An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome

Context

From March 2010 to June 2016, we conducted a quality improvement project at YNHCH, an academic medical center with ∼4500 births and 850 NICU admissions annually. We applied our interventions to all infants with NAS (infants exposed in utero to opioids who developed signs of withdrawal), but we analyzed only those born at ≥35 weeks’ gestation whose mothers took methadone daily for at least 1 month before delivery. We considered this population to be the most likely to develop signs of withdrawal.⁶ We excluded infants with significant comorbidities, including sepsis and the need for either surgery or respiratory support (supplemental oxygen, noninvasive ventilation, and/or intubation for ≥2 days).

During the preintervention period (January 2008 to February 2010), all infants at risk for NAS were admitted directly to our NICU after birth, where signs of NAS were monitored by using the FNASS. Infants with either 3 FNASS scores ≥8 or 2 scores ≥12 in a 24-hour period were given morphine (starting at 0.05 mg/kg per dose every 3 hours and adjusted based on subsequent FNASS scores). Infants were initially managed in the NICU and then, at the discretion of the attending neonatologist, were either discharged from the NICU or transferred to the inpatient unit. In either unit, infants were discharged at day 5 of life (if no morphine was given) or 1 day after morphine was stopped.

Interventions

In 2009, we noted an increase in the number of infants with NAS and formed a multidisciplinary team that included attending physicians, residents, staff nurses, nursing leadership, child life specialists, and social workers to develop interventions aimed at improving care of these infants and reducing ALOS. We identified 4 key drivers of ALOS: nonpharmacologic interventions, simplified assessment of infants, decreased use of morphine, and communication between units (Fig 1). During the next 5 years, using plan-do-study-act cycle methodology, we developed and implemented 8 interventions (listed below their respective key driver) aimed at reducing the ALOS of infants with NAS. The chronology of the interventions is listed in Table 1.

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FIGURE 1

Key driver diagram for NAS quality improvement project.

Nonpharmacologic Interventions

Simplified Assessment of Infants

We discontinued use of FNASS scores to guide pharmacologic management on the inpatient unit (FNASS was still used in the WBN and NICU). Instead, we developed and used our own functional assessment focused on 3 simple parameters: the infant’s ability to eat, to sleep, and to be consoled. If the infant was able to breastfeed effectively or to take ≥1 oz from a bottle per feed, to sleep undisturbed for ≥1 hour, and, if crying, to be consoled within 10 minutes, then morphine was neither started nor increased regardless of other signs of withdrawal. If the infant did not meet these criteria, staff first attempted to maximize nonpharmacologic interventions; if these attempts were unsuccessful, morphine was initiated or increased.

Decreased Use of Morphine

Communication Between Units

Study of the Intervention

We compared demographic features, including rates of polypharmacy (defined as methadone use in addition to mother’s use of cocaine, selective serotonin reuptake inhibitors, benzodiazepines, or opioids other than methadone) and outcomes of infants in the baseline and postimplementation periods. P values (2-tailed) are reported from pairwise t tests for continuous variables and from either χ² tests or Fisher’s exact tests (if cell count <5) for categorical variables. Analyses were performed by using SAS version 9.3 (SAS Institute, Inc, Cary, NC).

Measures and Analysis

Our primary outcome measure was ALOS, calculated from date of birth, measured as day of life 0, until date of discharge. Secondary measures included the proportion of infants treated with morphine and the average total cost of hospitalization, including direct and indirect costs. Cost information was obtained from the YNHCH analytics department and adjusted for inflation (2016 dollars).⁷ Process measurements included the proportion of infants who were taking ≥50% of their feeds as breast milk at time of discharge and the proportion of infants initially admitted to the NICU for management of NAS. As balancing measures, we tabulated the number of infants transferred to an ICU from the inpatient unit, the number of infants with seizures, and readmissions within 30 days of discharge related to withdrawal. We compared measures after the interventions were fully implemented (May 2015 to June 2016) with the same measures during the baseline period (January 2008 to February 2010). There were no additional hospitalwide interventions to reduce ALOS in newborns ≥35 weeks’ gestational age during the study period. To ensure completeness of data, records of all patients with administrative codes for NAS (International Classification of Diseases, Ninth Revision: 779.5 and 760.72; International Classification of Diseases, 10th Revision: P04.49 and P96.1) were reviewed for inclusion criteria. We used statistical process control (SPC) charts to evaluate the impact of our interventions. SPC charts were developed by using Microsoft Excel QIMacros. SPC uses statistical methods to analyze common cause variability, to produce control limits to assess the process capability, and to identify special cause variation, or incidences of statistically significant (P < .01) variability.⁸

Ethical Considerations

The Yale University Human Investigation Committee determined that this project was exempt from review. No interventions involved comparison of therapies and subjects were not randomized. All charts were accessed by quality team members and no personal health information was shared outside of the organization.