follow-up of infants until age 1 year (through 2015). Maternal-infant dyads were included if the infant was born in Texas at 22 to 43 weeks' gestational age to a woman aged 15 to 44 years insured by Texas Medicaid. Data analysis was performed from May 2019 to October 2020. EXPOSURE The primary exposure was prenatal opioid exposure, with infants stratified by the presence or absence of a diagnosis of NOWS during the birth hospitalization. MAIN OUTCOMES AND MEASURES Risk of infant mortality (death at age <365 days) was examined using Kaplan-Meier and log-rank tests. A series of logistic regression models was estimated to determine associations between prenatal opioid exposure and mortality, adjusting for maternal and neonatal characteristics and clustering infants at the maternal level to account for statistical dependence owing to multiple births during the study period. RESULTS Among 1 129 032 maternal-infant dyads, 7207 had prenatal opioid exposure, including 4238 diagnosed with NOWS (mean [SD] birth weight, 2851 [624] g) and 2969 not diagnosed with NOWS (mean [SD] birth weight, 2971 [639] g). Infant mortality was 20 per 1000 live births for opioid-exposed infants not diagnosed with NOWS, 11 per 1000 live births for infants with NOWS, and 6 per 1000 live births in the reference group (P < .001). After adjusting for maternal and neonatal characteristics, mortality in infants with a NOWS diagnosis was not significantly different from the reference population (odds ratio, 0.82; 95% CI, 0.58-1.14). In contrast, the odds of mortality in opioid-exposed infants not diagnosed with NOWS was 72% greater than the reference population (odds ratio, 1.72; 95% CI, 1.25-2.37). CONCLUSIONS AND RELEVANCE In this study, opioid-exposed infants appeared to be at increased risk of mortality, and the treatments and supports provided to those diagnosed with NOWS may be protective. Interventions to support opioid-exposed maternal-infant dyads are warranted, regardless of the perceived severity of neonatal opioid withdrawal.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrew P. Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Jared R. Wasserman
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Erika L. Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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20
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Goodstein MH, Stewart DL, Keels EL, Moon RY. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics 2021; 148:peds.2021-052046. [PMID: 34155135 DOI: 10.1542/peds.2021-052046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.
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Affiliation(s)
- Michael H Goodstein
- Division of Newborn Services, WellSpan Health, York, Pennsylvania .,Department of Pediatrics, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Dan L Stewart
- Department of Pediatrics, Norton Children's and School of Medicine, University of Louisville, Louisville, Kentucky
| | - Erin L Keels
- National Association of Neonatal Nurse Practitioners, National Association of Neonatal Nurses, Chicago, Illinois.,Neonatal Advanced Practice, Nationwide Children's Hospital, Columbus, Ohio
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21
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Pandey R, Kanike N, Ibrahim M, Swarup N, Super DM, Groh-Wargo S, Kumar D. Lactose-free infant formula does not change outcomes of neonatal abstinence syndrome (NAS): a randomized clinical trial. J Perinatol 2021; 41:598-605. [PMID: 32868858 DOI: 10.1038/s41372-020-00797-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/16/2020] [Accepted: 08/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine if lactose-free formula, compared to lactose-containing formula, decreases the cumulative morphine dose required to treat neonatal abstinence syndrome (NAS). STUDY DESIGN In a double-blind clinical trial, we randomized 74 infants (36-42 weeks gestation) at risk for developing NAS due to in-utero exposure to opioids to receive either lactose-free (Similac Sensitive®) or lactose-containing (Similac Advance®) infant formula. The primary outcome measure was the cumulative dose of morphine used for the treatment of NAS during the first 14 days of life. RESULTS Data on 69 (4 withdrew consent and 1 ineligible)/74 randomized infants were analyzed. Patient characteristics between the infant groups fed lactose-free (n = 34) vs. lactose-containing (n = 35) infant formula were similar except more common maternal heroin abuse in the latter group (p = 0.013). Cumulative morphine dose (20.7 ± 19.8 vs. 23 ± 23.5 mg, p = 0.61) between the two groups were similar. CONCLUSION Lactose-free vs. lactose-containing infant formula did not change the outcomes of infants with NAS.
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Affiliation(s)
- Rajesh Pandey
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.,Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Neelakanta Kanike
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.,Pediatrics, Deaconess Women's Hospital, Newburgh, IN, USA
| | - Mugahid Ibrahim
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.,Department of Pediatrics, Cork University Maternity Hospital (CUMH), Cork, Ireland
| | - Namita Swarup
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Dennis M Super
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Sharon Groh-Wargo
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Deepak Kumar
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
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22
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Yossuck P, Tacker DH. Drug Positivity Findings from a Universal Umbilical Cord Tissue Drug Analysis Program in Appalachia. J Appl Lab Med 2020; 6:285-297. [PMID: 33324976 DOI: 10.1093/jalm/jfaa196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND West Virginia has high rates of opioid-related health crises and deaths that extend to pregnant women and newborns. Our institutional screening approach has included universal umbilical cord tissue drug analysis (UCTDA) since 2013. The objective of this study was to retrospectively report incidence of in utero drug exposure using UCTDA data. METHODS Two sequential UCTDA data sets (October 2013 to September 2015, and October 2016 to September 2018) represent interrupted epochs given changes in interfaced data availability. UCTDA positivity (by drug class and parent drug) and numbers of drugs detected in each specimen were retrospectively analyzed. THC was removed from the analysis because of discontinuous testing, and 4 opioids were separated from the data set given the potential for both therapeutic and illicit use. RESULTS UCTDA specimens that were positive for drugs (22% overall) decreased between Epochs 1 and 2, from 25% to 20%. Increased positivity was noted for hydrocodone (+407%), oxycodone (+240%), amphetamines (+506%), and cocaine (+417%). Fentanyl and morphine positivity decreased by 75% and 18%, respectively, whereas buprenorphine detection increased 195%. Most positive specimens (80% overall) had 1 drug present, but specimens positive for 2 to 6 discrete drugs were found. CONCLUSION Universal UCTDA allows for unbiased assessment of drug exposure in infants. With the additional knowledge of therapeutic indications for drug use, UCTDA may allow for analysis of trends in illicit drug use and the impact of interventions to curb neonatal abstinence syndrome.
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Affiliation(s)
- Panitan Yossuck
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV.,Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Danyel H Tacker
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV.,Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University School of Medicine, Morgantown, WV
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23
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Peeler M, Gupta M, Melvin P, Bryant AS, Diop H, Iverson R, Callaghan K, Wachman EM, Singh R, Houghton M, Greenfield SF, Schiff DM. Racial and Ethnic Disparities in Maternal and Infant Outcomes Among Opioid-Exposed Mother-Infant Dyads in Massachusetts (2017-2019). Am J Public Health 2020; 110:1828-1836. [PMID: 33058701 PMCID: PMC7661985 DOI: 10.2105/ajph.2020.305888] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 11/04/2022]
Abstract
Objectives. To examine the extent to which differences in medication for opioid use disorder (MOUD) in pregnancy and infant neonatal opioid withdrawal syndrome (NOWS) outcomes are associated with maternal race/ethnicity.Methods. We performed a secondary analysis of a statewide quality improvement database of opioid-exposed deliveries from January 2017 to April 2019 from 24 hospitals in Massachusetts. We used multivariable mixed-effects logistic regression to model the association between maternal race/ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic) and prenatal receipt of MOUD, NOWS severity, early intervention referral, and biological parental custody at discharge.Results. Among 1710 deliveries to women with opioid use disorder, 89.3% (n = 1527) were non-Hispanic White. In adjusted models, non-Hispanic Black women (AOR = 0.34; 95% confidence interval [CI] = 0.18, 0.66) and Hispanic women (AOR = 0.43; 95% CI = 0.27, 0.68) were less likely to receive MOUD during pregnancy compared with non-Hispanic White women. We found no statistically significant associations between maternal race/ethnicity and infant outcomes.Conclusions. We identified significant racial/ethnic differences in MOUD prenatal receipt that persisted in adjusted models. Research should focus on the perspectives and treatment experiences of non-Hispanic Black and Hispanic women to ensure equitable care for all mother-infant dyads.
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Affiliation(s)
- Mary Peeler
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Munish Gupta
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Patrice Melvin
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Allison S Bryant
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Hafsatou Diop
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Ronald Iverson
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Katherine Callaghan
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Elisha M Wachman
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Rachana Singh
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Mary Houghton
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Shelly F Greenfield
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Davida M Schiff
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
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Engaging Mothers to Implement Nonpharmacological Care for Infants With Neonatal Abstinence Syndrome: Perceptions of Perinatal and Pediatric Nurses. Adv Neonatal Care 2020; 20:464-472. [PMID: 33009157 DOI: 10.1097/anc.0000000000000812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about nurse perceptions regarding engagement of mothers in implementation of nonpharmacological care for opioid-exposed infants. PURPOSE This study was designed to describe perinatal and pediatric nurse perceptions of (1) engaging mothers in the care of opioid-exposed infants and (2) facilitators and barriers to maternal engagement. METHODS This study used a qualitative descriptive design to interview perinatal and pediatric nurses in one Midwest United States hospital. Interviews were conducted via telephone using a semistructured interview guide and audio recorded. Audio files were transcribed verbatim and thematically analyzed using the constant comparative method. RESULTS Twenty-one nurses participated in the study, representing a family birth center, neonatal intensive care unit, and pediatric unit. Five major themes resulted from analysis: (1) vulnerability and bias; (2) mother-infant care: tasks versus model of care; (3) maternal factors affecting engagement and implementation; (4) nurse factors affecting engagement and implementation; and (5) recommendations and examples of nursing approaches to barriers. Minor themes supported each of the major themes. IMPLICATIONS FOR PRACTICE Nurses must engage mothers with substance use histories with empathy and nonjudgment, identify and promote maternal agency to care for their infants, and engage and activate mothers to deliver nonpharmacological care during the hospital stay and following discharge. IMPLICATIONS FOR RESEARCH Findings suggest interventions are needed to improve (1) nursing education regarding maternal substance use and recovery, (2) empathy for substance-using mothers and mothers in treatment, and (3) identification and support of maternal agency to provide nonpharmacological care to withdrawing infants.
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Abstract
The opioid crisis has grown to affect pregnant women and infants across the United States, as evidenced by rising rates of opioid use disorder among pregnant women and neonatal opioid withdrawal syndrome among infants. Across the country, pregnant women lack access to evidence-based therapies, including medications for opioid use disorder, and infants with opioid exposure frequently receive variable care. In addition, public systems, such as child welfare and early intervention, are increasingly stretched by increasing numbers of children affected by the crisis. Systematic, enduring, coordinated, and holistic approaches are needed to improve care for the mother-infant dyad. In this statement, we provide an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.
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Affiliation(s)
- Stephen W Patrick
- Division of Neonatology, Department of Pediatrics and Health Policy, School of Medicine, Vanderbilt University and Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Wanda D Barfield
- Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Brenda B Poindexter
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Medical Hospital Center, Cincinnati, Ohio
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Meyers JM, Tulloch J, Brown K, Caserta MT, D'Angio CT. A Quality Improvement Initiative To Optimize Antibiotic Use in a Level 4 NICU. Pediatrics 2020; 146:peds.2019-3956. [PMID: 33055227 DOI: 10.1542/peds.2019-3956] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Given the risks associated with antibiotics, efforts to reduce unnecessary antibiotic use in the NICU have become increasingly urgent. In 2016, a comprehensive 3-year quality improvement (QI) initiative was conducted in a level 4 NICU that sought to decrease the antibiotic use rate (AUR) by 20%. METHODS This local QI initiative was conducted in the context of a multicenter learning collaborative focused on decreasing unnecessary antibiotic use. Improvement strategies focused on addressing gaps in the core elements of antibiotic stewardship programs. Outcome measures included the AUR and the percent of infants discharged without antibiotic exposure. Process measures included the percent of infants evaluated for early-onset sepsis (EOS) and duration of antibiotics used for various infections. Statistical process control charts were used to display and analyze data over time. RESULTS The AUR decreased from 27.6% at baseline to 15.5%, a 43% reduction, and has been sustained for >18 months. Changes most attributable to this decrease include implementation of the sepsis risk calculator, adopting a 36-hour rule-out period for sepsis evaluations, a 36-hour antibiotic hard stop, and novel guideline for EOS evaluation among infants <35 weeks. The percent of infants discharged without antibiotic exposure increased from 15.8% to 35.1%. The percent of infants ≥36 weeks undergoing evaluation for EOS decreased by 42.3% and for those <35 weeks by 26%. CONCLUSIONS Our efforts significantly reduced antibiotic use and exposure in our NICU. Our comprehensive, rigorous approach to QI is applicable to teams focused on improvement.
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Affiliation(s)
| | | | - Kristen Brown
- Department of Nursing, University of Rochester Medical Center, Rochester, New York
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27
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Kaplan HC, Kuhnell P, Walsh MC, Crowley M, McClead R, Wexelblatt S, Ford S, Provost LP, Lannon C, Macaluso M. Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome. Pediatrics 2020; 146:peds.2019-0914. [PMID: 32913133 DOI: 10.1542/peds.2019-0914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite the standardization of care, formula feeding varied across sites of the Ohio Perinatal Quality Collaborative (OPQC). We used orchestrated testing (OT) to learn from this variation and improve nonpharmacologic care of infants with neonatal abstinence syndrome (NAS) requiring pharmacologic treatment in Ohio. METHODS To test the impact of formula on length of stay (LOS), treatment failure, and weight loss among infants hospitalized with NAS, we compared caloric content (high versus standard) and lactose content (low versus standard) using a 22 factorial design. During October 2015 to June 2016, OPQC sites joined 1 of 4 OT groups. We used response plots to examine the effect of each factor and control charts to track formula use and LOS. We used the OT results to revise the nonpharmacologic bundle and implemented it during 2017. RESULTS Forty-seven sites caring for 546 NAS infants self-selected into the 4 OT groups. Response plots revealed the benefit of high-calorie formula (HCF) on weight loss, treatment failure, and LOS. The nonpharmacologic treatment bundle was updated to recommend HCF when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC. CONCLUSIONS OT revealed that HCF was associated with shorter LOS in OPQC sites. Implementation of a revised nonpharmacologic care bundle was followed by additional LOS improvement in Ohio. Despite some challenges in the implementation of OT, our findings support its usefulness for learning in improvement networks.
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Affiliation(s)
- Heather C Kaplan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; .,Perinatal Institute.,James M. Anderson Center for Health Systems Excellence, and
| | - Pierce Kuhnell
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michele C Walsh
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Moira Crowley
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Richard McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Scott Wexelblatt
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Perinatal Institute
| | - Susan Ford
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Carole Lannon
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, and
| | - Maurizio Macaluso
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Sadee W, Oberdick J, Wang Z. Biased Opioid Antagonists as Modulators of Opioid Dependence: Opportunities to Improve Pain Therapy and Opioid Use Management. Molecules 2020; 25:E4163. [PMID: 32932935 PMCID: PMC7571197 DOI: 10.3390/molecules25184163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 12/20/2022] Open
Abstract
Opioid analgesics are effective pain therapeutics but they cause various adverse effects and addiction. For safer pain therapy, biased opioid agonists selectively target distinct μ opioid receptor (MOR) conformations, while the potential of biased opioid antagonists has been neglected. Agonists convert a dormant receptor form (MOR-μ) to a ligand-free active form (MOR-μ*), which mediates MOR signaling. Moreover, MOR-μ converts spontaneously to MOR-μ* (basal signaling). Persistent upregulation of MOR-μ* has been invoked as a hallmark of opioid dependence. Contrasting interactions with both MOR-μ and MOR-μ* can account for distinct pharmacological characteristics of inverse agonists (naltrexone), neutral antagonists (6β-naltrexol), and mixed opioid agonist-antagonists (buprenorphine). Upon binding to MOR-μ*, naltrexone but not 6β-naltrexol suppresses MOR-μ*signaling. Naltrexone blocks opioid analgesia non-competitively at MOR-μ*with high potency, whereas 6β-naltrexol must compete with agonists at MOR-μ, accounting for ~100-fold lower in vivo potency. Buprenorphine's bell-shaped dose-response curve may also result from opposing effects on MOR-μ and MOR-μ*. In contrast, we find that 6β-naltrexol potently prevents dependence, below doses affecting analgesia or causing withdrawal, possibly binding to MOR conformations relevant to opioid dependence. We propose that 6β-naltrexol is a biased opioid antagonist modulating opioid dependence at low doses, opening novel avenues for opioid pain therapy and use management.
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Affiliation(s)
- Wolfgang Sadee
- Department of Cancer Biology and Genetics, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
- Aether Therapeutics Inc., 4200 Marathon Blvd. Austin, TX 78756, USA
- Pain and Addiction Research Center, University of California San Francisco, San Francisco, CA 94158, USA
| | - John Oberdick
- Department of Neuroscience, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA;
| | - Zaijie Wang
- Departments of Pharmaceutical Sciences and Neurology, University of Illinois at Chicago. Chicago, IL 60612, USA;
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Alsaleem M, Berkelhamer SK, Wilding GE, Miller LM, Reynolds AM. Effects of Partially Hydrolyzed Formula on Severity and Outcomes of Neonatal Abstinence Syndrome. Am J Perinatol 2020; 37:1177-1182. [PMID: 31238343 DOI: 10.1055/s-0039-1692684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This study compares the effect of partially hydrolyzed formula (PHF) and standard formula (SF) on the severity and short-term outcomes of neonatal abstinence syndrome (NAS). STUDY DESIGN We performed a retrospective chart review of 124 opioid-dependent mothers and their term or near-term infants. Infants were categorized according to the predominant type of formula consumed during the hospital stay. Finnegan's scale was used to assess symptoms of withdrawal. RESULTS A total of 110 infants met our inclusion criteria. Thirty-four (31%) infants were fed predominantly PHF, 60 (54%) infants were fed SF, and 16 (15%) infants were fed maternal breast milk. There was no difference between the infants in the PHF and SF groups with respect to requirement of morphine (MSO4) therapy, maximum dose of MSO4 used, duration of MSO4 treatment or length of hospital stay after performing multivariate analyses to control for type of drug used by the mother, maternal smoking, regular prenatal care, inborn status, and maximum Finnegan score prior to MSO4 treatment. CONCLUSION Use of PHF failed to impact short-term outcomes in infants treated for NAS including maximum MSO4 dose, duration of MSO4 treatment, and length of hospital stay. A prospective randomized controlled trial may be indicated to confirm this finding.
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Affiliation(s)
- Mahdi Alsaleem
- Division of Neonatal-Perinatal Medicine, The State University of New York at Buffalo, Buffalo, New York
| | - Sara K Berkelhamer
- Division of Neonatal-Perinatal Medicine, The State University of New York at Buffalo, Buffalo, New York
| | - Gregory E Wilding
- Department of Biostatistics, The State University of New York at Buffalo, Buffalo, New York
| | - Lorin M Miller
- Department of Biostatistics, The State University of New York at Buffalo, Buffalo, New York
| | - Anne Marie Reynolds
- Division of Neonatal-Perinatal Medicine, The State University of New York at Buffalo, Buffalo, New York
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Enhancing Safe Sleep Counseling by Pediatricians through a Quality Improvement Learning Collaborative. Pediatr Qual Saf 2020; 5:e327. [PMID: 32766498 PMCID: PMC7339247 DOI: 10.1097/pq9.0000000000000327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/12/2020] [Indexed: 11/26/2022] Open
Abstract
Background Approximately, 3,500 infants die annually from sleep-related infant deaths in the United States. We sought to improve pediatricians' counseling on safe sleep from birth through 6 months of age through a virtual quality improvement learning collaborative (QILC). Our aim was appropriate screening, counseling, and documentation of safe sleep advice in 75% of eligible patient encounters after the QILC. Methods We formed a 9-month QILC for inpatient and outpatient pediatricians. Pediatricians collected data on safe sleep documentation in a newborn discharge or well-child visit note. Data were submitted at baseline and in 9 subsequent phases. Participants met monthly via a webinar, which included a QI presentation, data review, and facilitated discussion among participants. Practices were contacted 12 months after the conclusion of the QILC to assess sustainment. Results Thirty-four pediatricians from 4 inpatient and 9 outpatient practices participated in the QILC. At baseline, documentation of safe sleep practices varied greatly (0%-98%). However, by the end of the QILC, all participating practices were documenting safe sleep guidance in over 75% of patient encounters. Aggregate practice data show a significant, sustained improvement. The 12-month follow-up data were submitted from 62% of practices, with sustainment of improvement in 75% of practices. Conclusion A facilitated, virtual QILC is an effective methodology to improve safe sleep counseling among a diverse group of pediatric practices. It is one step in improving consistent messaging around safe sleep by healthcare providers as pediatricians work to decrease sleep-related infant deaths.
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Eckardt P, Bailey D, DeVon HA, Dougherty C, Ginex P, Krause-Parello CA, Pickler RH, Richmond TS, Rivera E, Roye CF, Redeker N. Opioid use disorder research and the Council for the Advancement of Nursing Science priority areas. Nurs Outlook 2020; 68:406-416. [PMID: 32279897 DOI: 10.1016/j.outlook.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/03/2020] [Accepted: 02/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic diseases, such as opioid use disorder (OUD) require a multifaceted scientific approach to address their evolving complexity. The Council for the Advancement of Nursing Science's (Council) four nursing science priority areas (precision health; global health, determinants of health, and big data/data analytics) were established to provide a framework to address current complex health problems. PURPOSE To examine OUD research through the nursing science priority areas and evaluate the appropriateness of the priority areas as a framework for research on complex health conditions. METHOD OUD was used as an exemplar to explore the relevance of the nursing science priorities for future research. FINDINGS Research in the four priority areas is advancing knowledge in OUD identification, prevention, and treatment. Intersection of OUD research population focus and methodological approach was identified among the priority areas. DISCUSSION The Council priorities provide a relevant framework for nurse scientists to address complex health problems like OUD.
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Affiliation(s)
| | | | - Holli A DeVon
- University of California Los Angeles School of Nursing, Los Angeles, CA
| | - Cynthia Dougherty
- Dept of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA
| | | | | | - Rita H Pickler
- The Ohio State University College of Nursing, Columbus, OH
| | | | - Eleanor Rivera
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Colonial Penn Center, Philadelphia, PA
| | - Carol F Roye
- Pace University, College of Health Professions, Pleasantville, NY
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Clemans-Cope L, Holla N, Lee HC, Cong AS, Castro R, Chyi L, Huang A, Taylor KJ, Kenney GM. Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey. J Perinatol 2020; 40:463-472. [PMID: 31911649 PMCID: PMC7042156 DOI: 10.1038/s41372-019-0568-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 11/22/2019] [Accepted: 12/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices. STUDY DESIGN We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California. RESULTS Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in. CONCLUSIONS We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.
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Affiliation(s)
- Lisa Clemans-Cope
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA.
| | - Nikhil Holla
- George Washington University, Washington, DC, USA
| | - Henry C Lee
- Division of Neonatal & Developmental Medicine, Stanford University, Stanford, CA, USA
| | - Allison Shufei Cong
- California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Stanford, CA, USA
| | - Robert Castro
- Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Chyi
- Walnut Creek Medical Center, Kaiser Northern California NAS Workgroup Co-chair, Walnut Creek, CA, USA
| | - Angela Huang
- Department of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Kimá Joy Taylor
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA
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Quality Improvement Learning Collaborative Improves Timely Newborn Follow-Up Appointments. Jt Comm J Qual Patient Saf 2019; 45:808-813. [PMID: 31607501 DOI: 10.1016/j.jcjq.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND American Academy of Pediatrics guidelines indicate that newborns should follow up with their primary care providers within three days of discharge from the newborn nursery. Many barriers exist to achieving timely follow-up, with potential implications on a newborn's health. The goal of this project was to improve rates of timely newborn follow-up through a nine-month quality improvement learning collaborative (QILC). Timely newborn follow-up was defined as an appointment scheduled within three days of newborn discharge. METHODS Both inpatient hospitalist and outpatient pediatric practices were eligible to participate. Inpatient and outpatient practices aimed to have 75% of newborns scheduled appropriately by six months into the project. In addition, outpatient practices aimed to have 60% of newborns seen appropriately by their provider. All practices aimed to have their progress sustained at conclusion of the QILC. Practices submitted data at baseline and nine subsequent phases. Monthly webinars featured a quality improvement didactic, data review, and discussion of practices' changes, successes, and challenges. RESULTS Eleven practices and 24 physicians participated in the QILC. Aggregate data from the practices showed continual improvement in all measured newborn scheduling metrics throughout the nine-month learning collaborative, with sustainment of progress over the last three months of the QILC. CONCLUSION A QILC is successful for increasing timely newborn follow-up for both the newborn hospitalist and outpatient pediatrician. Pediatric providers can learn from others' strategies and successes to incorporate meaningful changes in their practice.
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Clinical Decision Support to Improve Dosing Weight Use in Infants with Neonatal Abstinence Syndrome. Pediatr Qual Saf 2019; 4:e184. [PMID: 31572886 PMCID: PMC6708646 DOI: 10.1097/pq9.0000000000000184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/11/2019] [Indexed: 01/08/2023] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Opioid abuse in the United States is a public health emergency. From 2000 to 2009, prenatal maternal opiate use increased from 1.19 to 5.63 per 1,000 births, with up to 80% of in utero opioid-exposed infants requiring pharmacotherapy. This study aimed to increase the percentage of neonatal abstinence syndrome (NAS) medication orders based on birth weight (BW) in neonates admitted to a neonatal intensive care unit with a principal diagnosis of NAS from 29% to 90%, within 4 months of project initiation, and to sustain this for 6 months. Methods: This project occurred at an academic medical center with 5,000 deliveries per year and a 49-bed Level III neonatal intensive care unit. We used the Institute for Healthcare Improvement methodology, largely focusing interventions on clinical decision support (CDS) tools. We plotted all measures on Shewhart charts, and Nelson rules differentiated special versus common cause variation. Results: The percent of orders based on BW increased from 29% to 78% after implementing multiple interventions focused primarily on CDS. However, this later decreased to 48% as workarounds began. There was also a significant decrease in the length of stay variability, which persisted throughout the project. Discussion: CDS is a helpful tool to guide prescribing behavior; however, workarounds can negate its usefulness. Standardized use of BW for weight-based NAS medication prescribing can decrease the length of stay variability. Further studies are needed using a human factors approach to minimize workarounds in CDS and potentially decrease the length of stay in neonates with NAS.
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Treating infants with neonatal abstinence syndrome: an examination of three protocols. J Perinatol 2019; 39:1377-1383. [PMID: 31383946 DOI: 10.1038/s41372-019-0450-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/06/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Describe the characteristics of infants with NAS and determine if treatment outcomes varied between three protocols. STUDY DESIGN Based on medical record data, infant treatment for NAS-related withdrawal reflected one of three protocols: (1) No rescue dose (n = 836, 52.7%): Prescriber ordered initiation and escalation doses and determined when infants were eligible for weaning, (2) Rescue dose (n = 233, 14.7%): No rescue dose with the addition of a prescriber-ordered rescue dose, (3) Rescue dose by order set (n = 516, 32.6%): Rescue dose with addition of nurse-assisted order of morphine during escalation. RESULTS The no rescue dose group had longer length of stay, days to wean, and inpatient days, and greater initial morphine dose than the two rescue dose groups (p < 0.001). Treatment outcomes between the two rescue dose protocols did not differ. CONCLUSIONS The benefits related to rescue dosing further inform the development of a standardized NAS treatment protocol.
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MacVicar S, Kelly LE. Systematic mixed-study review of nonpharmacological management of neonatal abstinence syndrome. Birth 2019; 46:428-438. [PMID: 30938466 DOI: 10.1111/birt.12427] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neonatal abstinence syndrome is a multisystem disorder resulting from exposure to maternal addictive substance use in pregnancy. Withdrawal is characterized by neonatal tremors, feeding difficulties, and sleep disruption. The aim of this systematic review is to explore the nonpharmacological management of infants at risk of neonatal abstinence syndrome after prenatal exposure. METHODS A systematic mixed-study review was conducted. A search of CINAHL, MEDLINE, AMED, PsycARTICLES, PsycINFO, and Web of Science was performed for relevant articles published between January 2007 and June 2018. Quantitative and qualitative data were extracted and thematic analysis undertaken. The findings were synthesized as a narrative summary. RESULTS Fourteen studies were included in the review, of which nine were quality improvement initiatives and five explored complementary therapies. The most common components of nonpharmacological management were consolation therapy and rooming-in of mother and baby. Implementation strategies incorporated family integrated care and practitioner training in the evaluation of neonatal withdrawal. When nonpharmacological management was applied, there was a reduction in the need for pharmacotherapy and a shorter hospital stay for newborns. Potential barriers to effective management included unreliable assessment tools, judgmental practitioner attitudes, and limited breastfeeding promotion. CONCLUSIONS Providing and optimizing nonpharmacological management for the infant at risk of neonatal abstinence syndrome improves outcomes by reducing their length of hospital stay and the need for pharmacotherapy.
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Affiliation(s)
- Sonya MacVicar
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Lauren E Kelly
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
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Cook CE, Fantasia HC. Interventions for the Treatment of Neonatal Abstinence Syndrome. Nurs Womens Health 2019; 23:357-365. [PMID: 31251931 DOI: 10.1016/j.nwh.2019.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/06/2019] [Accepted: 05/01/2019] [Indexed: 06/09/2023]
Abstract
The growing incidence of neonatal abstinence syndrome (NAS) among newborns is a public health crisis that is a sequela of the national opioid crisis. When fetuses are exposed to opioids in utero, whether through prescription pain medication, illicit substances, or supervised medication-assisted opioid treatment, neonates can experience withdrawal symptoms shortly after birth. Opioid withdrawal manifests with symptoms of central nervous system and autonomic nervous system dysfunction. Treatment of NAS begins with nonpharmacologic interventions, and if a neonate requires more intensive treatment, care will escalate to include pharmacologic treatments, including morphine, methadone, and buprenorphine. When pharmacologic therapy begins, nonpharmacologic intervention is not ceased; rather, the two are used in conjunction in an attempt to reduce the amount of medication required for successful treatment. Herein we review nonpharmacologic nursing interventions, discuss the most common pharmacologic treatments for NAS, and present practice implications for nurses who work with childbearing families.
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Snowden JN, Akshatha A, Annett RD, Crawford MM, Das A, Devlin LA, Higgins RD, Hu Z, Lindsay E, Merhar S, Campbell Nesmith C, Pratt-Chavez H, Ross J, Simon AE, Smith MC, Turley CB, Walden A, Young L, Whalen B. The ACT NOW Clinical Practice Survey: Gaps in the Care of Infants With Neonatal Opioid Withdrawal Syndrome. Hosp Pediatr 2019; 9:585-592. [PMID: 31324654 DOI: 10.1542/hpeds.2019-0089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased fivefold over the last 10 years. Standardized NOWS care protocols have revealed many improved patient outcomes. Our objective for this study is to describe results of a clinical practice survey of NOWS management practices designed to inform future clinical studies in the diagnosis and management of NOWS. METHODS A cross-sectional survey was administered to medical unit directors at 32 Institutional Development Award States Pediatric Clinical Trial Network and 22 Neonatal Research Network sites in the fall of 2017. Results are presented as both the number and percentage of positive responses. Ninety-five percent Wilson confidence intervals (CIs) were generated around estimates, and χ2 and Fisher's exact tests were used to compare the association between unit type and reporting of each protocol. RESULTS Sixty-two responses representing 54 medical centers were received. Most participating NICU and non-ICU sites reported protocols for NOWS management, including NOWS scoring (98% NICU; 86% non-ICU), pharmacologic treatment (92% NICU; 64% non-ICU), and nonpharmacologic care (79% NICU; 79% non-ICU). Standardized protocols for pharmacologic care and weaning were reported more frequently in the NICU (92% [95% CI: 80%-97%] and 94% [95% CI: 83%-98%], respectively) compared with non-ICU settings (64% [95% CI: 39%-84%] for both) (P < .05 for both comparisons). Most medical centers reported morphine as first-line therapy (82%; 95% CI: 69%-90%) and level 3 and level 4 NICUs as the location of pharmacologic treatment (83%; 95% CI: 71%-91%). CONCLUSIONS Observed variations in care between NICUs and non-ICUs revealed opportunities for targeted interventions in training and standardized care plans in non-ICU sites.
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Affiliation(s)
- Jessica N Snowden
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas;
| | - A Akshatha
- Kapiolani Women and Children's Hospital, Honolulu, Hawaii
| | - Robert D Annett
- University of Mississippi Medical Center, Jackson, Mississippi
| | | | - Abhik Das
- RTI International, Research Triangle Park, North Carolina
| | - Lori A Devlin
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - Rosemary D Higgins
- College of Health and Human Services, George Mason University, Fairfax, Virginia
| | - Zhuopei Hu
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Elizabeth Lindsay
- Department of Pediatrics, Section of Neonatology, Tulane University, New Orleans, Louisiana
| | | | - Clare Campbell Nesmith
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Judith Ross
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Alan E Simon
- Environmental Influences on Child Health Outcomes Program, National Institutes of Health, Bethesda, Maryland
| | - M Cody Smith
- West Virginia University Medical Center, Morgantown, West Virginia
| | - Christine B Turley
- Department of Pediatrics, College of Medicine, University of South Carolina, Columbia, South Carolina
| | - Anita Walden
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Leslie Young
- University of Vermont Medical Center, Burlington, Vermont; and
| | - Bonny Whalen
- Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Oji-Mmuo CN, Schaefer EW, Liao L, Kaiser JR, Sekhar DL. The Possibility of Early Discharge for Newborns Being Monitored for Neonatal Abstinence Syndrome Based on Modified Finnegan Score Distributions. Clin Pediatr (Phila) 2019; 58:641-646. [PMID: 30813757 DOI: 10.1177/0009922819832022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We tested the hypothesis that Modified Finnegan Neonatal Scoring System (MFNSS) scores can guide early discharge at 72 hours for newborns at risk for neonatal abstinence syndrome (NAS). A retrospective cohort study with a primary outcome of early discharge of newborns at risk for NAS using mean MFNSS scores recorded before pharmacologic treatment was performed. Quantile regression was used to develop percentile curves of mean MFNSS scores. A total of 202 term newborns at risk for NAS with 5066 mean MFNSS scores recorded before pharmacologic treatment were studied. Sixty-eight of 121 (56%) newborns not treated at 72 hours had mean MFNSS scores <50th percentile and only 1 was ultimately treated (1.5%, 95% confidence interval: 0% to 8%). No newborns with mean MFNSS scores <25th percentile at 72 hours were treated. Newborns at risk for NAS with mean MFNSS scores <50th percentile can be safely discharged by 72 hours if families can assure close outpatient follow-up.
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Affiliation(s)
| | | | - Lucia Liao
- 2 Penn State College of Medicine, Hershey, PA, USA
| | | | - Deepa L Sekhar
- 1 Penn State Health Children's Hospital, Hershey, PA, USA
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Terao M, Hoffman JM, Brilli RJ, Finch A, Walsh KE, Coffey M. Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts. ACTA ACUST UNITED AC 2019; 5:111-130. [PMID: 32789105 DOI: 10.1007/s40746-019-00155-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Purpose of review Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives. Recent Findings Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care. Summary Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.
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Affiliation(s)
- Michael Terao
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Office of Quality and Patient Care and Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Richard J Brilli
- Nationwide Children's Hospital; Pediatrics, Ohio State University College of Medicine, Columbus, OH
| | - Amanda Finch
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
| | - Kathleen E Walsh
- MD, MS, James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Maitreya Coffey
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
- The Hospital for Sick Children, Toronto, Ontario, Canada
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Crane D, Marcotte M, Applegate M, Massatti R, Hurst M, Menegay M, Mauk R, Williams S. A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants. J Subst Abuse Treat 2019; 102:53-59. [PMID: 31202289 DOI: 10.1016/j.jsat.2019.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/12/2019] [Accepted: 04/25/2019] [Indexed: 12/12/2022]
Abstract
A collaborative led by state health and human service agencies, academic leaders, and stakeholders tested interventions to expand use of medication assisted treatment (MAT) through a maternal medical home (MMH) model that coordinated behavioral health and prenatal care with social supports for pregnant women with opioid use disorder (OUD) enrolled in Medicaid. The program was anchored in four clinical organizations with distinct models of care: community behavioral health, residential behavioral health, hospital-based obstetrical practice, and co-located obstetrical and behavioral health. A modified version of the Institute for Healthcare Improvement Breakthrough Series Model for Improvement was implemented using monthly performance data feedback to conduct small tests of change and improve care. Administrative data from the state's Medicaid, vital statistics, and child welfare systems were linked to evaluate the impact of MOMS on 252 mother-infant dyads compared to a sample of 846 Medicaid beneficiaries with OUD in the third trimester of pregnancy. MOMS participation was associated with increased likelihood of MAT in trimesters one, two and three (AOR = 2.30, 4.40, 2.75, respectively), behavioral health counseling during trimesters two and three (AOR = 3.75 and 2.07, respectively), retention in MAT during postpartum months one through three and four through six (AOR = 2.86, 2.40, respectively), and marginally lower out-of-home placement of infants born to mothers with OUD (AOR = 0.66). Within the MOMS program, greater participation in behavioral health treatment and MAT (χ2(3) ≥ 12.09) was observed in the co-located behavioral health/obstetrical care practice site compared to behavioral health-led and obstetrical provider-led sites.
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Affiliation(s)
- Dushka Crane
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Michael Marcotte
- Tri-State Maternal-Fetal Medicine Associates, United States of America.
| | - Mary Applegate
- FACP - NASHP, Ohio Department of Medicaid, United States of America.
| | - Richard Massatti
- Ohio Department of Mental Health and Addiction Services, United States of America.
| | - Mark Hurst
- Ohio Department of Mental Health and Addiction Services, United States of America.
| | - Michelle Menegay
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Rachel Mauk
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Susan Williams
- Ohio Department of Job and Family Services, United States of America.
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Whalen BL, Holmes AV, Blythe S. Models of care for neonatal abstinence syndrome: What works? Semin Fetal Neonatal Med 2019; 24:121-132. [PMID: 30926259 DOI: 10.1016/j.siny.2019.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.
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Affiliation(s)
- Bonny L Whalen
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, DHMC Pediatrics, One Medical Center Dr., Lebanon, NH, 03756, USA.
| | - Alison V Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, DHMC Pediatrics, One Medical Center Dr, Lebanon, NH, 03756, USA.
| | - Stacy Blythe
- School of Nursing and Midwifery, Western Sydney University, Translational Health Research Institute (THRI), Locked Bag 1797, Western Sydney University, Penrith, NSW, 2751, Australia.
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Abstract
BACKGROUND Perinatal substance exposure is an increasing concern in infants being cared for in neonatal intensive care units. Current recommendations support nonpharmacologic treatments for this population of infants. Multimodal (motion, sound) seats are often employed to soothe infants. PURPOSE The purpose of this study was to survey neonatal intensive care unit nurses on their practices regarding the use of a motion/sound infant seat. METHODS Sixty-six nurses (52% of 126 total nurses) completed the survey about their self-disclosed practices that included (1) reasons for use; (2) rationale for choice of settings of motion and sound; (3) duration of time infants spent in seat in one session; (4) perception of positive infant response; (5) who places infants in the seat; and (6) nursing instructions dispensed prior to use. RESULTS Chief reasons for use were infant state, lack of persons to hold infants, and a diagnosis of neonatal abstinence syndrome. Rationale for choice of motion and sound settings included trial and error, prior settings, personal preferences/patterns, assumptions, and random selection. Nurse responses regarding the amount of time the infant was placed in the seat in a single session ranged from 10 to 360 minutes, with determining factors of infant cues, sleeping, feeding, and someone else to hold the infant. IMPLICATIONS FOR PRACTICE As nonpharmacologic treatments evolve, nurses need guidelines for safe, effective interventions to care for infants. IMPLICATIONS FOR RESEARCH Further research is necessary to ascertain the responses of withdrawing infants and to establish guidelines and education for use of the motion/sound infant seat.
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Shining a Light: Integrating Protocols Into Clinical Practice for Treatment of Neonatal Abstinence Syndrome. J Addict Nurs 2019; 30:61-66. [PMID: 30830002 DOI: 10.1097/jan.0000000000000267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The epidemic use of opioids is negatively influencing the health of the American people. Pregnant women and their unborn babies have not escaped the ravages of substance use. A dramatic increase in maternal opioid use has led to an increasing number of infants experiencing withdrawal symptoms known as neonatal abstinence syndrome (NAS). The purpose of this article is to highlight best practice for the management of infants with opioid withdrawal. REVIEW OF PROTOCOLS AND TREATMENTS Review of available protocols and treatments revealed wide variation in the treatment of NAS and little use of standardized guidelines or protocols, despite current recommendations of the American Academy of Pediatrics. There is supporting evidence showing that the use of standardized protocols reduces the length of treatment and enhances outcomes in the neonatal population. EVIDENCE-BASED RECOMMENDATIONS Evidence-based strategies to address gaps in practice include developing strong protocols to identify infants at risk and implementing standardized plans when treating NAS. Consistent assessment, initial treatment with nonpharmacologic measures, and conservative use of pharmacologic agents are important elements to an NAS treatment protocol. CONCLUSIONS AND IMPLICATIONS In evaluating the current literature for best practice in the management of the newborn with opioid withdrawal, it is clear that evidence-based standardized protocols need to be in place for the best treatment of the mother-infant dyad, caring for both the infants with NAS as well as the mothers with opioid use disorder.
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Syvertsen JL, Toneff H, Madden DR, Clapp JD. Conceptualizing Neonatal Abstinence Syndrome as a Cascade of Care: A Qualitative Study With Healthcare Providers in Ohio. Adv Neonatal Care 2018; 18:488-499. [PMID: 30234507 DOI: 10.1097/anc.0000000000000552] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The opioid epidemic remains a serious issue in the United States and presents additional challenges for women of childbearing age. An increasingly common complication of opioid use is neonatal abstinence syndrome (NAS), or infant withdrawal from in utero exposure to opioids. PURPOSE The objective of our qualitative study was to identify service needs and barriers to care in the NAS epidemic in Ohio, which has among the highest rates of opioid use and NAS in the nation. METHODS Drawing on interviews with 18 healthcare providers, we investigated the challenges, opportunities, and service gaps in treating NAS. Open-ended questions covered opioid misuse and drug treatment, provision of and barriers to healthcare, and suggestions to improve prevention and programming. Content analysis identified major themes. FINDINGS Providers were primarily women (67%) and included individuals working in healthcare administrative positions, hospital settings, clinics, and social support positions for pregnant women or new mothers. Our results suggest that rather than an acute diagnosis, NAS is better conceptualized as a "cascade of care" including (1) prevention, (2) prenatal care, including drug treatment, (3) labor and delivery, and (4) aftercare. Providers identified challenges and opportunities at each stage of the cascade that could influence NAS outcomes. IMPLICATIONS FOR PRACTICE Our results suggest that greater resources, coordination, and cross-disciplinary education are urgently needed across the cascade of care to effectively address NAS. IMPLICATIONS FOR RESEARCH Framing NAS as a cascade of care allows researchers to identify points along a cascade where mothers and infants require enhanced care and access to social and health services.
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