Special Note: Many WHA members proud of their quality improvement efforts had prepared special poster presentations that were to be displayed in the Capitol Rotunda during WHA’s Advocacy Day 2020, which was cancelled due to the COVID-19 pandemic. WHA is pleased to highlight these efforts in today’s and future editions of The Valued Voice.
Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic observed in the general population. Since 2000, opioid use disorder in pregnant women has increased from 1.19% to 5.63% per 1,000 live births in the United States.¹ Consequently, infants with Neonatal Abstinence Syndrome (NAS), which results from intrauterine opioid exposure, has increased 5-fold in the past 15 years. Infants born to mothers with opioid use disorder traditionally have been treated pharmacologically with additional opioids after being assessed for withdrawal symptoms using the Finnegan Neonatal Abstinence Scoring System (FNASS).² However, this scoring tool has never been validated and lacks internal consistency and interrater reliability. Monitoring and treatment of NAS results in prolonged hospitalizations, disrupts infant-parent bonding and leads to a substantial health care burden.
The health care team at SSM St. Mary’s Hospital in Madison wanted to reduce pharmacological interventions and average length of stay in infants diagnosed with NAS. The team wanted a model that focused on non-pharmacologic therapies and a simplified evidence-based, family-centered approach to assessment for infants exposed to opioids prenatally. The supportive care included increased skin-to-skin contact with mothers and babies, feeding on demand, calming techniques and maintaining a quiet environment. Focus was on the mother as the treatment for her baby and how she could provide the supportive care her baby needed. The model of care and assessment implemented is called Eat Sleep Console (ESC). This strategy shifted the goal from reducing withdrawal symptoms by exposing an infant to additional opioids to an approach prioritizing the overall functional well-being of the infant. The ESC model of care, developed by the New England Perinatal Quality Improvement Network, led to significant decreases in average length of stay and opioid administration at Yale New Haven Children’s Hospital.²
ESC replaced FNASS as the method of assessment for infants at risk for NAS at SSM St. Mary’s Madison. Their multidisciplinary team created an algorithm and provided education and training to all members of the health care team. Families and caregivers were educated on the new assessment tool and on methods to help console their infants. Educational materials were distributed in the clinic before birth to help the mothers prepare for what would happen in the hospital. Suggestions on how to calm a baby are shared on a poster in the hospital room and mothers are encouraged to be with their babies continuously to help calm and soothe them.
From January 2017 to December 2018, 76 infants were identified at risk for NAS with length of stays ranging from three to 44 days, with the average length of stay being 9.86 days. The average doses of morphine given per month was 40 with a low of 15.5 doses to a high of 132 doses. The percentage of infants who received morphine was 38%.
Since implementation of the ESC method in April 2019, there have been 38 infants identified to be at risk for NAS through December 2019, and the average length of stay decreased to 5.6 days. The percentage of infants receiving morphine decreased to 3%, and no infants were readmitted for signs of withdrawal and no adverse events were reported.
The goal of using the Eat Sleep Console method is not to eliminate the use of opioids to treat NAS, but to assess each infant individually and use other methods of non-pharmacologic treatment before pharmacologic intervention.
Members of the health care team appreciate the new scoring method, as the interrater reliability improved, and the infant does not have to be disturbed to do the assessment. Many families have also noticed the difference. One example is a mother who was on opioid replacement therapy during pregnancy had her second baby scored with ESC while her first was scored with FNASS. She reported that she was “happy to see that her baby was disturbed less, and she was able to help with the assessment and treatment this time.”
See the poster presentation.
References
¹American College of Obstetricians and Gynecologists (ACOG) 2017. Opioid use and opioid use disorder in pregnancy. Committee opinion 711.
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy.
²Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6):e20163360.