Neonatal Abstinence Syndrome:

Transcription

1 Neonatal Abstinence Syndrome: Reconsidering the Standard Approach Matthew Grossman, M.D. Assistant Professor of Pediatrics Yale School of Medicine Quality and Safety Officer Yale-New Haven Children s Hospital

2 DISCLOSURE The content of this presentation does not relate to any product of a commercial entity; therefore, I have no relationships to report.

3 Opioids in the US Prescriptions grew 4-fold over last decade More deaths than car accidents 91 people die each day from opioids In 2012, enough opioids were prescribed to give every adult in the US one prescription Patrick, et al. Journal of Perinatology. 2015; 35: Source:

4 NAS per 1000 Hospital Births Incidence of NAS in the US, Year Patrick SW, et. al. Neonatal Abstinence Syndrome and Associated Healthcare Expenditures United States, JAMA May 9;307(18): Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to J Perinatol. Apr

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6 Source: Grossman Family Album

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8 Source: Langenfeld, et al. Drug and Alcohol Dependence 2005;77:31 6.

9 Source: Jackson L, et al. Archives of Disease in Childhood 2004;89: F300 4.

10 Source: Coyle MG. Journal of Pediatrics 2002;140:561 4

11 Source: MS Brown et al. Journal of Perinatology 2014; (1-6)

12 Agthe, et al. Pediatrics 2009;123:e Source:

13 Standard Approach Medications NICU Finnegan Scores Medication Dosing Staff cares for the baby

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17 LOS (days) Length of Stay: Methadone-Exposed Infants P < June 2006 July

18 Medication Studies DTO vs. DTO plus clonidine: 17 days vs. 12 days Morphine vs. Phenobarbitone: 8 days vs. 12 days Morphine vs. DTO 30 days vs. 27 days DTO vs. DTO plus Phenobarbitone 79 days vs. 38days Methadone vs. Morphine 17 days vs. 24 days

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22 % Treated with Morphine Percent of NAS Patients Treated with Morphine 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Year

23 LENGTH OF STAY (Days) Length of Stay: Methadone exposed infants Mean=22.5 UCL LCL 0.0 ADMIT DATE

24 The standard approach: why? Medications

25 Source: Grossman Family Album Abraham, et al. J Obstet Gynaecol Can 2010;32(9):

26 Intervention 1 Focus on non-pharmacologic care 26

27 LENGTH OF STAY (Days) Length of Stay: Methadone exposed infants 70.0 Standardized non-pharm care UCL Mean= Mean= LCL 0.0 ADMIT DATE

28 The standard approach: why? Medications NICU

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32 Intervention 2 Direct transfer to the general inpatient unit 32

33 1/30/08 6/12/08 7/18/08 10/15/08 12/1/08 1/13/09 2/7/09 4/6/09 5/13/09 6/14/09 9/10/09 10/5/09 12/18/09 2/23/10 3/19/10 6/23/10 9/23/10 11/23/10 12/18/10 2/17/11 3/8/11 4/27/11 5/19/11 7/26/11 9/16/11 10/7/11 12/1/11 12/26/11 2/11/12 4/17/12 5/13/12 6/8/12 7/16/12 9/27/12 10/14/12 11/17/12 1/25/13 2/23/13 3/21/13 4/15/13 5/21/13 6/9/13 8/21/13 9/26/13 11/21/13 11/30/13 12/30/13 2/4/14 3/26/14 4/19/14 5/10/14 LENGTH OF STAY (Days) Length of Stay: Methadone exposed infants Standardized non-pharm care Direct transfer to inpatient unit 50.0 UCL Mean= Mean=13.2 Mean= CL LCL 0.0 ADMIT DATE

34 The standard approach: why? Medications NICU Finnegan Scores

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36 The infant with a score of 7 or less was not treated with drugs for the abstinence syndrome because, in our experience, he would recover rapidly with swaddling and demand feedings. Infants whose score was 8 or above were treated pharmacologically Finnegan LP, et al. Assessment and treatment of abstinence in the infant of the drug- dependent mother. Int Clin Pharmacol Biopharm. 1975;12(1 2):19 32

37 Problems with the Finnegan Long lengths of stay and lots of meds Purpose of treatment is to get the scores below threshold Must disturb the infant and exacerbate signs of withdrawal Can be slow to respond Powerful and potentially harmful meds to give to treat a sneeze or a yawn

38 Intervention 3 Discontinuation of the Finnegan Scoring tool and adoption of a functional scoring approach 38

39 1)Can the baby eat? 2)Can the baby sleep? 3)Can the baby be consoled?

40 ESC Study Analyzed 50 consecutive NAS babies admitted to our general inpatient unit from March 2014 to August 2015 Assessed every 2-6 hours using the FNASS, but did not guide management Management decisions based on ESC

41 Outcomes 1. Proportion of infants treated with morphine vs. proportion predicted to be treated with morphine using the FNASS approach 2. Days the two approaches disagreed 3. FNASS scores the day after the two approaches disagreed

42 Results Proportion of Infants that Received Morphine 80% 70% 60% 50% p< % 40% NAS infants (n=50) 30% 20% 10% 12% 0% Received Morphine (ESC) Would Have Received Morphine (Finnegan)

43 Results On 78 days (26.4%) the ESC Led to LESS Morphine than Predicted by The Finnegan The following day, the average Finnegan score decreased by 0.9 points, and decreased in 69% of cases. On 2 days (0.7%) the ESC Led to MORE Morphine than Predicted by The Finnegan In both cases the average Finnegan score increased by 1.7 Points the next day

44 Results No readmissions No seizures No ICU transfers

45 Source:

46 The standard approach: why? Medications NICU Finnegan Scores Medication Dosing

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48 Intervention 4 Decrease in morphine up to 3 times per day 48

49 Intervention 5 PRN Dosing

50 1/30/08 7/2/08 8/30/08 11/19/08 1/13/09 2/19/09 5/5/09 6/13/09 9/10/09 10/21/09 2/2/10 3/12/10 6/23/10 10/10/10 12/10/10 2/9/11 3/8/11 5/10/11 6/10/11 9/10/11 10/7/11 12/1/11 1/5/12 4/3/12 5/13/12 6/26/12 8/20/12 10/12/12 11/17/12 1/25/13 3/6/13 4/4/13 5/21/13 7/4/13 9/10/13 11/20/13 11/30/13 1/12/14 2/19/14 4/12/14 5/10/14 6/14/14 6/26/14 8/7/14 9/23/14 11/19/14 1/6/15 2/16/15 4/14/15 LENGTH OF STAY (Days) Length of Stay: Methadone exposed infants 70.0 Standardized non-pharm care Novel assessment tool on inpatient unit 60.0 Direct transfer to inpatient unit Spread to NICU team Prenatal counseling 50.0 UCL Mean=22.5 Rapid med weaning 40.0 Mean=13.2 Mean=10.2 Mean= LCL 0.0 ADMIT DATE

51 The standard approach: why? Medications NICU Finnegan Scores Medication Dosing Staff cares for the baby

52 Cleveland, et al., JOGNN;43(3):

53 How do moms feel? Addiction is misunderstood Guilty Judged Mistrusting of nurses

54 His nurse was like his muscles are locking up because of his junkie mom. I didn t want to visit, I would call before and if that nurse was there, I wouldn t even go.

55 because we re gonna leave and he s gonna cry and they re gonna leave him crying because they re gonna be like, you know what? His parents are jerks!

56 if you re using while you re pregnant, you have a problem; a big problem... and you need help. You obviously don t care about your- self, about anything, except the drug. Make it a little bit easier on that mother if she s showing initiative... if she s taking the time to be there. If she loves her child, you can see it and you can feel it. If it s obvious that she s there for the baby then embrace it; make it easier. You don t know what her circumstances are. You don t know what she s been through or how hard her life has been. You don t know what she was feeling when she was pregnant... if she was being abused, if she was poor. Whatever the reason she was using while she was pregnant... you just don t know. So, try to make it easier for her.

57 Intervention 6 Empowering messaging

58 Source:

59 Source:

60 Old Protocol Goal: suppress withdrawal signs NICU: Mom visits Finnegan Scores: treat the number supportive care feed on demand Morphine Surprise! Staff takes care of infant New Protocol Goal: have infant function as a normal neonate Mother and child together Eat/Sleep/Console: treat the infant SUPPORTIVE CARE No feeding schedule Meds on page 3 Prenatal preparation Staff coaches parents

61 1/30/08 7/12/08 11/10/08 1/21/09 4/6/09 6/13/09 9/18/09 12/23/09 3/19/10 9/18/10 12/10/10 2/21/11 4/27/11 7/4/11 9/29/11 12/1/11 2/11/12 5/7/12 6/26/12 10/9/12 11/17/12 2/23/13 3/28/13 5/22/13 8/21/13 11/20/13 12/10/13 2/11/14 4/19/14 6/8/14 6/26/14 9/8/14 11/14/14 1/9/15 3/11/15 5/26/15 7/17/15 8/22/15 10/21/15 12/4/15 4/28/16 7/7/16 8/31/16 9/27/16 10/29/16 12/21/16 1/19/17 3/3/17 4/3/17 4/30/17 5/28/17 6/25/17 LENGTH OF STAY (Days) Length of Stay: Methadone exposed infants 70.0 Standardized non-pharm care 60.0 Direct transfer to inpatient unit 50.0 UCL Mean=22.5 Novel assessment tool on inpatient unit Prenatal counseling 40.0 Mean=13.2 Mean=10.2 Spread to NICU team Rapid med weaning Meds as needed 30.0 Mean=7.7 Empowering messaging Mean= LCL 0.9 ADMIT DATE

62 Average Length of Stay (Days) Average Length of Stay - Methadone Exposed Infants Focus on supportive management 20 Transfers directly from WBN to Floor 15 NICU included in effort Length of Stay (days) 10 5 Protocol Change: More aggressive weans Discontinued Finnegan Scoring Year More aggressive weans

63 % Treated with Morphine Percent of NAS Patients Treated with Morphine 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% % Treated with Morphine 40.0% 30.0% 20.0% 10.0% 0.0% Year

64 Percent Treated Percent Treated with Morphine 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Date

65 Average maximum morphine dose (mg/dose) Average Maximum Morphine Dose p < Average maximum morphine dose (mg/dose) Year

66 % Breastfeeding 60.0% Breastfeeding Rate 50.0% 40.0% 30.0% % Breastfeeding 20.0% 10.0% 0.0% Year

67 Total Cost ($) Total Average Cost of NAS Care p < Total Cost ($) Year

68 Boston Medical Center Had been using FNASS approach Finnegan prioritization from June-November 2016 Developed ESC approach as a scoring tool Piloting since December 2016

69 Eat, Sleep, Console Flowsheet TIME EATING Poor feeding due to NAS Y/N SLEEPING < 1 hr after feeding due to NAS Y/N CONSOLABILITY Please rate the infant s consolability: Soothes with little support 1 Soothes with some support 2 Soothes with great support 3 Did the infant require >10 minutes to console Y/N

70 Boston Medical Center Results Use of morphine decreased from 82% to 40% Length of stay decreased from 18 days to 10 days No readmissions

71 Additional Spread

72 Long-Term Outcomes?

73 Conclusions Hugs before drugs Empower families Rooming-in Non-Pharmacologic care as 1 st line treatment ESC approach PRN meds Ask why Source: Grossman Family Album

74 Acknowledgements David Hersh, MD Adam Berkwitt, MD Erin Nozetz, MD Marcelle Applewaite, RN Kim Carter, RN Liz O Mara, RN Matt Bizzarro, MD Yogangi Malhotra, MD Jonathan Miller, MD Camisha Taylor, RN Rachel Osborn, MD