Neonatal abstinence syndrome management A quality improvement initiative

Neonatal abstinence syndrome management: A quality improvement initiative to educate caregivers, & providers in the outpatient setting Nguyen J, MD*. Chau K, DO*. Lilly C, MD. Ashmeade TL, MD. Balakrishnan M, MD. University of South Florida at Tampa General Hospital, Tampa, FL. BACKGROUND • The U. S. incidence of antenatal drug use & Neonatal Abstinence Syndrome (NAS) has increased with >50% of opioid exposed infants developing NAS. • NAS is associated w/prolonged hospital length of stay & increased health care costs. • Outpatient medical management for NAS may decrease health care costs. • Little is known related to: • Parents response to coordinated inpatient & outpatient interventions for NAS • Outpatient healthcare provider level of knowledge & comfort w/NAS management OBJECTIVES METHODS INTERVENTIONS • Cycle 1: • 6/11/13 to 9/19/13 • • Cycle 2: • 9/20/13 • to 12/11/13 • • • Cycle 3: • 12/12/13 to • 4/30/14 NAS Outpatient Weaning Algorithm Developed JNFP comprehensive discharge planning Developed & implemented tools for providers: NAS outpatient management guideline, methadone dose adjustment algorithm, EMR note template Developed & implemented tools for parents: erasable magnetic tablet for care plan, NAS symptom diary Standardized methadone concentration & prescription instructions for providers Developed provider education curriculum (USF Pediatric attendings, residents, nurse practitioners) Revised NAS guideline: scheduled minimum 4 follow-up appointments, increased % of weans, encouraged wean at first outpatient appointment Revised NAS EMR template to improve efficiency Developed clinic NAS poster for healthcare providers: prompting survey distribution, providing management tips, pharmacy contact information Placed reminder sticker on NAS symptom diary to bring diary to each appointment Confirmed 3 local pharmacies consistently stocked prescribed methadone concentration Revised NAS EMR template to improve efficiency TGH’s occupational therapy handouts available in outpatient clinics (e. g. positioning techniques, swaddling instructions, range of motion exercises). Included consideration of outpatient counseling by mother when deciding social work’s clearance of infant for outpatient methadone management Secondary Primary Use a multi-disciplinary approach in NAS management to improve consistency of care • Describe our center’s comprehensive outpatient NAS management program • Assess the program’s safety RESULTS After implementation* 100% of parents responded being comfortable: Healthcare provider knowledge & attitudes survey responses Input measure • Parent compliance in bringing NAS symptom diary to pediatric appointments Process measure • Healthcare provider compliance w/NAS outpatient management guidelines & EMR template Inpatient NAS management 1. Caring for & soothing their NAS infant 2. Administering methadone to their infant 3. Understanding the diagnosis of NAS prior to delivery 4. Comfort level in identifying NAS signs & symptoms 5. Finding medical team helpful in providing anticipatory guidance (defined as <10% requiring hospital readmission) • Achieve healthcare provider compliance w/the program: 1. >75% compliance w/outpatient management guideline 2. >75% of healthcare providers using EMR note template • Describe duration & cumulative dose of outpatient methadone exposure • >75% of healthcare providers & parents having improved knowledge & attitudes towards NAS Outcome • Duration of outpatient methadone treatment measure • Cumulative dose methadone exposure Outpatient NAS management Receiving anticipatory guidance education Delivering anticipatory guidance to parents 0 Balancing • Appropriate weight gain (>20 g/day) measure • Hospital readmissions for NAS management 10 20 30 40 50 60 70 % reporting “comfortable” rating 80 Post-implementation (n=34) Pre-implementation (n=40) Total # surveys distributed: 67 Description of input & process measures. SETTING • TGH is an academic medical center with ~ 5, 500 deliveries/year ~70 NICU admits/year for NAS diagnosis ~20 infants/year d/c w/outpatient management • USF/TGH Joint Neonatal Follow-up Program (JNFP) uses methadone for outpatient NAS management • USF/TGH’s NICU NAS infants may be discharged for outpatient management if: 1. Controlled NAS symptoms on methadone ≤ 0. 16 mg/kg/day once daily 2. Cleared by TGH social work Inclusion criteria: NAS infants discharged from USF/TGH NICU for outpatient methadone management w/USF Pediatric follow-up. CONTACT: mbalakri@health. usf. edu, Division of Neonatology, 1 Tampa General Circle, F 170, Tampa, FL 33611 Cycle 1 a (N=97) Cycle 2 a (N=124) Cycle 3 a (N=82) All cyclesa (N=303) Outpatient methadone algorithm compliance, n (%) 65(67) 90(73) 58(71) 213(70) EMR template used, n (%) 76(78) 96(77) 60(73) 232(77) Infant weight assessment documented in EMR, n (%) 83(86) 109(88) 65(79) 257(87) NAS symptoms documented in EMR, n (%) 91(94) 120(97) 81(99) 292(96) Current dose documented in EMR, n (%) 89(92) 112(90) 74(90) 263(87) NAS symptom diary brought to pediatric clinic appointment, n (%) 43(44) 62(50) 52(63) 157(52) N: number of appointments in each cycle. a. Date of NICU discharge determines which cycle infants are included. Description of outcome & balancing measures. Cycle 1 a (N=4) Cycle 2 a (N=10) Cycle 3 a (N=6) All cyclesa (N=20) Number of pediatric clinic appointments for NAS, average (range) Total duration of methadone from NICU discharge to time methadone discontinued in cycle, days±SD (range) Average NICU discharge dose of methadone, mg±SD 8 (4 -13) 58. 8± 15. 2 (40 -80) 0. 35± 0. 08 9 (5 -20) 61. 8± 27. 5 (32 -132) 0. 39± 0. 13 11 (7 -13) 69. 7± 12. 6 (46 -86) 0. 45± 0. 08 10 (4 -20) 63. 6± 22. 1 (32 -132) 0. 4 ± 0. 11 Average dose at methadone discontinuation, mg±SD Average outpatient cumulative methadone dose from NICU discharge to time methadone discontinued in cycle, mg±SD Weight (g) at first pediatric clinic appointment, average (range) 0. 13± 0. 04 0. 11± 0. 02 15. 6 ± 9. 8 0. 11± 0. 01 0. 11± 0. 03 16. 8± 4 15. 6± 7. 8 3370± 261 3240± 536 3370± 261 3300± 458 Average weight gain (g/day) on outpatient methadone management, mg±SD 26± 9. 4 29. 4± 9. 4 31. 8± 3. 9 29. 4± 8. 4 0 2 Hospital readmissions for NAS management 13. 6± 5. 8 N: Number of infants in each cycle. Infants who required hospital readmission & were completely weaned off of methadone during hospital admission or did not wean off of methadone before the end date of cycle 3 were excluded from this data analysis (2 infants). a. Date of methadone discontinuation determines which cycle infants are included. 90 There was no significant difference in helpfulness of NAS educational materials. *Parent survey response rates: #1 at pre-implementation: 100% (n=5), #2 at 1 st appointment: 73% (n=22), #3 at appointment when methadone discontinued: 40% (n=20) DISCUSSION A multidisciplinary approach to outpatient NAS management can: • Be safe when a comprehensive management program is implemented • Result in appropriate infant weight gain • Demonstrate healthcare provider compliance w/an outpatient management guideline & EMR template • Improve parent & provider knowledge & attitudes regarding care of a NAS infant More research is needed to determine the long term effects of cumulative methadone dose exposure & duration of exposure on infant outcomes.