EAT, SLEEP, CONSOLE The Yale Method of assessment and treatment of neonates during withdrawal from opiates

Transcription

1 EAT, SLEEP, CONSOLE The Yale Method of assessment and treatment of neonates during withdrawal from opiates NICOLE DUNCAN BSN, RN, CPN MAY 2018 Pediatric Educator, MultiCare Health System

2 DISCLAIMER I have no conflict of interests

3 OBJECTIVES Briefly discuss the opioid crisis and review the impact on the neonate Define Neonatal Abstinence Syndrome Discuss the Finnegan scoring tool Introduce and discuss the Yale Protocol for management of Neonatal Abstinence Syndrome Evaluate the outcomes of implementing the Yale Protocol

4 POLL Poll Everywhere

5 THE OPIOID PROBLEM Opioids have become a major problem in this country. Lots of people are using them, and some of those people are pregnant. - Matthew Grossman, MD

6 OPIOID STATS , the number of NAS babies around the country quintupled (NIH) Of 28 states that made their data publicly available between 1999 and 2013, the condition was found in 1.5 to 6.0 per 1,000 hospital births % of people, age15-44 filled a prescription for opioids The percentage of Medicaid-enrolled women who filled at least one opioid prescription during pregnancy during increased from 18.5% to 22.8% (CDC)

7 WHAT DOES THIS MEAN? 4% of NICU beds occupied by a newborn with NAS Nation wide average length of stay: 23 days ( ) $1.5 Billion annual burden on the health care system (2012) Average cost of hospitalization $44,800 per newborn

8 NEONATAL ABSTINENCE SYNDROME NAS is an array of signs and neurobehaviors experienced by the newborn that occur after abrupt discontinuation of gestational exposure to substances taken by the mother. Neonatal abstinence syndrome: Article in Current opinion in pediatrics January 2012 Source: PubMed

9 SYMPTOMS OF NAS

10 MANAGEMENT OF NAS Tier 2 Tool Tier 1 Nonpharmacologic interventions Medications Scoring tool American Academy of Pediatrics Thanks Vector Toons for the clip art

11 FINNEGAN 95% of NICUs were using Finnegan 21 items Nervous system disturbances Metabolic disturbances GI disturbances 3 scores of 8 or 2 scores of 12 medication Morphine, methadone, phenobarbital, clonidine Fairly standard weaning protocol when scores < 8

12 ON TO YALE

13 YALE - THE BEGINNINGS Number of infants exposed to methadone in utero increased by 74% from ALSO: 22.4 days Average cost: $44,800 98% of these infants were treated with morphine Goal: Over 5 years Decrease ALOS by 50% Decrease use of Morphine 50%

14 YALE S PROJECT 4 KEY DRIVERS Non pharmacologic interventions Simplified assessment of infants Decreased use of morphine Communication between units

15 INTERVENTIONS: TIER 1 TREATMENT Non pharmacologic interventions Standardized 4 interventions 1. Low stim environment 2. Staff engaged parents 3. Staff trained to view nonpharm interventions as equivalent to medications 4. Encouraged breast-milk feedings Prenatal counseling of parents Empowering the parents

16 INTERVENTIONS: WHY FINNEGAN? Simplified assessment of infants 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. 1975

17 CAN THE BABY BE A BABY? Can the baby eat? Can the baby sleep? Can the baby be consoled?

18 INTERVENTIONS: WHY MEDICATIONS? Decreased use of morphine Withdrawal from opioids or sedative-hypnotic drugs may be life threatening, but ultimately, drug withdrawal is a self limited process. Unnecessary pharmacologic treatment will prolong drug exposure and the duration of hospitalization to the possible detriment of maternalinfant bonding. The only clear benefit of pharmacologic treatment is the short-term amelioration of clinical signs. -Hudak ML, Tan RC; COMMITTEE ON DRUGS; COMMITTEE OF FETUS AND NEWBORN; American Academy of Pediatrics: Neonatal drug withdrawal.

19 INTERVENTIONS: WHY NICU? Communication between units

20 YALE THE RESULTS 287 infants met inclusion criteria LOS decreased from 22.4 days 5.9 days The number if infants treated with morphine decreased from 98% to 14% The max dose of morphine for that group decreased from 1.04 mg/kg/day to 0.5 mg/kg/day Breastmilk feeds increased from 20-45% Decrease cost of stay from about $45,000 to about $11,000 per case. Estimated decrease of 2,618 patient days from for a cost savings of $1.2 million per year or $5.4 million total

21 YALE LESSONS LEARNED Mother soothing her child was much more powerful than what could be offered by the ICU LOS could be greatly decreased by focusing on baby and family-centered care Challenge traditional approaches to pediatric disease management Respect the power of nonpharmacological approaches to disease management Sustained Reduction in Length of Stay for Neonates with Neonatal Abstinence Syndrome

22 ESC APPROACH IN PRACTICE Background ESCape implemented in 2017 ALOS decreased from 16 to 6.65 days 21 babes with NAS in % received morphine (9) 1 of those was only given 1 dose 3 of the 9 were started in the NICU or at another facility and weaned 5 (or 7?) without parents 5 of those received morphine

23 ESC APPROACH IN PRACTICE ALOS 25 days Implemented ESC Jan of 2018

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25 Moms feel guilt and judged If you re using during pregnancy, you have a problem. Addiction is a DISEASE! I just needed support it s heartbreaking to see them sick and know that its your doing and [the RN] kind of came back at me with like it s your fault type feeling. I wish I had known a lot more about NAS before I gave birth I didn t think about the consequences. I did [but I didn t know] they would affect the baby so much.

26 RESOURCES Asti, Lindsey & S Magers, Jacqueline & Keels, Erin & Wispe, Jonathan & Mcclead, Richard. (2015). A Quality Improvement Project to Reduce Length of Stay for Neonatal Abstinence Syndrome. Pediatrics /peds Atwood, Emily & Sollender, Grace& Hsu, Erica & Arsnow, Christine & Fianagan, Victoria & Celenza, Joanna. (2016). A Qualitative Study of Family Experience with Hospitalization for Neonatal Abstinence Syndrome. Pediatrics Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2(1 2): Grossman, M. R., Lipshaw, M. J., Osborn, R. R., & Berkwitt, A. K. (2017). A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome. Hospital Pediatrics, 8(1), 1-6. doi: /hpeds Grossman, Matthew & K. Berkwitt, Adam & R. Osborn, Rachel & Xu, Yaqing & A. Esserman, Denise & D. Shapiro, Eugene & J. Bizzarro, Matthew. (2017). An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome. Pediatrics e /peds Ko JY, Wolicki S, Barfield WD, et al. CDC Grand Rounds: Public Health Strategies to Prevent Neonatal Abstinence Syndrome. MMWR Morb Mortal Wkly Rep 2017;66: DOI: Volpe Holmes, Alison & C Atwood, Emily & Whalen, Bonny & Beliveau, Johanna & Dean Jarvis, J & C Matulis, John & L Ralston, Shawn. (2016). Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost. PEDIATRICS e e /peds

27 QUESTIONS? Nicole Duncan, BSN, RN, CPN Pediatric Deployed Clinical Educator