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Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. Neonatal Abstinence Syndrome: Treating Pregnant Women presentation by Dr. Rick McClead, Mona Prasad, Jacqueline Magers and Gail A. ...

Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. Neonatal Abstinence Syndrome: Treating Pregnant Women presentation by Dr. Rick McClead, Mona Prasad, Jacqueline Magers and Gail A. Bagwell

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Nas treating pregnant_women_final Nas treating pregnant_women_final Presentation Transcript

  • Neonatal  Abs,nence  Syndrome  (NAS):    Trea,ng  Pregnant  Women  and  their  Newborns   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  • Introduc,ons  •  Rick  McClead  MD  MHA   –  Professor  and  Vice  Chairman  Department  of  Pediatrics,  The  Ohio  State  University   –  Medical  Director,  Quality  Improvement,  Na,onwide  Children’s  Hospital,  Columbus  Ohio  •  Mona  Prasad  DO  MPH   –  Assistant  Professor,  OBGYN,  The  Ohio  State     –  Medical  Director,  STEPP  program,  The  Ohio  State  University  •  Jacqueline  Magers  Pharm  D  BCPS   –  Clinical  Pharmacy  Specialist-­‐NICU   –  Na,onwide  Children’s  Hospital,  Columbus,  Ohio  •  Gail  A.  Bagwell  RN,  MSN,  CNS   –  Perinatal  Outreach  Program     –  Na,onwide  Children’s  Hospital,  Columbus,  Ohio  
  • Disclosure  Statement  •  Drs  Prasad  and  Magers,  and  Ms  Bagwell  have   nothing  to  disclose.  •  Dr  McClead  has  been  funded  by  Cardinal   Health  Founda,on  2010-­‐2012  for  a   medica,on  error  preven,on  program.  
  • Learning  Objec,ves  •  List  2  reasons  why  substance  abusing  pregnant   women  should  not  be  detoxified  during  pregnancy  •  Describe  how  improvement  science  can  be  used  to   reduce  the  length  of  hospitaliza,on  for  neonates   suffering  from  NAS  •  Describe  the  pharmacology  of  illicit  drugs  and  of   those  medica,ons  used  to  treat  withdrawal  •  Describe  challenges  that  nurses  face  when  caring   for  babies  and  families  struggling  with  NAS  
  • Substance  Abuse  in  the  US  •  Opiates  in  pregnancy:  at  least  7000  births     per  year   –  Preterm  birth   –  Low  birth  weight   –  Perinatal  mortality   –  Neonatal  Abs,nence  Syndrome  (NAS)   –  ?Long  term  neurobehavioral  abnormali,es  
  • Methadone  and  Addic,on  •  Methadone  has  been  used  for  more  than  40   years  in  the  treatment  of  addic,on  •  Important  benefits  include  deterrent  from   high  risk  behaviors,  incarcera,on,  spread  of   STDs  •  Addicts  remain  opiate  dependent,  but   func,onal  
  • Methadone  and  Mothers  •  Similar  benefits  have  been  iden,fied  in  the   pregnant  woman  maintained  on  methadone   as  in  the  non-­‐pregnant  popula,on  
  • Methadone  and  Mothers  •  Methadone  Maintenance  associated  with   beeer  prenatal  care   –  Earlier,  more  compliant  •  Improved  nutri,on  and  weight  gain  •  Beeer  prepara,on  for  paren,ng  •  Less  children  in  the  foster  care  system  •  Improved  enrollment  in  substance  abuse   treatment  and  recovery  
  • To  Detox  or  Not  Detox  
  • To  Detox  or  Not  Detox  •  Why  would  you?   –  Pregnancy  without  exposures  seems  ideal   –  Limit  high  risk  behaviors:  risk  of  infec,ons,   incarcera,on,  adverse  social  outcomes   –  Limit  the  impact  of  NAS  
  • To  Detox  or  Not  Detox  •  Why  wouldn’t  you?   –  Data  supports  maintenance   –  Possibly  harmful  to  mother     –  Intrauterine  abs,nence  syndrome  (IAS)   –  Lack  of  resources  to  safely  do  it   –  It  isn’t  effec,ve  
  • To  Detox  or  Not  Detox  •  Fetal  Risk  of  detox   –  Asser,ons  of  fetal  response  to  acute  withdrawal   •  Hypoxia   •  Meconium   •  Seizures   •  Hyperac,vity   •  Catecholamine  Excess   •  Asphyxia  
  • To  Detox  or  Not  Detox  
  • To  Detox  or  Not  Detox  •  Fetal  Risk  of  Detox  may  be  independent  of   maternal  status  •  Recently  coined  IAS  (Intrauterine  Abs,nence   Syndrome)  
  • To  Detox  or  Not  Detox  •  Zuspan  1975:  Monitored  fetal  response  to   methadone  taper  and  iden,fied    elevated   catecholamines  in  the  face  of  normal   maternal  catecholamines,  improved  with   increased  methadone  dose  
  • To  Detox  or  Not  Detox  •  Fetal  Risk:  Is  there  a  role  of  IAS?  •     
  • To  Detox  or  Not  Detox  •  Case  report  of  withdrawal  in  29  week  EGA   with  IUGR  and  AEDF.  Dopplers  returned  to   normal  aier  administra,on  of  methadone  •  Suggests  that  withdrawal  can  acutely  and   reversibly  affect  fetal  placental  circula,on  
  • – Dashe,  et  all  reported  on  34  opiate   dependent    women,  enrolled  in  12  day   detox  – 59%  successfully  detoxed  and  did  not   relapse,  29%  resumed  antenatal  opiate   use,  12%  did  not  complete  the  program  
  • To Detox or Not Detox•  The  largest  single  study  of  pregnant  opiate   dependent  pa,ents  •  Retrospec,ve  case  series  of  101  pa,ents  who   underwent  a  21-­‐day  inpa,ent  opiate   detoxifica,on  with  methadone  
  • To  Detox  or  Not  Detox  •  Compared  results  of  miscarriage  and  preterm   delivery  to  published  rates  of  miscarriage  and   preterm  delivery  in  the  standard  popula,on  •   1  miscarriage  in  5  women  undergoing  in   detox  in  the  first  trimester,  no  losses  in   second  trimester  and  one  PTD  in  the  third   trimester  
  • To  Detox  or  Not  Detox  •  Effec,veness   – 50%  completed  detox,  and    1  pa,ent   remained  drug  free  at  delivery  
  • Aier  Delivery…  •  In  utero  drug  exposure,  followed  by  an   abrupt  cessa,on  at  birth,  may  cause  infants   to  suffer  from  withdrawal  symptoms,  known   as  neonatal  abs,nence  syndrome  (NAS).  •  Maternal  use  of  opioids  is  the  most  common   cause  of  NAS   – May  be  seen  with  barbiturates,  alcohol,   nico,ne  and  other  psychoac,ve  drugs.  
  • Aier  Delivery…  •  Drug  withdrawal  in  the  neonate  is  self-­‐limi,ng.     –  Withdrawal  symptoms  develop  in  55%  to  94%  of   infants  exposed  to  opioids  or  heroin  in  utero.   –  Severe  cases  require  pharmacological   interven,on.   –  Presenta,on  of  withdrawal  symptoms  are   variable  and  dependent  upon  the  type  of  drug,   amount  of  last  maternal  dose,  ,ming  of  the  last   maternal  dose,  and  infant  and  maternal   metabolism.  
  • Neonatal  Abs,nence  Syndrome   Withdrawal symptoms High  pitch  crying                 Sleeplessness  /Cranky                         Feeding  problems   Diarrhea/vomi,ng   Shakes/tremors   Overac,ve  suck   hep://www.flickr.com/photos/dey/  
  • Neonatal  Abs,nence  Syndrome   The  Problem  •  AAP  recommends  therapy  with  same  class  as   the  prenatal  substance  used,  and  based  on   symptom  severity.   –  No  standardized  therapy   –  High  variability  in  prac,ces  among  providers   –  Best  approach  has  not  been  determined   –  Hospitaliza,on  is  oien  prolonged  (8-­‐79  days).  
  • Why  is  a  prolonged  NICU  LOS  so  bad?  •  Increased risk of preventable harm•  Increased stress on families already stressed•  Impaired parent-infant attachment•  Increased financial burden on families & society.•  At Nationwide Children’s Hospital, nearly half of the our neonates are fully-capitated Medicaid manage care patients.
  • Background  •  Na,onwide  Children’s  Hospital  is  a  large,  free-­‐ standing  academic  pediatric  facility  in  Columbus,   Ohio  with  450  licensed  beds  •  Neonatal  Services   –  8  Intensive  care  nurseries   •  191  Neonatal  beds   •  2200  admissions/year   •  22%  <  1500  g  birth  weight   29
  • Neonatal  Abs,nence  Syndrome   Our  Specific  Problem  •  6-­‐fold  increase  in  the  number  of  pa,ents  at  NCH   with  NAS  from  2004-­‐2008   –  200  NAS  pa,ents  in  2008   –  NAS  LOS  exceed  58  days  prior  to  2009   –  Methadone  protocol  established  in  early  2009   •  LOS  decreased  to  31  days   •  Literature  suggested  decreased  LOS  with  oral   morphine  •  Established  QI  Team  to  reduced  LOS  for  neonates   with  NAS  
  • Aim  &  Key  Drivers  for  NAS   Design Changes / Interventions Key Drivers RN  educa,on  re  pa,ent     assessment  &  Finnegan   Nursing  Assessment   scoring   Specific AimReduce  LOS  of  main     Nursing  Documenta,on   Compliance  Monitoring  campus  NAS  pa,ents    from  31  to  24  days    by  December  31,  2010     Weaning  Protocol   Develop  oral  morphine     Weaning  protocol  Balancing  Measure:   Maternal  Management   Collaborate  with  OBGYNs  30-­‐day  readmission   31
  • Pharmacologic  Interven,ons  
  • Pharmacologic  Interven,ons  •  Pharmacology  of  illicit   drugs  •  What  drugs  result  in  a   withdrawal  that  needs   pharmacological   treatment  and  when?  •  When  are  adjunct   medica,ons   warranted?  
  • Cocaine   •  CNS  s,mulant    blocks  the  reuptake  of   catecholamines  (epinephrine  and  dopamine)   –  Intense  euphoria,  decreased  fa<gue,  increased  alertness   •  Complica,ons:  cardiovascular  events,  fever   •  Withdrawal:    characteris,c  syndrome  of   withdrawal  effects,  although  they  are  not  life-­‐ threatening  Doering  PL.    Substance-­‐related  disorders:  overview  and  depressants,  s<mulants,  and  hallucinogens.    In:    Pharmacotherapy.    6th  ed.    Dipiro  JT,  ed.    New  York:  McGraw-­‐Hill;  2005.  
  • Amphetamines  /  Methamphetamines  /   Bath  Salts   •  CNS  s,mulant    increases  ac,vity  of   catecholamines  by  increasing  release,  blocking   reuptake,  and  inhibi,ng  the  degrada,ve  enzyme   –  Diminished  fa<gue,  increase  alertness,  suppress  appe<te   •  Complica,ons:    cardiovascular  events,  respiratory   problems,  extreme  anorexia,  agita,on   •  Withdrawal:    strong  craving,  not  life-­‐threatening  Doering  PL.    Substance-­‐related  disorders:  overview  and  depressants,  s<mulants,  and  hallucinogens.    In:    Pharmacotherapy.    6th  ed.    Dipiro  JT,  ed.    New  York:  McGraw-­‐Hill;  2005.  
  • Seda,ves  /  Hypno,c  Agents  •  Focus  on  what  we  most  commonly  see:       –  Benzodiazepines   –  An<depressants   –  Barbiturates  •  Complica,ons:    lower  blood  pressure,   drowsiness,  memory  impairment/confusion  •  Withdrawal:    may  be  life-­‐threatening  in  a   neonate  
  • Opiates  /  Opioids   •  Opiates  vs.  Opioids     µ δ κ1 κ3 Morphine   +++   +   +   Methadone   +++   Fentanyl   +++   Buprenorphine   P   NA   -­‐-­‐   NA   Naloxone   -­‐-­‐-­‐   -­‐   -­‐-­‐   -­‐-­‐   +  agonist,  -­‐  antagonist,  P  par<al  agonist,  NA  data  not  available  or  inadequate.       The  number  of  symbols  is  an  indica<on  of  potency.  Reisine  T,  Pasternak  G.    Opioid  Analgesics  and  Antagonists.    In:    The  Pharmacological  Basis  of  Therapeu8cs.    9th  ed.    Hardman  JG,  Limbird  LE,  eds.    New  York:  McGraw-­‐Hill;  1996.  
  • Opiates  /  Opioids   Receptor   Agonists   Antagonists   subtype   Analgesia        supraspinal   µ1, κ3, δ1, δ2 Analgesic   No  effect        spinal   µ2, δ2, κ1 Analgesic   No  effect   Respiratory   µ2 drive   No  effect   func<on   GI  tract   µ2, κ transit   No  effect   Seda<on   µ, κ No  effect   •  Withdrawal:    anxiety,  piloerec,on,  abdominal   cramps,  diarrhea,  insomnia     –  May  progress  to  be  life  threatening  in  a  neonate  Reisine  T,  Pasternak  G.    Opioid  Analgesics  and  Antagonists.    In:    The  Pharmacological  Basis  of  Therapeu8cs.    9th  ed.    Hardman  JG,  Limbird  LE,  eds.    New  York:  McGraw-­‐Hill;  1996.  
  • Pharmacologic  Interven,ons   •  When  to  add  pharmacologic  therapy?   –  When  nonpharmacological  measures  have  been   unsuccessful  in  consoling/stabilizing  the   neonate   •  Indica,ons:    seizures,  poor  feeding,  diarrhea  and   vomi,ng  resul,ng  in  excessive  weight  loss  and   dehydra,on,  inability  to  sleep  and  fever  unrelated  to   infec,on   •  What  medica,on(s)  should  be  used?   –  Depends  on  what  neonate  was  exposed  to  Neonatal  drug  withdrawal.    American  Academy  of  Pediatrics  Commi]ee  on  Drugs.    Pediatrics.    1998;101:1079-­‐1088.  
  • Pharmacologic  Interven,ons  •  Cocaine,  amphetamines,  methamphetamines   –  Suppor,ve  care  •  Bath  salts     –  Suppor,ve  care   –  Benzodiazepines  if  needed  •  Seda,ves/hypno,cs     –  Phenobarbital    
  • Morphine  vs.  Methadone   •  Use:    opioid/opiate  exposure   Dose  (mg/kg/ Onset     Peak   T1/2   Metabolism   dose)   (min)   IV:    0.05-­‐0.2         IV:    10   IV:    20  min   PT:    10-­‐20hr   Liver      M6G   Morphine   PO:    0.15-­‐0.6   PO:    30   PO:    1  hr   FT:    4.5-­‐13hrs   (ac<ve;  18hr),   M3G  (inac<ve)   Liver    inac<ve   Methadone   PO:    0.05-­‐0.2   PO:    30-­‐60       PO:    2-­‐4  hrs   16-­‐25  hrs   metabolite  PT:    preterm;  FT:    full  term;    M6G:    morphine-­‐6-­‐glucuronide;  M3G:    morphine-­‐3-­‐glucuronide  
  • Oral  Morphine  Ini,a,on  Protocol   Protocol  should  be  ini,ated  if  an  infant  has  2  consecu,ve  scores  >  8  or  1  score  >  12   within  a  24  hour  period  (just  as  was  done  previously  with  the  methadone  taper).   Concentra,on  of  Enteral  Morphine  to  be  used  for  ALL  doses:  0.2  mg/mL  Star,ng  Dose:    Enteral:  0.05  mg/kg/dose  PO  q3h    IV:  0.02  mg/kg/dose  IV  q3h      (IV  morphine  and  enteral  morphine  doses  are  not  equivalent)  Titra,on:    Enteral:    Increase  by  0.025-­‐0.04  mg/kg  every  3  hrs  un,l  controlled  (NAS  <8)    IV:    increase  by  0.01  mg/kg  every  3  hrs  un,l  controlled  (NAS  <8)   *Rescue  Dose*:    If  infant  has  1  score  of  >  12,  double  the  previous  dose  given  (enteral   or  IV)  x  1  and  then  adjust  accordingly:   -­‐    If  NAS  score  now  <  12:  make  the  scheduled  maintenance  dose  (MD)  the  same   as  the  rescue  dose  that  was  just  administered.    The  first  higher  MD  should  be   given  at  the  next  scheduled  care/feed.   -­‐    If  NAS  score  s<ll  >  12:  increase  next  dose  by  50%.    Con<nue  to  do  so  un<l   score  is  <  12.    Once  <12.  then  follow  guideline  listed  above.  
  • Oral  Morphine  Weaning  Protocol  Wean:    Once  stabilized  on  a  dose  for  72-­‐96  hours,  use  this  dose  as  the  star<ng  point  of  the  wean  (please  note  this  dose  on  infant’s  card).    Begin  weaning  the  dose  by  10%  (of  the  original  dose  when  the  first  wean  was  started)  every  24-­‐48  hours.    Drug  may  be  discon<nued  when  a  single  enteral  dose  is  <  0.02  mg/kg/dose.       *Ad  lib  infants*:    Given  the  shorter  dura<on  of  ac<on  of  enteral  morphine,  it  is  best   suited  to  be  dosed  on  a  q3hr  schedule.    Infants  should  be  allowed  to  ad  lib  feed   volumes  but  kept  on  a  q3hr  schedule.   *Backslide*:    If  infant’s  NAS  scores  become  consistently  elevated  (ex:  2  consecu<ve    >   8)  during  the  weaning  process,  assure  that  nonpharmacological  measures  are   op<mized  (ie:  swaddling,  holding,  decreased  s<muli,  etc.)  before  going  back  to   pervious  dose  at  which  pa<ent  was  stable.    If  infant’s  scores  con<nue  to  be  elevated   (even  amer  physical  exam  to  ensure  nothing  else  is  wrong/bothering  the  infant),   either  weight  adjust  medica<on  and/or  con<nue  to  back  up  in  a  stepwise  fashion   un<l  pa<ent’s  scores  are  <  8.    Once  stabilized  on  a  new  dose  for  minimum  48  hrs.   resume  10%  wean  but  consider  weaning  at  longer  intervals.  Discharge:    Observe  in-­‐house  x  48-­‐72  hours  off  of  medica<on  before  discharge.  
  • Adjunct  Therapy  -­‐  Phenobarbital  •  Consider  star<ng  phenobarbital  if:   –  Polysubstance  exposure  is  suspected/confirmed  or  if  majority  of  NAS  score  is   due  to  CNS  disturbances  (hyperac<ve  reflexes,  tremors,  increased  muscle   tone,  presence  of  jerks,  etc).    •  Loading  Dose  (up  to  physician  discre,on  if  needed):  10  mg/kg/dose  PO   q12hr  x  2  doses     –  Enteral  formula<on  contains  a  high  percentage  of  alcohol.  Recommend   dividing  dose  to  decrease  risk  of  emesis  and/or  seda<on.    •  Maintenance  Dose:  5  mg/kg/dose  PO  once  daily,  preferably  in  the   evening.  Dose  may  be  divided  BID  if  concern  for  excess  seda<on.  Do  NOT   rou<nely  weight  adjust.    •  Wean:  Recommend  discharging  infant  home  on  phenobarbital  with   subsequent  weaning  to  be  done  either  in  Neo  Clinic  or  by  infant’s  PCP.    •  Phenobarbital  levels  should  not  be  needed  for  this  indica<on  unless  the   infant  experiences  seizures  or  seizure-­‐like  ac<vity.  If  suspected,  a   phenobarbital  level  and/or  a  neurology  consult  may  be  warranted  at  that   <me.    
  • Adjunct  Therapy  -­‐  Clonidine   •  Consider  star<ng  clonidine  if:     –  Majority  of  NAS  score  is  due  to  autonomic  over-­‐s,mula,on  (swea<ng,  fever,   yawning,  mo]ling,  sneezing,  etc.)   –  Infant  is  requiring  >  0.1  mg/kg/dose  of  morphine  q3hr  and  is  s<ll  not  stabilized.     •  Maintenance  Dose  (0.1  mg/mL  suspension):     –  Given  that  the  infant  will  be  receiving  morphine  on  a  q3hr  basis,  for  ease  of   administra<on  recommend  1  mcg/kg/dose  PO  every  6  hrs  (range:  4-­‐6  mcg/kg/ DAY  divided  q4-­‐6hr)     •  Side  effects  of  clonidine  include  bradycardia,  hypotension  upon  ini<a<on   and  then  rebound  hypertension  when  drug  is  discon<nued.     •  Do  NOT  recommend  discharging  pa<ent  home  on  clonidine.  Amer  pa<ent   has  shown  stabiliza<on  off  of  morphine  for  minimum  of  24hrs,  discon<nue   the  clonidine  and  monitor  in-­‐house  for  minimum  of  48hrs  due  to  risk  of   rebound  hypertension.    Agthe  ,  et  al.    Pediatrics.  2009;123:e849-­‐e856.  Hoder.    Psychiatry  Research.  1984;13:243-­‐251.  
  • Caregiver  Educa,on  and  Support  
  • Caregiver  Educa,on  and  Support  •  Pa,ent  Assessment  •  Finnegan  Scoring  tool  •  Maternal  Substance  Use/Abuse  •  Ongoing  educa,on  and  training  
  • Staff  concerns  in  2009:  •  Poor  communica,on  and  inconsistency  of   plans  of  care  •  Poor  competency  with  assessment  and         documenta,on  of  symptoms  •  Stress  related  to  neonatal  care  •  Stressful  family  dynamics  &  interac,ons  •  Discharge  planning    
  • Aim & Key Drivers for NAS Design Changes / Interventions Key Drivers RN  educa,on  re  pa,ent     assessment  &  Finnegan   Nursing  Assessment   scoring   Specific AimReduce  LOS  of  main     Nursing  Documenta,on   Compliance  Monitoring  campus  NAS  pa,ents    from  31  to  24  days    by  December  31,  2010     Weaning  Protocol   Develop  oral  morphine     Weaning  protocol  Balancing  Measure:   Maternal  Management   Collaborate  with  OBGYNs  30-­‐day  readmission   49
  • I.  Nursing  Assessment  and  Scoring  •  Finnegan  Training  Courses  (  March-­‐  April   2010)   •  Two  half  day  NAS  Workshops   •  Train  the  trainer  format  •  Implement  standardized  training  of  new  staff   with    commercially  produced  program  •  Ongoing  competency  for  all  staff    
  • Workshop  Intra-­‐rater  Reliability  Pre-­‐Workshop  Post-­‐  Workshop  
  • II.  NCH  NAS  Taskforce  •  Repository  of  informa,on,  resources,  and  ideas  for  poten,ally   beeer  prac,ces  •  Monthly  interdisciplinary  collabora,ve  mee,ngs:   •  Interprofessional  educa,on     •  Developed  prac,ce  guidelines   •  Enhanced  antenatal  professional  communica,on,  collabora,on   •  Provided  educa,on  and  training  of  L/D  and  WBN  staff   •  Outreach  educa,on  and  support  for  providers  in  the  Region.    •  MOD  Grant:  improved  maternal  Methadone  treatment   reten,on  rate  by  25%    
  • Staff  Stress  •  Nurses  struggle  with  issues  of  beneficence   and  non-­‐maleficence,  frustra,on,  burnout   and  dissa,sfac,on  when  caring  for  this   popula,on  of  pa,ents  and  families  •  We  surveyed  our  staff  to  determine  what   they  were  experiencing  
  • 2013  NCH  NAS  Taskforce  Goal  1.  Determine  NCH  staff  level  of  comfort  in  caring  for  the  NAS  pa,ents  and  families  2.  Determine  if  addi,onal  educa,on,  training  and  resources  are  needed  to  help  staff  care  for  and  cope  with  NAS  pa,ents  and  families  
  • The  Survey  •  Qualita,ve  and  quan,ta,ve  data  •  Sent  to  all  nursing  staff  of  Neonatal  Services   (LPN,  RN,  APN)  via  email.  N=  580  •  Returns=  167  •  Response  rate=  28%  
  • Demographic  Data  N=167           Years  of  NICU  experience  RNs=  130  (78%)               0-­‐5  years=  50  (30%)  LPNs=  5  (3%)   6-­‐10  years=  37  (22%)   11-­‐20  years=  29  (17%)  APNs=  30  (18%)   Over  20  years=  48  (28%)  MD=1  (0.6%)   Unknown=  3  (2%)  Unknown=1  (0.6%)  
  • What  are  some  of  the  biggest  challenges  that   you  experience  caring  for  babies  with  NAS        1.  Finnegan  Scoring   -­‐  “subjec,ve”   -­‐  Comfort  with  r/t  competency   -­‐  Struggle  between  NNPs  and  RNs            2.  Parents/Families              -­‐  Level  of  involvement            -­‐    Awtudes:  resenxul,  denial,  lying,  level  of  knowledge   3.  Pa,ent  Care   -­‐  Seemingly  ineffec,ve  care-­‐  fussiness,  skin  breakdown   -­‐  Lack  of  consistency  between  providers  and  prac,,oners  
  • What  are  some  of  the  biggest  challenges  that   you  experience  caring  for  babies  with  NAS  4. Workload –  Not enough time to console –  Too many babies to care for5. “Ethics” –  Patience for self and of others –  “Prejudiced nurses”
  • 2013  NCH  NAS  Taskforce  Ac,on  Plan  1.  Staff  Educa,on:     –  NAS  quarterly  taskforce  mee,ngs   –  VON  iNICQ  NAS  Webinar  series   –  Annual  NCH  conference-­‐  NAS  Postconference   –  Ohio  Opiate  Summit   –  Podcasts  by  Neonatologist  and  Addic,on  Specialist   –  Ethics  lectures  for  staff  
  • 2013  NCH  NAS  Taskforce  Ac,on  Plan  2.  Staff  Resources   –  Develop  website  or  sharepoint  for     •  Guidelines,  references,  ar,cles   •  Mee,ng  minutes   •  iNICQ  proceedings   –  Bedside  resource  packet   –  EPIC  EMR  with  best  prac,ce  alerts   –  Unit  based  NAS  commieees  with  Superusers  
  • 2013  NCH  NAS  Taskforce  Ac,on  Plan  3.  Staff  Training   –  FNAST  ongoing  competency  training   –  Inter-­‐rater  reliability  tes,ng  4.  Re-­‐survey  in  2013  
  • References  •  D’Apolito,  K.  and  Finnegan,  L.  Assessing  the  Signs  and  Symptoms   of  Neonatal  Abs,nence  using  the  Finnegan  Scoring  Tool:  an  inter-­‐ observer  reliability  program.  Neo  Advances,  2010.  •  Maguire  D,  Webb  M,  Passmore  D,  Cline  G.  NICU  Nurses  Lived   Experience:  Caring  for  Infants  With  Neonatal  Abs,nence   Syndrome.    Adv  Neonatal  Care.  2012  Oct;12(5):281-­‐5.  •  Murphy-­‐Oikonen  J,  Brownlee  K,  Montelpare  W,  Gerlach  K.  The   Experiences  of  NICU  Nurses  in  Caring  for  Infants  with  Neonatal   Abs,nence  Syndrome.  Neonatal  Network.  Sept/Oct  2010;  29  (5):   307-­‐313.    
  • h]p://www.eecs.umich.edu/dco/services/courseservices.php  
  • How  are  we  doing?   Length  of  Stay  for  NAS  Infants  Admieed  to  the  Main  Campus  NICU*   Morphine  Failures   RN  staff  reeduca,on   Modifica,on  of  morphine  protocol  (March  2011)   Modifica,on  of  morphine  protocol  (March  2010)   Ini,a,on  of  morphine  protocol  (December  2009)   Ini,a,on  of  NAS  Taskforce  (November  2009)   Implementa,on  of  methadone  protocol  (May  2009)  •  Excludes  infants  admieed  with  LOS  due  to  other  factors  such  as  prematurity,  low  birth  weight,  birth  defects,  etc.  
  • Spread  to  Local  Maternity  Center   Methadone   Morphine  Protocol  
  • All  Cause  Readmissions  •  28  Readmissions  2010-­‐2012(N=  440)   –  NAS  symptoms  (2)   –  CNS  symptoms  unrelated  to  NAS  Hx  (3)   –  Feeding  issues  unrelated  to  NAS  Hx  (4)   –  BPD  exacerba,on  (1)   –  Infec,ons  (13)   –  Surgical  problems  (5)  
  • Summary  
  • Summary•  Substance abusing pregnant women should not be routinely detoxed prenatally•  Formal training of staff in the use of the Finnegan tool led to better assessment and documentation of withdrawal symptoms, and a more reliable weaning program.•  Standardize pharmacotherapy can impact LOS of NAS patients 68
  • Summary•  Oral morphine weaning protocol associated with a significant decrease in LOS for NAS patients.•  Morphine weaning failures due to high maternal methadone dosing and polypharmacy•  Maternity centers with NAS babies can achieve LOS of < 20 days. 69