Interventions reduce length of stay for neonatal abstinence syndrome

By Will Boggs MD

NEW YORK (Reuters Health) - Staff education and implementation of a standard treatment protocol can dramatically reduce the length of stay (LOS) for neonatal abstinence syndrome (NAS), according to results of a quality improvement project.

"Choose a weaning protocol and stick to it," Dr. Richard E. McClead Jr., from Nationwide Children's Hospital, Columbus, Ohio, told Reuters Health by email. "Monitor compliance with the protocol using statistical process control (SPC) charting methodology. Learn from your data and continually improve your processes."

Reported lengths of stay for treating NAS range from 6 to 79 days, depending on the treatment, symptom severity, and maternal opioid dose.

Dr. McClead's team initiated a project aimed at reducing the length of stay for patients admitted to the neonatal intensive care unit (NICU) with NAS to 24 days. Their initial intervention using a methadone protocol had lowered the average length of stay from more than 36 days to 31 days.

Key drivers of their project included communication among medical and nursing staff, minimization of variability in Finnegan NAS Scoring System (FNASSS) scoring by the neonatal nurses, use of a standard initiation and weaning protocol, and collaboration with obstetricians-gynecologists and addiction specialists to optimize prenatal management of opioid-addicted pregnant women.

After implementation of the oral morphine protocol, the average LOS decreased to 27 days and remained there through the next two years. Further narrowing of the upper and lower control limits of the protocol, along with retraining of nursing staff on FNASSS scoring, resulted in a decrease in average LOS to 18 days.

None of the study infants admitted to the main campus NICUs was readmitted within 30 days of follow-up due to NAS symptoms, according to the May 4 Pediatrics online report.

"Minimizing LOS is important because time spent in a hospital is not beneficial for the infant-parent attachment," the authors wrote. "Future research should track these children beyond the first year of life for various outcomes, especially neurologic and behavioral factors, but also to determine overall health and whether the children are seeking medical treatment of conditions related to their diagnosis of NAS."

"Since publication of our work we have learned about new drug combinations that may offer even better results," Dr. McClead said. "More importantly, we are finding that non-pharmacologic treatments may actually help us to shorten hospitalization without the use of opiates or other drugs."

"With any (quality improvement) project involving physicians and/or nurses, the biggest challenge is obtaining consensus around standardized care," Dr. McClead added. "Even when national bodies published standard of care guidelines, it is usually several years before those standards are widely adopted. That challenge is made even more difficult when there is not a guideline to which a (quality improvement) leader can point. Such is the case with the management of infants with neonatal abstinence syndrome."

Dr. Veeral N. Tolia, a neonatologist with MEDNAX at Baylor University Medical Center, Dallas, Texas, agreed. He told Reuters Health by email, "All quality improvement interventions need to be tailored for the individual hospital. The challenge is twofold - developing unique solutions and then generating institutional 'buy in' for implementation."

"Developing an approach that is multidisciplinary and standardized can improve care for infants with NAS," Dr. Tolia concluded.

Dr. Alan Spitzer, MEDNAX's senior vice president for research, education, and quality, Sunrise, Florida, told Reuters Health by email, "The management of NAS needs to be developed at each individual hospital and has to vary from baby to baby. No two infants with NAS will present in an identical fashion. Management of each NAS patient is going to be very different depending upon the type of drug exposure and availability of certain drugs in the community, whether there was polypharmacy used, duration and frequency of drug use during pregnancy, etc."

"The main message from my perspective is that if you thoughtfully focus on any issue in the NICU, you can usually develop a better approach and improve the outcome," Dr. Spitzer said.

"There is clinical variation in the management of NAS, even among physicians within the same institution," Dr. Jerry Lee, medical director of ProgenyHealth, Plymouth Meeting, Pennsylvania, told Reuters Health by email. "Implementation of a well-researched institutional treatment protocol can reduce clinical variation, resulting in decreased lengths of stay - which not only has a cost-savings benefit, but also promotes development of the mother-baby dyad and reduces risk of hospital-acquired morbidity."

He added, "The management of infants with NAS does not end when the infant and mother leave the hospital setting. It is very important to have a strong case-management program assisting families, as we do at ProgenyHealth, throughout the first year of life. Supporting these families through education and ensuring that they receive necessary health care services, results in lower readmissions to the hospital and improved health outcomes."

A portion of a Cardinal Health Foundation grant supported the Finnegan score training for this study. The authors reported no disclosures.

SOURCE: http://bit.ly/1OXPzc4

Pediatrics 2015.

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