pqcnc annual meeting newborn / nas packet

8/13/2019 PQCNC Annual Meeting Newborn / NAS Packet

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The Perinatal Quality Collaborative of North CarolinaAnnual Meeting & Initiative Kickoff

January 7, 2014

Durham, NC

8:30 am Registration

The Power of Teams: Exclusive Human Milk in the NCCC - April Caines, BSN, RNC-NIC, CLE

Welcome Remarks- Marty McCaffrey, MD

The Power of Teams: Hows Your Baby? Cherrie Welch, MD

The Power of Teams: Catheter Association Bloodstream Infections David Fisher, MD

Lessons on Teams from a Lifetime at War Rob Dubois

The Power of Teams: Coronary Heart Disease Alex Kemper, MD

The Power of Teams: 39 Weeks Amanda French, RN, MSN

The Dynamics of Teams: An Interactive Workshop Facilitating Teamwork in PerinatalSettings Ben Saypol, PhD

The Power of Teams: NCABSI Sheri Carroll, MD

Lunch

Creating a Team for Maternal Safety: The Case of Preeclampsia- Elliott Main, MD

Neonatal Abstinence Syndrome: Scope and Evolving Issues- Stephen Patrick, MD, MPH, MS

Quality Improvement and the Bottom Line- Marty B. Scott, MD, MBA

Maternal Track: Family Perspectives and ACOG Guidelines Arthur Ollendorff, MD, Kathy andClark Ellis

Do They Know You Care? An Interactive Workshop Fostering Empathy in PerinatalSettings Ben Saypol, PhD

Neonatal Abstinence Syndrome Action Plan panel discussion with Martha Bordeaux, MSN, PNP-BC, Carl Seashore, MD, FAAP, John Wimmer, MD, and Brock Harris, PharmD, BCPS

Ask the Experts panel discussion with Elliott Main, MD, Stephen Patrick, MD, MPH, MS, and JimConway

The Power of Teams: Patient and Family Engagement Diane Mills, RN

Power and Privilege of Patient and Family Centered Care - Jim Conway

5:50 pm Adjournment


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Perinatal Quality Collaborativeof

North Carolina

Neonatal Abstinence Syndrome

Initiative Charter

Problem Statement:

A recent national study indicated that illicit drug use is 16.2%

among pregnant teens and 7.4% among pregnant women aged 18

to 25 years. Neonatal abstinence syndrome (NAS) is a drug

withdrawal syndrome in newborns following birth. While this is a

growing population in our hospitals there remains no standards of

care or treatment. PQCNC NICU and Nursery PQITs will share

strategies and lessons learned while working over a 9-month

period to develop potentially better practices and employ QI

methodologies to establish a standard of care within North

Carolina hospitals.

Mission:

Provide the education and support necessary to develop standards

of care in NC hospitals for the NAS population.

Aim:

Create a multidisciplinary hospital based community focused on

providing a standardized approach to the identification,evaluation, treatment and discharge of the NAS infant and family

by 30 September 2014.

Scope:

Working with perinatal quality improvement teams in

participating centers the initiative will focus on the time between

the admission of the infant and the discharge of the infant.

Method:

Invite teams from NICUs and Nurseries to participate in thecollaborative organized by PQCNC to include learning sessions,

web conferencing and coaching to support perinatal quality

improvement teams (PQITs) to use quality improvement

strategies to implement elements of the action plan

Measurement Strategy:

1. Number of infants discharge with NAS diagnosis2. Process measures that support achieving the ultimate

outcome.


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NAS

ActionPlan

Perinatal Quality Collaborative of North Carolina

Overall Aim: Create a multidisciplinary hospital based community focused on providing a standardized approach to theidentification, evaluation, treatment and discharge of the NAS infant and family by 30 September 2014.

Outcome Key Metrics Secondary Metrics

Provide a

standardized

approach to the

identificationof

the at risk infant

and family

1) Each nursery has a protocol that

defines indications and procedures

for screening for infants at risk for

withdrawal

Each nursery that cares for infants with

neonatal withdrawal develops/reviews

guidelines/policies that defines:

Identification of eligible infants fortoxicology testing

Type of toxicology testing to includebut not limited to urine and meconium

Process for obtaining urine andmeconium for testing

Process for communicating results tomother or caregiver

Referral to CPS Criteria for Social Work consult

Provide a

standardized

approach to the

identificationof

the at risk infant

and family

2) Each nursery ensures proper

toxicology testing

Develop order sets to include but not limited

to:

Urine and Meconium toxicologytesting as the primary toxicologytesting methods

Reason for testing: known history ofdrug use, meets testing criteria

Provide a

standardized

approach to the

identificationof

the at risk infant

and family

3) Each nursery develops criteria

for toxicology testing

Toxicology testing should be completed on all

the following infants:

Known maternal history for druguse

Positive Maternal drug screen atany point in pregnancy

Mother meets following criteriabutnot limited to include infant fortesting:

o No/late prenatal care (


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NAS

ActionPlan



Provide a

standardized

approach to the

identificationof

the at risk infant

and family

4) Each nursery educates staffandfamilies

Each nursery develops appropriate education

to ensure staff competency and family

understanding

Provide astandardized

approach to the

identificationof

the at risk infant

and family

5) Each nursery identifies barriersto discharge

Each nursery identifies: If CPS referral is needed Identification of PCP Center specific barriers

Provide a

standardized

approach to the

evaluationof the

at risk infant and

family

6) Each nursery adheres to a

standardized plan for the

evaluation of infants at risk for or

showing signs of withdrawal

Each nursery adopts either the Finnegan or

Modified Finnegan assessment-scoring tool

Each nursery develops evidenced based

protocols for scoring to include but not limited

to:

When to score How to score Non-pharmacologic treatments When to begin pharmacologic

treatment

Provide a

standardized

approach to the

evaluationof the

at risk infant and

family

7) Each nursery develops a

standardized plan to provide

consistency in scoring of the infant

at risk for or showing signs of

withdrawal

Each nursery adopts an inter-observer

reliability program

Inter-observer reliability testing forstaff using the Finnegan/ModifiedFinnegan scoring tool(Neoadvances Inter-ObserverReliability Program)

Testing for staff should be done onemployment to the unit andannually


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NAS

ActionPlan



Provide astandardizedapproach to theevaluationof theat risk infant andfamily

8) Each nursery recognizes theimportance of consistency withcaregivers

Each nursery identifies a core of localchampions that are the primary caregivers

Provide a

standardizedapproach to theevaluationof theat risk infant andfamily

9) Each nursery educates staff and

family

Each nursery develops education appropriate

to ensure staff competency and familyunderstanding

Provide astandardizedapproach to thetreatmentof theat risk infant andfamily

10) Each nursery employs non-pharmacologic treatmenttechniques prior to initiation ofpharmacologic treatment

Non-pharmacologic supportive measures willbe started immediately after identif ication andinclude:

Minimizing environmental stimuli Promoting adequate rest and sleep Providing sufficient caloric intake to

establish weight gain

Swaddling Skin to Skin Holding

Breastfeeding and the provision of expressedhuman milk should be encouraged if notcontraindicated for other reasons


11) Each nursery develops andadheres to a standardized plan forthe pharmacologic treatment of theinfants at risk for or showing signsof withdrawal

Each nursery develops center definedtreatment protocols to include but not limitedto:

(continued next page)


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NAS

ActionPlan




12) Each nursery develops andadheres to a standardized plan forthe pharmacologic treatment of theinfants at risk for or showing signsof withdrawal

Initiation of first line medication:o Nurseries should choose

between Morphine, Methadoneor Clonidine as first linemedications.

o Medications will be initiatedbased on the following process

in scoring: Average of any 3consecutive scores is >/=8 oraverage of any 2 consecutivescores is >/=12

o Dosing Initiation of second line medication

o Center defined initiationparameters

o Nurseries should choosebetween Morphine, Clonidineor Phenobarbital

o Dosing Weaning

o Center defined weaningparameters

oWhich medication to wean first

o Dosing Escalation

o Center defined escalationparameters

o Which medication to escalatefirst

o DosingProvide astandardizedapproach to thetreatmentof theat risk infant andfamily

13) Each nursery educates staff and

parents



understanding


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NAS

ActionPlan



Provide astandardizedapproach to thedischargeof the atrisk infant andfamily

14) Each nursery has astandardized minimum length ofstay for all at risk infants

Adhere to AAP length of stay standard of 3-7days for all at risk infants

Provide astandardizedapproach to thedischargeof the atrisk infant andfamily

15a) Each nursery adheres to astandardized plan for the dischargeof infants and family/caregiver

Each nursery develops stability triggers fornotification of proper organizations, familyand PCP of pending discharge.

Each nursery should develop Infant andfamily/caregiver criteria for discharge toinclude but not limited to:

All infants:

Identified caregiver Medically stable with adequate weight

nutrition

Clearance from all hospital or outsideagencies (social work, CPS etc.)

PCP identified Follow-up appointments made orcaregiver notified of needed follow-up

appointments

Outpatient resources identified Caretaker demonstrates normal infant

care

Caretaker demonstrates ability toadequately feed infant

Caregiver demonstrates non-pharmacologic treatments

CC4C referral


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NAS

ActionPlan



Provide astandardizedapproach to thedischargeof the atrisk infant and

family

15b) Each nursery adheres to astandardized plan for the dischargeof infants and family/caregiver

In addition to above criteria infant dischargeon medications:

Assess home situation Need two successful weans before

discharge

PCP agreement to accept infant Withdrawal symptoms controlled Successful feeding with weight gain Caregiver provides return

demonstration of medicationadministration

Caregiver recognizes symptoms ofwithdrawal

Caregiver is educated as to when tonotify PCP if concerned

Provide astandardizedapproach to the

dischargeof the atrisk infant andfamily

16) Each nursery educates staff andfamily



understanding


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NAS

Action

PlanRe

ferences

Perinatal Quality Collaborative

ofNorth Carolina

NAS

Action Plan References

Chan, D., K, J., Koren, G. (2003). New Methods for

Neonatal Drug Screening, Neoreviews, 4;e236.

Chasnoff, I,J. (2003). Prenatal Substance Exposure:

Maternal Screening and Neonatal Identification and

Management, Neoreviews, 4;e228.

Montgomery, D., Plate, C., Alder, S.C., Jones, M., Jones,

J., Christensen, R.D. (2006). Testing for fetal exposure

to illicit drugs using umbilical cord tissue vs meconium,

Journal of Perinatology, 26, 1114.

Jansson, L.M., Velez, M., Harrow, C. (2009). The Opioid

Exposed Newborn: Assessment and Pharmacologic

Management, J Opioid Manag. 5(1): 4755.

DApolito, Finnegan, L. (2010). Assessing Signs &

Symptoms of Neonatal Abstinence Using the Finnegan

Scoring Tool: An Inter-Observer Reliability Program,

NeoAdvances.

Zimmerman-Baer, U., Notzli, U., Rentsch, K., Bucher H.(2010). Finnegan neonatal abstinence scoring system:normal values for first 3 days and weeks 56 in non-addicted infants, Addiction, 105, 524528.

Sarkar, S., Donn. S.M. (2006). Management of neonatal

abstinence syndrome in neonatal intensive care units: a

national survey, Journal of Perinatology, 26, 1517.

Lucas, K., Knobel, R.B. (2012). Implementing PracticeGuidelines and Education to Improve Care of Infants

With Neonatal Abstinence Syndrome, Advances in

Neonatal Care, 12(1) pp. 40-45.

Backes, C.H., Backes, C.R., Gardner, D. et al, (2012).

Neonatal abstinence syndrome: transitioning

methadone-treated infants from an inpatient to an

out atient settin , Journal of Perinatolo , 32 425-430.


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NA

SActionPlanR

eference


North Carolina

NAS


Agthe, A.G., Kim, G.R., Mathias, K.B. et al (2009).

Clonidine as an Adjunct Therapy to Opioids for Neonatal

Abstinence Syndrome: A Randomized, Controlled Trial,

Pediatrics, 123;e849.

The Academy of Breastfeeding Medicine Protocol

Committee (2009). ABM Clinical Protocol #21:

Guidelines for Breastfeeding and the Drug-Dependent

Woman, BREASTFEEDING MEDICINE, 4(4).

Jansson, L.M., Choo. R., Velez, M.L. et al, (2008).

Methadone Maintenance and Breastfeeding in the

Neonatal Period, Pediatrics,121;106.

Abdel-Latif, M.E., Pinner, J., Clews, S. et al, (2006).

Effects of Breast Milk on the Severity and Outcome of

Neonatal Abstinence Syndrome Among Infants of Drug-

Dependent Mothers, Pediatrics, 117;e1163.

Bell, S.G. (2012). Buprenorphine: A Newer Drug for

Treating Neonatal Abstinence Syndrome, NeonatalNetwork, 31(3).

Leikin, J.B., Mackendrick, W.P., Maloney, G.E., et al.

(2009). Use of clonidine in the prevention and

management of neonatal abstinence syndrome, Clinical

Toxicology, 47, 551555.

Coyle, M.G., Ferguson, A., Lagasse, L., Oh, W., Lester, B.

(2002). Diluted tincture of opium (DTO) and

phenobarbital versus DTO alone for neonatal opiatewithdrawal in term infants, THE JOURNAL OF

PEDIATRICS MAY.

Velez, M., Jansson, L.M. (2008). The Opioid Dependent

Mother and Newborn Dyad: Nonpharmacologic Care, J

Addict Med,2: 113120.


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NA

SAction

PlanReference


North Carolina

NAS


Lainwala, S., Brown, E.R., Weinschenk, N.P., Blackwell,

M.T., Hagadorn, J.I. (2005). A RETROSPECTIVE STUDY

OF LENGTH OF HOSPITAL STAY IN INFANTS TREATED

FOR NEONATAL ABSTINENCE SYNDROME WITH

METHADONE VERSUS ORAL MORPHINE

PREPARATIONS, Advances in Neonatal Care, 5(5) pp

265272.

Isemann, B., Meinzen-Derr, J., Akinb, H. (2011).

Maternal and neonatal factors impacting response to

methadone therapy in infants treated for neonatal

abstinence syndrome, Journal of Perinatology, 31, 25

29.

Bio. L.L., Siu, A., Poon, C.Y. (2011). Update on the

pharmacologic management of neonatal abstinence

syndrome, Journal of Perinatology, 31, 692701.

Gaalema, D.E., Scott, T.L., Heil, S.H., et al, (2012).

Differences in the profile of neonatal abstinencesyndrome signs in methadone- versus buprenorphine-

exposed neonates, Addiction, 107 (Suppl. 1), 5362.

OGrady, M.J., Hopewell, J., White, M.J. (2009).

Management of neonatal abstinence syndrome: a

national survey and review of practice, Arch Dis Child

Fetal Neonatal Ed, 94:F249F252.

Abrahams, R.R., Kelly, S.A., Payne, S. et al, (2007).

Rooming-in compared with standard care for newborns

of mothers using methadone or heroin, Canadian Family

Pyhsician, October, 53.

Johnson, P.N., Harrison, D.L., Castro, C.H., Miller, J.L.

(2012). A pilot study assessing the frequency and

complexity of methadone tapers for opioid abstinence

syndrome in children discharged to home, Research in

Social and Administrative Pharmac , 8, 455-463.


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NAS

Action

PlanRe

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ofNorth Carolina

NAS


Hudak, M.L., Tan, R.C. (2012). The Committee on Drugs

and the Committee on Fetus and Newborn. Neonatal

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Provincial Council for Maternal and Child Health (2010).

Neonatal Abstinence Syndrome (NAS) Clinical Practice

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Prenatal Substance Abuse: Short and Long Term Effects

on the Exposed Fetus, Pediatrics, 131, 1009.

Jansson, L.M., Velez, M. (2012). Neonatal AbstinenceSyndrome, Curr Opin Pediatr, 24:252258.

Su, P.H., Change, Y.Z., Yang, C., Ng, Y.Y., Chen, J.Y.,Chen, S.C. (2012). Perinatal Effects of Combined Use ofHeroin, Methadone, and Amphetamine duringPregnancy and Quantitative Measurement of Metabolitesin Hair,Pediatrics and Neonatology (2012) 53, 112e117.

Moller, M., Karaskov, T., Koren, G. (2010). Opioid Detection

in Maternal and Neonatal Hair and Meconium:

Characterization of an At-Risk Population and

Implications to Fetal Toxicology, Ther Drug Monit _

Volume 32, Number 3.

Beauman, S.S., (2005). Identification and Managementof Neonatal Abstinence Syndrome, Journal of Infusion

Nursing Vol. 28, No. 3, May/June.

Murphy-Oikonen, J., Montelpare, W., Southon, S.,

Bertoldo, L., Persichino, J. (2010). Identifying Infants at

Risk for Neonatal Abstinence Syndrome A Retrospective

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