How to Reshape Your Approach to NOWS, Today

Transcription

1 How to Reshape Your Approach to NOWS, Today Adam Czynski, DO Assistant Professor of Pediatrics Warren Alpert Medical School Brown University Director, Newborn Nursery Clinical Neonatologist Women & Infants Hospital

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3 8 th Largest Birthing Hospital in the Country Largest Birthing Hospital in Rhode Island 9,100 Births a year Pediatric Services include NICU and Newborn Nursery 62% of Payer mix is either Self Pay or Medicaid / Medicare Health Plans

4 Rhode Island s Opioid Crisis Drug overdoses in Rhode Island are a public health crisis. The number of deaths are increasing RI ranks 7 th in the nation in overdose deaths from prescription drugs (Statistica,2015) Between overdose deaths for women have increased by 63% (RI DOH,2015) RI has the nations highest rate of illicit drug use per capita and nonmedical use of prescription opioids and ranks far above the national average

5 Overdose Deaths In Rhode Island

6 Overdose Deaths In Rhode Island

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9 14.4 % of Pregnant women prescribed an opioid during pregnancy Bateman et al, Anesthesiol. 2014

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11 NAS Statistics in Rhode Island NAS rates in RI have more than doubled in the last decade / births /10,000 births /10,000 births 97% of the 95 births in 2015 were born at Women & Infants, of the 97%, 98% were managed in the Mother Baby Unit The average charge is $70, compared regionally the average is $93,815.00

12 Patient Story Baby M was born on in February 2016 Involved parents Both parents on methadone Total stay was 38 Days Total morphine need was 50.6 mg total 18.7 mg a day 2.3 mg /kg/ dose Stayed on 4 different hospital units Parents Felt Judged and Powerless

13 Support Judged and Powerless Empowerment Knowledge and Understand

14 Understanding Opioid Addiction Understanding the biochemistry helps to better assess NOWS Understanding opioid effects on the body is important to understand the need for treatment

15 Opioids and Pleasure Kosten et al. Sci Pract Perspect. 2002

16 Opioids and Physical Dependence Kosten et al. Sci Pract Perspect. 2002

17 Opioids and Physical Dependence Kosten et al. Sci Pract Perspect. 2002

18 Opioids and Physical Dependence Kosten et al. Sci Pract Perspect. 2002

19 Opioids and Physical Dependence Kosten et al. Sci Pract Perspect. 2002

20 Tolerance and Dependence Tolerance is the drive to take larger doses of opioids to achieve the same feelings of pleasure Dependence is the need for opioids to treat the effects of an upregulated locus ceruleus causing unregulated norepinephrine release

21 Patient Story Baby M was born on in February 2016 Involved parents Both parents on methadone Total stay was 38 Days Total morphine need was 50.6 mg total 18.7 mg a day 2.3 mg /kg/ dose Stayed on 4 different hospital units

22 Problem Identification Poor Communication Healthcare Provider to Healthcare Provider Healthcare Provider to Family No Central Treatment Location Reduced focus on Discharge Flexibility with Protocol Provider Preference Inconsistency with Rounding Families felt judged and powerless

23 The Journey Begins Act Plan Study Do

24 Plan Develop a new model of care for babies with NAS 1. Centralize our Care 2. Improve Communication Between the Family and Team 3. Create Structure 4. Empower our Patient s Family 5. Discharge Begins on Day 1

25 Centralize Location of Care Model of care changed from a boarder nursery to a more family centered approach and became centralized NAS Task Force initiated Criteria for Rooming In was developed Education and support for the nursing staff is ongoing First line of therapy for babies with NAS is nonpharmacologic, with clustered supportive care Care is a team approach with parents included every step of the way Developed Cuddler program

26 Improve Communication: I get 6 different messages from 4 different people - Every family in a hospital

27 Team Communication Expanded the Team to including all stakeholders The Team became the Family Care Team

28 Family Care Rounds Doctors Community Partners Family Doctors NP NP Chaplin Community Partners Chaplin Case Management Family Family Care Rounds Occupational Therapy Social Work Nursing Nursing Social Work Case Management Occupational Therapy

29 Family Care Rounds Doctors Family Partners NP Care Rounds Start Every Community Day at 13:30 Chaplin Case Management Family Occupational Therapy Conducted in the Patient Room with entire team Social Work Nursing Family responsible to update team about previous 24 hours Date of Discharge is discussed everyday

30 IMPLEMENTATION

31 Implementation May 2016 we went live with our Family Centered Care Model Babies kept in the room with the mother Nursing and Family partnered to assign NAS Scores Families were informed of our new model during prenatal consults

32 Retrospective cohort study conducted at Women & Infants Hospital (WIH) with infants born between May 2015 April Infants born between May 2015-April 2016 were treated using the WIH standard of care for NAS infants. Infants born between May 2016-April 2017 were treated using Family Care Rounds in addition to the WIH standard of care.

33 Length of stay (LOS), length of treatment (LOT), and total number of morphine doses were analyzed using generalized linear models with a Poisson distribution. Covariates included birth weight, gestational age, and DCYF involvement. Covariates were selected based on conceptual reasons, published literature, characteristics that differed between groups, and were not highly correlated.

34 Table 1. Caregiver and infant characteristics by type of care N (%)or Mean (SD) Caregiver Characteristics Race Family Care Rounds (n = 20 ) WIH Standard of Care (n= 16) P- Value White 16 (84.2%) 12 (92.3%) Public Insurance 18 (94.7%) 12 (92.3%) DCYF Involvement 11 (55.0%) 3 (18.8%) Infant Characteristics Gender (boy) 8 (40.0%) 9 (56.3%) Birth weight (g) 3188 (564) 2895 (480) Discharge weight (g) 3447 (928) 3239 (616) Gestational Age (weeks) 38.7 (1.8) 38.5 (1.5) 0.686

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38 Conclusions

39 Buprenorphine

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42 Take Home Message