Columbus, OH – July 2018
Over the last five years, the largest children’s hospitals in Ohio have demonstrated that they can significantly reduce length of hospital stay and overall infant exposure to opioids when they follow strict treatment protocols for babies with neonatal abstinence syndrome (NAS).
Institutions outside of this Ohio Children’s Hospital NAS Consortium, though, are experiencing increases in NAS cases as well. Could the consortium’s protocols and lessons be spread successfully throughout the state, even to smaller hospitals without much quality improvement experience?
It takes a lot of work, but a recent study in Pediatrics shows that it can be done.
“Everyone wanted to participate, but we knew it would be daunting – smaller hospitals are already stretched thin, and this was just one more thing we were asking them to do,” says Richard E. McClead, MD, Associate Chief Medical Officer of Nationwide Children’s Hospital, a member of the hospital’s Division of Neonatology and a co-author of the study. “They became comfortable with the “learning center” approach, however, and these hospitals were able to see a difference in outcomes through this quality improvement project.”
A total of 26 Level -3 units and 26 Level-2 units across Ohio participated, along with two Level-1 nurseries. Among other interventions, they were asked to adhere to a pharmacological bundle, including a strict protocol for opioid weaning, and a non-pharmacological bundle, including the promotion of maternal involvement and breastfeeding when possible.
The “learning center” approach was adopted from the Breakthrough Series Model of the Institute for Healthcare Improvement. Participants met face-to-face three different times, participated in monthly webinars and regularly discussed challenges and successes. The project lasted 18 months.
Overall, the average length of pharmacological treatment decreased from 13.4 days to 12 days and average length of stay decreased from 18.3 days to 17 days, for a total reduction of 2,041 hospital days. The authors note that the largest Ohio children’s hospitals had already undergone a number of NAS QI initiatives – a 2014 publication documented that they previously reduced length of pharmacological treatment from 33.8 days to 21.3 days, for example – so decreases shown in the most recent study are smaller than they might be in states that have not already attempted these QI efforts.
Including the mothers as part of the care team was a change for many of the hospitals, Dr. McClead says. Even when staff members understood that encouraging maternal involvement could improve outcomes, some had difficulty overcoming judgmental attitudes toward the mothers. The QI project emphasized “trauma-informed” care, educating staff members about the difficult lives many opioid-addicted women have faced and bringing in women with past addiction issues to speak about their experiences.
A focus on breastfeeding was also difficult for some institutions, in part because state laws are unclear: does a prohibition on dispensing illegal drugs mean that women who take those drugs are dispensing them when they breastfeed?
Dr. McClead says that it is completely appropriate for a mother in treatment, even a mother who is taking opioids as a part of that treatment, to breastfeed her child. And medically speaking, opioid-addicted mothers not in treatment may also breastfeed their children, because so little of the drug is transmitted in breast milk. But some confusion in the laws means hospitals aren’t always willing to promote breast feeding in those situations, Dr. McClead says.
Still, the overall success of this statewide project should encourage other regions to try it too.
“Large academic centers have figured out ways to improve the adverse impacts of NAS, and other centers should have the opportunity to benefit from what we know,” Dr. McClead says.
Walsh MC, Crowley M, Wexelblatt S, Ford S, Kuhnell P, Kaplan HC, McClead R, Macaluso M, Lannon C; Ohio Perinatal Quality Collaborative. Ohio Perinatal Quality Collaborative improves care of neonatal narcotic abstinence syndrome. Pediatrics. 2018 Jun; 141 (6).
Hall ES, Wexelblatt SL, Crowley M, Grow JL, Jasin LR, Klebanoff MA, McClead RE, Meinzen-Derr J, Mohan VK, Stein H, Walsh MC; OCHNAS Consortium. A multicenter cohort study of treatments and hospital outcomes in neonatal abstinence syndrome. Pediatrics. 2014 Aug; 134(2) :e527-34.