Guju, Elizabeth, MS4

Kowalski, Wendy J, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksUSF-LVHN SELECTAnalyzing Compliance with the NICU NeonatalAbstinence Syndrome PathwayElizabeth Guju MS4USF MCOM- LVHN CampusWendy J. Kowalski MDLehigh Valley Health Network, wendy_J.Kowalski@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/select-programPart of the Medical Education CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtGuju, E. Kowalski, W. (2019, March). Analyzing Compliance with the NICU Neonatal Abstinence Syndrome Pathway. Poster Presented at:2019 SELECT Capstone Posters and Presentations Day. Kasych Family Pavilon, Lehigh Valley Health Network, Allentown, PA..© 2018 Lehigh Valley Health NetworkLehigh Valley Health Network, Allentown, Pennsylvania• Overall, this project assessed compliance with the Comprehensive Pathway for Perinatal Substance Abuse and determined that only one compliance point met the 100% compliance goal. • Data gathered allowed departments (Obstetrics, NICU, MBU) to identify areas where pathway compliance is low so that changes could be implemented.• Possible reasons for non-compliance were discussed within the involved departments. • Current and future changes include:– development of order sets that include both urine/meconium drug screens and Finnegan scoring– non-pharmacologic management of NAS– modification of the pathway to better define outpatient follow-up needs– re-education of nursing and providers regarding proper Finnegan scoring and morphine weaning protocols.  Analyzing Compliance with the NICU Neonatal Abstinence Syndrome Pathway REFERENCES• Internally designed quality improvement project within the LVHN Labor and Delivery, NICU, and Mother Baby Units.• Retrospective chart review of neonates placed on the Comprehensive Pathway for Perinatal Substance Abuse (from July 1, 2017- July 1, 2018).• Charts identified using a urine (UDS-10) or meconium (MecDS) drug screen code. • Exclusion criteria: the baby died or the baby was transferred to an outside center for care. • Pathway compliance was measured using 6 pre-determined compliance points (see Table 1). • Number of charts included for each compliance point was determined on chart-by-chart basis, as following the Comprehensive Pathway for Perinatal Substance Abuse.• Chart review of consisted of looking through EPIC specifically in the clinical notes, lab orders, and nursing flow-sheets tab. • Percent compliance and non-compliance with the pathway was determined for each compliance point.• Qualitative data for 5-6 recorded.• Goal for pathway compliance was set at 100% for each compliance point 1 through 6.Elizabeth Guju MS4; Wendy Kowalski M.D.BackgroundMethodsResults DiscussionConclusions[1] Hudak ML, Tan RC, The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Official Journal of the American Academy of Pediatrics. 2012; 129; e540.[2] Kocherlakota P.  Neonatal Abstinence Syndrome. Pediatrics. 2014(134); 457-561.[3] Carter LC et al. Opioid Use Disorder during pregnancy: An overview. Journal of the American Academy of Physician Assistants. 2019(3); 32-35.[4] Tolia, VN et al. Increasing Incidence of Neonatal Abstinence Syndrome in U.S.Neonatal ICU's. New England Journal of Medicine 2015; 372: 2118-2126.[5] Corr T, Hollenbaek, C. The Economic Burden of Neonatal Abstinence Syndrome in the United States. Addiction. 2017 Sep; 112(9): 1590-1599.[6] Zimmermann-Baer U, Notzli U, Rentsch K, Bucher HU. Finnegan Neonatal Abstinence Scoring System: Normal values for first 3 days and weeks 5-6 in non-addicted infants. Journal for the Study for Addiction. 2010(105); 524-528.[7] Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacotherapy. In: Nelson NM, ed. Current Therapy in Neonatal-Perinatal Medicine. 2nd ed. New York: Mosby Yearbook, 1990:53–61.[8] Patrick SW, Benneyworth BD, Schumacher R, Davis MM. Variation in hospital type in treatment of neonatal abstinence syndrome in the United States. Pediatric Academic Societies. 2013. [9] Lawal et al. What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC Medicine. 2016; 14-35.[10] Kaltenbach et al. Prenatal exposure to methadone or buprenorphine: Early Childhood development outcomes . Drug Alcohol Dependence (2018)185; 40-49.[11] Oei J, Feller JM, Lui K. Coordinated outpatient care of the narcotic-dependent infant. Journal of Paediatric Child Health 2001; 37: 266–270.[12] Grossman et al. An Initiative to Improve the Quality of Care of Infants with Neonatal Abstinence Syndrome. Pediatrics. 2017(139); e20163360[13] Hollinger, N et al. Evaluation of the appropriate weaning of the neonatal morphine solution (NMS) in the treatment of neonatal abstinence syndrome (NAS) and its effect on the length of stay (LOS). Poster presented at American Society of Health System Pharmacists Midyear Clinical Meeting. December 8, 2013; Orlando, FL.Problem Statement• Neonatal abstinence syndrome (NAS) is a withdrawal syndrome of newborns that develops after birth with the abrupt discontinuation of in utero exposure to drugs of abuse. It typically manifests in the first few days of life and clinical symptoms include neurologic excitability, autonomic instability, impaired weight gain, irritability, and gastrointestinal dysfunction.• It has been shown that an algorithmic management of NAS is useful for the standardization of management in order to ensure all infants at risk are identified and receive proper treatment and outpatient follow-up.• Specifically, clinical pathways are common tools used to standardize the care processes in order to maximize patient outcomes and improve organizational efficiency.• Lehigh Valley Health Network (LVHN) aims to provide the best quality of maternal and neonatal care through implementation of the multidisciplinary Comprehensive Pathway for Perinatal Substance Abuse. (Figure 1) This pathway was developed to ensure all mothers with substance abuse and their infants at risk for NAS, or with NAS, are identified, treated, and followed after discharge. Pathway compliance has not previously been assessed. • This is a quality improvement project designed to assess compliance and non-compliance (in percentage %) with the LVHN multidisciplinary Comprehensive Pathway for Perinatal Substance Abuse. • A total of 161 charts were pulled due to having either UDS10 or MecDS code ordered. • 2 charts were excluded (refer to Table 2 for full description of analyzed groups). • Refer to Table 3 for percentage compliance at each compliance point 1 through 6. • Qualitative data regarding documented provider reasoning for non-compliance with compliance points 5 and 6 is presented in Table 4. General Discussion:• The only compliance point that met 100% goal was referral to OCYS.• Compliance point 1 had 88.05% compliance. Reasons for non-compliance may be late order entry or late attempt at collecting the urine/meconium samples. Orders must be placed in a timely manner after birth for results to be reliable. Providers also occasionally cancel the Meconium drug screen when the urine is resulted as negative, which is inappropriate and requires re-education. – To improve compliance: An order set that includes Finnegan scoring and both drug screens was developed and is currently in the process of being incorporated into the EPIC electronic medical record. • Compliance point 2 had 84.90% compliance. Reasoning for non-compliance may include clinical time limitations for nursing staff with Finnegan scoring as well as miss-education of providers of when Finnegan scoring needs to be conducted. Upon initial data assessment it appeared that compliance with scoring was even worse; however, the majority of babies that did not get Finnegan scoring were preterm infants who were NPO and/or on narcotics for surgery. Finnegan scoring has not been validated, nor is it appropriate, for either of these populations. – To improve compliance: Re-education about when to start Finnegan scoring and on which babies. • Compliance point 3a had 100% compliance and point 3b had 71.43%. One contributing factor for apparent non-compliance with the CAC follow-up is that babies of mothers, who are compliant with prescribed medications, such as suboxone or methadone, who are not showing any signs of NAS, or whose mothers are in a program for chronic pain or narcotic abuse, do not actually need OCYS referral or CAC follow-up. – To improve compliance: Guidelines regarding this are not currently well specified in the pathway;  modification will be made with clear guidelines on who should be seen in CAC after discharge, regardless if an OCYS referral was indicated.  • Compliance point 4 met closes to 100% goal at 94.45% compliance. Reasons for non-compliance include the subjective nature of the scoring. There is NICU provider discretion allowed for choosing to keep the infant with Mom in MBU if an elevated score is felt to be due to environmental factors and there is no required use of non-pharmacological measures for NAS. – To improve compliance: Re-education of mom and nursing would allow infants to be calmed with non-pharmacologic measures and reduce need to come to NICU or need medications. • Compliance point 5 and 6 had 73.33% and 60.00% compliance. Based off of qualitative data collected if was determined that often babies with borderline scores, aka scores close to 8, will not get weaned daily for provider fear of making them withdraw more. This practice only increases the length of stay (LOS) for these babies.– To improve compliance:  Re-education of providers with encouragement to continue to wean morphine as  long as scores are <8. Project limitations: • Compliance was measured only through assessment of documentation in EPIC. SELECT Principles:• A quality improvement project focused on the SELECT domain of health systems.• NAS caries an enormous burden in terms of hospital days and costs. • Using data obtained from this project, LVHN is able to improve standardization of care, for both inpatient and outpatient follow-up, to mother of infants and infants with NAS. Figure 1: Comprehensive Pathway for Perinatal Substance Abuse

Analyzing Compliance with the NICU Neonatal Abstinence Syndrome Pathway

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Analyzing Compliance with the NICU Neonatal Abstinence Syndrome Pathway

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