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

1. Neonatal
Abs,nence
Syndrome
(NAS):
Trea,ng
Pregnant
Women
and
their
Newborns
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

2. 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

3. 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.

4. 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

6. 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

7. 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

8. Methadone
and
Mothers
• Similar
benefits
have
been
iden,fied
in
the
pregnant
woman
maintained
on
methadone
as
in
the
non-­‐pregnant
popula,on

9. 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

10. To
Detox
or
Not
Detox

11. 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

12. 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

13. 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

14. To
Detox
or
Not
Detox

15. To
Detox
or
Not
Detox
• Fetal
Risk
of
Detox
may
be
independent
of
maternal
status
• Recently
coined
IAS
(Intrauterine
Abs,nence
Syndrome)

16. 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

17. To
Detox
or
Not
Detox
• Fetal
Risk:
Is
there
a
role
of
IAS?
•

18. 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

19. – 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

20. 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

21. 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

22. To
Detox
or
Not
Detox
• Effec,veness
– 50%
completed
detox,
and
1
pa,ent
remained
drug
free
at
delivery

24. 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.

25. 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.

26. 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/

27. 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).

28. 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.

29. 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

30. 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

31. Aim
&
Key
Drivers
for
NAS
Design Changes / Interventions
Key Drivers RN
educa,on
re
pa,ent
assessment
&
Finnegan
Nursing
Assessment
scoring
Specific Aim
Reduce
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

32. Pharmacologic
Interven,ons

33. 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?

34. 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.

35. 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.

36. 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

37. 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.

38. 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.

39. 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.

40. Pharmacologic
Interven,ons
• Cocaine,
amphetamines,
methamphetamines
– Suppor,ve
care
• Bath
salts
– Suppor,ve
care
– Benzodiazepines
if
needed
• Seda,ves/hypno,cs
– Phenobarbital

41. 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

42. 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.

43. 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.

44. 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.

45. 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.

46. Caregiver
Educa,on
and
Support

47. Caregiver
Educa,on
and
Support
• Pa,ent
Assessment
• Finnegan
Scoring
tool
• Maternal
Substance
Use/Abuse
• Ongoing
educa,on
and
training

48. 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

49. Aim & Key Drivers for NAS
Design Changes / Interventions
Key Drivers RN
educa,on
re
pa,ent
assessment
&
Finnegan
Nursing
Assessment
scoring
Specific Aim
Reduce
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

50. 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

51. Workshop
Intra-­‐rater
Reliability
Pre-­‐Workshop
Post-­‐
Workshop

52. 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%

53. 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

54. 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

55. 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%

56. 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%)

57. 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

58. 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 for
5. “Ethics”
– Patience for self and of others
– “Prejudiced nurses”

59. 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

60. 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

61. 2013
NCH
NAS
Taskforce
Ac,on
Plan
3.
Staff
Training
– FNAST
ongoing
competency
training
– Inter-­‐rater
reliability
tes,ng
4.
Re-­‐survey
in
2013

62. 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.

63. h]p://www.eecs.umich.edu/dco/services/courseservices.php

64. 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.

65. Spread
to
Local
Maternity
Center
Methadone
Morphine
Protocol

66. 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)

67. Summary

68. 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

69. 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