Welcome to the OPQC NAS

August Action Period Call

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participants and full name

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Neonatal Abstinence

Syndrome Project

Action Period Call

Ohio Perinatal Quality Collaborative

August 19, 2014

Welcome!

Please don’t put us on

HOLD!

If you need to step away:

– Use the MUTE button on your phone or

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Time Topic Presenter

3:00 pm Welcome, Agenda Review, roll call/sign in Susan Ford

3:05 pm Data Overview

Heather Kaplan, MD

3:15 pm Update from OARRS Susan Ford

3:20 pm Lessons Learned: Implementing the

Pharmacological Bundle

• Hospital #1 – Morphine

• Hospital #2 – Methadone

Presenters

3:50 pm Next Steps

• Data Submission Review

• Monthly Progress Report

Susan Ford

Agenda

Roll Call: Please sign in with your hospital affiliation and the

names of your team members on the call in the

Question box

Promedica Toledo Children’s

Miami Valley

Mercy Anderson

Aultman

Mt. Carmel East OSU

UH Rainbow Babies & Children’s

Bethesda North Hospital

Nationwide Dublin Methodist

Akron Children’s Summa

Cincinnati Children’s

Hillcrest Hospital Fairview Hospital

Cleveland

Clinic

Dayton Children’s

Nationwide Riverside Methodist

Nationwide Grant

Nationwide Mt. Carmel St. Ann’s

UH Cincinnati

Good Samaritan Hospital

MetroHealth

Mt. Carmel West Nationwide Doctor’s

Akron Children’s

Nationwide Children’s

Mercy Children’s Hospital

Atrium Medical Center

Fort Hamilton

Mercy Hospital Fairfield

Mercy Medical Center Canton

The Christ Hospital

St. Rita’s

Medical Center

Blanchard Valley

Southview Medical Center

Good Samaritan Hospital Dayton

Kettering

Mercy Health West

Southern Ohio Medical Center

Genesis Healthcare System

OhioHealth MedCentral Mansfield

Marion General

Elyria Medical Center -UH

Mercy Regional Medical Center Lorain

ProMedica Bay Park

Tripoint Medical Center (Lake Health)

Lima Memorial Health System

Springfield Regional Medical Center

Adena Regional

Medical Center

Soin Medical Center

Upper Valley Medical Center

Licking Memorial Health System

NAS Participating Sites 2014

1/2014 start Level 3

and Level 2 teams

Akron Children’s St. Elizabeth

Health Center/Mahoning

Valley

Trumbull Memorial

4/2014 start

Level 2 teams

Key Driver Diagram Project Name: OPQC Neonatal NAS Leader: Walsh

SMART AIM

KEY DRIVERS INTERVENTIONS

By increasing identification of and

compassionate withdrawal treatment for full-term infants born with

Neonatal Abstinence Syndrome (NAS), we will reduce length of stay by 20% across participating sites by June 30, 2015.

Improve recognition and non-judgmental support for Narcotic

addicted women and infants

Connect with outpatient support and treatment program prior to

discharge

Standardize NAS Treatment Protocol

Optimize Non-Pharmacologic Rx Bundle

• Initiate Rx If NAS score > 8 twice. •Stabilization/ Escalation Phase •Wean when stable for 48 hrs by 10% daily.

•Swaddling, low stimulation. •Encourage kangaroo care •Feed on demand- MBM if appropriate or lactose free, 22 cal formula

•All MD and RN staff to view “Nurture the Mother- Nurture the Child” •Monthly education on addiction care

Attain high reliability in NAS scoring by nursing staff

Partner with Families to Establish Safety Plan for Infant

Fulltime RN staff at Level 2 and 3 to complete D’Apolito NAS scoring training video and achieve 90% reliability.

• Establish agreement with outpatient program and/or Mental Health •Utilize Early Intervention Services

Collaborate with DHS/ CPS to ensure infant safety.

Prenatal Identification of Mom Implement Optimal Med Rx Program

Engage families in Safety Planning. Partner with other stakeholders to influence policy and primary

prevention. Provide primary prevention materials to sites.

To reduce the number of moms and babies with narcotic exposure, and

reduce the need for treatment of NAS.

GLOBAL AIM

• Please submit data even

if there were no

NAS patients in your

hospital for the month.

• Please submit NAS data

by the 5th of each month.

• Instructions and Data

Dictionary, as well as the

Data Collection Form can

all be found on the OPQC

(SharePoint) site.

Member Log In-NAS (left

sidebar) -Data Collection

OARRS- Ohio Automated Rx

Reporting System Per Ohio Revised Code Section 4729.80(A)(12), as enacted by Ohio HB 483

of the 130th General Assembly, you or your delegate are now authorized

to request information from the Ohio Automated Rx Reporting System

(OARRS) relating to the mother of a patient, if the prescriber or their

delegate certifies that it is for the purpose of providing medical treatment to

a newborn or infant patient diagnosed as opioid dependent and the

prescriber has not been denied access to the database by the board.

Key Driver:

Intervention:

Pharmacological Bundle

Standardize NAS Treatment Protocol

• Initiate Rx If NAS score > 8 twice. •Stabilization/ Escalation Phase •Wean when stable for 48 hrs. (Morphine) or 72 hrs. (Methadone) by 10% daily. (see weaning tables)

Source: https://neoadvances.org

Source: http:pyschiatricnews.org

OCHA Protocol

Initiate (modified

Finnegan Scoring)

NAS score > 8 q3h two times

> 12 one time

Pharmacologic Bundle Drug: Morphine/Methadone

0.05 mg/kg PO

Escalate If ≥ 12, increase dose

Stabilize No increase for 48 hrs.

Wean 10% of max dose daily; see protocol

weaning schedule examples

Discharge 48 hours off Morphine

72 hours off Methadone

Moving Towards a Standardized Approach

Hospital 1 process

• Prior to State protocol had instituted a

newer process for ~ 1 year

– Extensive education: all (part & full time)

– Pre/post testing

– 3 campuses

• Really wanted to be part of the new

process

• posed a challenge

Hospital 1 process

1. Decided to proceed with information and

rationale

2. Compared our current process with the

other weight based protocol Wanted to strive for as short LOS as clinically

appropriate and beneficial for families and society

Wanted to decrease total morphine dose given as

well

Hospital 1 process

• Goals to simplify and stepwise towards the new process

• Picked the key similarities, key differences

• Buy in from key people (really everyone) 1. MD (attendings)

2. NNP

3. CNS

4. Clinical coordinator (charge RN)

5. Bedside nurses

6. PharmD & pharmacy

Hospital 1 process

• Buy-in included

– Continue to use the modified finnegan scoring

– Mostly changing the dose (NNP & MD)

• Increased dose to start

• Change dosing regimen to weight vs. scores

– Simplify the process

• Ordering in EHR listed as Ohio NAS protocol

• One page summary for NNP/ residents listed

identically as in EHR

Hospital 1 process

• Ongoing issues

– Questions will occur regardless of preparation

• Full time/ part time

• New hires

• Smaller units with increased experience ( volume

and patient/ RN ratio) vs. larger unit with more staff

• Different clinical circumstances

Hospital 1 process

• Have done “ top 10 “ questions

– As questions arose, published a list or FAQ • Scoring questions, feeding, etc.

– Plan to update again soon

• Notify NNP and MD staff to willingly call for questions and concerns, regardless if on service or not (open door)

• Multidisciplinary rounds: bedside RN, attending, NNP, family, and at times clinical coordinator

• Most of the patients, given locale, are cared for NNPs, not residents(assists with consistency)

Hospital 1 process

• Future directions

– Going to trial ad lib feedings and q 3-4

feedings

• Currently strict with q3 feeding and dosing

– Review the video again and audit bedside

staff with scoring as a means of continued

education

• RN project

– Working with hospital staff to consider change

of local to outside the NICU/ SCN as locus of

inpatient care

Hospital 1 process

Current concerns

• Still may have staff opinion in scoring vs consistency RN project with audits

– Previously, had observed 90-95% consistency in inter-user reliability

– Casual reports of differing scores

• Comparing data vs. prior process

– Increased LOS

– Increased morphine dose

– No change in subutex or methadone use

Lisa

Implementing A New Methadone Protocol

PDSA, Successes, and Failures

Hospital #2

In the Beginning

• Length of treatment

– >35 days

– Everyone had an opinion

– Everyone had their own way to treat based on where

they had been trained

• The art of medicine

– Inconsistent and subjective use of Finnegan scoring

tool

Identify a Problem

• We’ve done that or we wouldn’t be here

Inter-Observer Reliability

• Entire staff completed the program within 1 month

• Immediate length of treatment drop of 10 days

• Neonatologists, NNPs, RNs, PCAs, unit clerks,

resident physicians

• Everyone must be on the same page and using the

same vocabulary

• Publicize the results

• Staff meeting, bulletin board, electronic

Building on Success

or

Things that Make you go

Hmmm…

• Discussion of other facilities length of treatment which were

much shorter than ours (OCHA data review)

• Get all physicians/NNPs on board with need to change

practice

– “Not just a nursing issue”

– Concern for “cookbook medicine”

– Skepticism that we could decrease days that drastically

– Maybe our babies are different…exposure/poly drug etc…

First PDSA

Plan, Do

• Let’s try a change on just one patient…

– We’ll see what happens with length of treatment/LOS

• Might shorten a little bit

– Review of OCHA protocol

• With NNPs, Residents and Attending physician

• No patient needed it, felt like a non-issue

• Finally the patient arrived

– “Quick” review of previous information with providers

– Increased anxiety about the change in dose frequency

– Questions from RNs at bedside about changing of dose frequency

– Multiple discussions on rounds and throughout day

– Quick wean of Methadone over less than 20 days

– Social services in the baby’s county were unprepared for the baby to be ready for discharge

First PDSA

Study

• Did the results match our prediction?

– Exceeded our expectations

– Decreased length of treatment

– Skepticism…will it work again?

• What did we learn?

– We didn’t do a good job reviewing change in protocol with the nursing staff

• Made it difficult on night shift when residents in house on call.

– Social work needs to be involved in changes to protocol…

– Need to keep social work updated on progress and anticipated discharge

First PDSA

Act

• Did we Adapt, Adopt or Abandon

• We adopted albeit with some skepticism

– Would it really work that way again???

Second Verse (PDSA)

Same as the First

• The next patient arrived and we repeated the protocol

with the same result

• Fully adopted the protocol

Successes

• Decreased length of treatment

• Agreement by providers

• Education of resident staff paid off

• Length of treatment now an average length of treatment

14.4 days

Failures

• Focused primarily on providers for protocol change

• Didn’t focus enough on the nurses

– RNs have now had education on the protocol

• Didn’t anticipate the need for such frequent social work

updates

– Brought our social worker into the team

• Didn’t have enough faith that we would succeed in

decreasing length of treatment

Discussion and Questions

• What barriers are you encountering in

attempting to implement the

pharmacological bundle at your hospital?

• What success have you had in

implementing elements of the

pharmacological bundle at your hospital?

• Questions for Jenn or Lisa….

Save the Date(s)!

• OCPIM December Conference to be held

in Columbus on December 3rd and 4th

• Opportunities include:

– Poster presentation

– Breakout Session

– Exhibitor

Next Steps

• Continue testing small tests of change (PDSA)

• Please submit NAS Data. August data will be

due 9/5. Remember to please submit and check

“No Eligible Babies for the Month” if there

were no NAS patients at your site during July.

• Monthly Progress Report

– Will be sent out 8/25; due 9/5

The OPQC NAS Project is

funded by The Ohio

Department of Medicaid