Welcome! Neonatal Abstinence Syndrome Project Action Period Call Ohio Perinatal Quality Collaborative April 15, 2014
Please don t put us on HOLD! If you need to step away: Use the MUTE button on your phone or You can use *6 to place the call on MUTE and *6 to come off of MUTE
Agenda Time Topic Presenter 3:00 pm Welcome, review of Agenda, roll call Sandy Fuller 3:10 pm Key Driver Diagram & Project AIM Overview of past 90 days 3:15 pm Review of Scoring Tool Q&A with teams 3:25 pm Review of Non-Pharmacological Treatment Q&A with teams 3:35 pm Data Collection Q&A with teams 3:45 pm Next Steps IRB Update Next Month Focus Monthly Progress Report/Data Reminder May AP Call Michele Walsh, MD Sandy Fuller Amy Thomas, RN Nationwide Children's Julie Medas, RN, CNS MetroHealth Moira Crowley, MD Jenney Nobbe Michele Walsh, MD Sandy Fuller
Roll Call: Please sign in with your hospital affiliation and the names of your team members on the call
Participating Neonatal Teams Akron Children s Hospital Akron Children s Mahoning Valley Akron Children's St Elizabeth Akron Children s Summa Aultman Hospital Bethesda North Hospital Cincinnati Children s Hospital Cleveland Clinic Dayton Children s Hospital Fairview Hospital Good Samaritan Hospital Hillcrest Hospital Mercy Anderson Hospital Mercy St. Vincent Medical Center MetroHealth Medical Center Miami Valley Hospital Mount Carmel East Hospital Mount Carmel West Hospital Nationwide Children s NTW-Doctor s Hospital NTW-Dublin Methodist NTW-Grant NTW-Mount Carmel St. Ann's NTW-Riverside Promedica Toledo Children s The Ohio State University Medical Center - Wexner University Hospital - Cincinnati UHCMC Rainbow Babies and Children s Hospital
Key Driver Diagram Project Name: OPQC Neonatal NAS Leader: Walsh GLOBAL AIM To reduce the number of moms and babies with narcotic exposure, and reduce the need for treatment of NAS. SMART AIM By increasing identification of and compassionate withdrawal treatment for full-term infants born with Neonatal Abstinence Syndrome (NAS), we will reduce length of stay by 20% across participating sites by June 30, 2015. KEY DRIVERS Prenatal Identification of Mom Implement Optimal Med Rx Program Improve recognition and nonjudgmental support for Narcotic addicted women and infants Attain high reliability in NAS scoring by nursing staff Optimize Non-Pharmacologic Rx Bundle Standardize NAS Treatment Protocol Connect with outpatient support and treatment program prior to discharge Partner with Families to Establish Safety Plan for Infant Partner with other stakeholders to influence policy and primary prevention. INTERVENTIONS All MD and RN staff to view Nurture the Mother- Nurture the Child Monthly education on addiction care Fulltime RN staff at Level 2 and 3 to complete D Apolito NAS scoring training video and achieve 90% reliability. Swaddling, low stimulation. Encourage kangaroo care Feed on demand- MBM if appropriate or lactose free, 22 cal formula Initiate Rx If NAS score > 8 twice. Stabilization/ Escalation Phase Wean when stable for 48 hrs by 10% daily. Establish agreement with outpatient program and/or Mental Health Utilize Early Intervention Services Collaborate with DHS/ CPS to ensure infant safety. Engage families in Safety Planning. Provide primary prevention materials to sites.
How will we accomplish our AIM? Develop and implement a standardized process for the identification, evaluation, treatment and discharge management of an infant with neonatal abstinence syndrome. Standardization of Scoring Tool; improve consistency in use of Modified Finnegan Tool with D Apolito video Standardization of protocol bundles Small tests of change (PDSA s) towards implementing standardized protocol into Ohio hospitals Create a culture of compassion, understanding, and healing for the mother infant dyad affected by the problem of neonatal abstinence syndrome. Nurture the Mother-Nurture the Child video
Progress to Date January 27 th : Project Kick Off Learning Session in Columbus February Action Period Call: Finnegan Scoring Tool March Action Period Call: non-pharmacological bundle Creation of Data Collection Tool with participant feedback
Scoring Tool Key Driver: Attain high reliability in NAS scoring by nursing staff Intervention: Fulltime RN staff at Level 2 and 3 to complete D Apolito NAS scoring training video and achieve 90% reliability.
Scoring and Inter-Rater Reliability at Nationwide Children s Question: How do we increase the inter-rater reliability amongst our NICU nurses scoring of NAS infants? Background info: NICU Nurses completed a survey to test the comfort level and proper usage of the Inter- Rater Reliability Testing. Hypothesis: Increased frequency of Scoring will improve the confidence level and inter-rater reliability percentages of NICU nurses.
Main Campus A2 NICU = C4C NICU Design Changes / Interventions Specific Aim Increase the confidence level of the A2 NICU RN staff regarding Finnegan Scoring Tool/Inter-Observer Rater Reliability by 10% by August 31, 2013. Counter Balance Measure: maintain inter-rater reliability scores at greater than 90% Key Drivers Staff confidence level with the use of Finnegan Scoring Tool Staff education and training of Finnegan Scoring Tool Staff inter- rater reliability scoring Conduct pre and post surveys on staff confidence with use of Finnegan. 1) Staff education/training using Assessing signs and symptoms of Neonatal Abstinence using the Finnegan Scoring Tool video. 2) Scoring simulation 3) NAS Super Users for validation, ongoing support 4) Ongoing competency training Utilize Inter-Rater Reliability scoring minimally once every 12 hours to maintain reliability rates >90%....
PDSA to reach our AIM Plan: After re-education with video and simulation have 2 nurses score an infant every 12 hours (Inter-rater reliability = Each RN scores individually at the same time while observing the other RN performing the assessment.) Do: Dual score completed once every 12 hours with an NAS Super User or an NNP Study: Nurses involved indicated an increased confidence in their scoring; inter-rater reliability increased as well. Act: Decided to adopt process. Currently in our NICU, inter-rater reliability scoring is greater than 95%
Conclusion Continue to provide staff education and keep updated on the many changes with NAS not only in the Nationwide Children s Hospital healthcare system, but globally. Continue to use Inter-Rater Reliability tool on a consistent basis
What are other hospitals testing? Steal Shamelessly-Share Seamlessly Have a parent observe and participate when the nurse completes the infant s scoring. Track an additional variable of the infant weight on the Scoring Tool. Feed the infant prior to scoring; does this impact the score? Increase inter-rater reliability among NICU staff; other sites are working on this with their Post Partum and/or Newborn Nursery nursing staff.
Questions Please click on the raised hand icon on the right of your screen to ask a question OR type it into the chat box.
Non-Pharmacological Bundle Key Driver: Optimize Non- Pharmacologic Rx Bundle Intervention: Swaddling, low stimulation. Encourage kangaroo care Feed on demand- MBM if appropriate or lactose free, 22 cal formula
MetroHealth NAS Treatment in the Newborn Nursery
What are other hospitals testing? Steal Shamelessly-Share Seamlessly Having the mother rooming-in with the infant. Involving Labor & Delivery nurses in non-pharmacological approach; specifically skin to skin contact. Cuddling Volunteer Programs for NAS infants. Primary Nurse assigned to infant for consistency of care; will this increase the use of non-pharmacological bundle? Improving documentation/charting of non-pharmacological activities.
Questions Please click on the raised hand icon on the right of your screen to ask a question OR type it into the chat box.
Data Collection for NAS So far you have been filling out paper data collection forms Please keep filling these out! Soon we will have the database ready for you to enter them. Our target release date is May 1 st!
Did you know that we have a document that may assist you in filling out the data collection form? You can find it on the Sharepoint site Click on the link that says Data collection There is one! Your team should have also received this document at the January Learning Session.
Eligibility Any infant 37 weeks gestational age at birth with IN UTERO narcotic exposure and with the diagnosis of Narcotic Abstinence Syndrome (NAS) who is identified after birth and is being monitored for signs and symptoms of opiate withdrawal with the Finnegan scoring system. Infants may be inborn or outborn and transferred to a participating center after birth. Infants may be born outside the state of Ohio. Exclusion Infants who were only exposed to narcotics postnatally are not included in this study.
What if I don t have any eligible babies for a calendar month? (calendar month based on the baby birth month) Don t worry! It s easy to tell us! 1. Fill in the Checkbox and indicate the Month/Year you did not have any babies 2. Once the data entry system is ready you will check this box and hit Submit 3. Do not fill out the rest of the form
Question #2: Location of care for the infant Record the highest level of care the infant received during the hospitalization: 1= Normal nursery (Level 1) 2 = NICU Level 2 (step-down/transitional nursery) 3 = NICU Level 3 Question #3: Maternal Narcotic exposure Check all that apply for question #3. In the data instruction sheet you will find a list of narcotics that you may encounter.
Question #4: Non-pharmacologic treatment Record yes if the infant was treated with swaddling, low stimulation, feeding on demand with breast milk when applicable or regionally approved formula, rooming in with mother, or other comfort measures (specify in the spaces marked other ) before starting pharmacologic treatment for withdrawal symptoms. If it is unclear, record Can t determine.
Question #5: Pharmacologic Treatment If you answer Yes complete the rest of Question #5 If you answer No or Can t Determine STOP completing this form Clarification: If your site is not using morphine or methadone as your primary opiate, select other and specify which opiate medication is being used.
Question #6: Length of Treatment with opiate drugs Record the number of days the infant was treated with opiate medications (morphine or methadone) for NAS Day of start of opiate drug treatment is day number 1 Question #7: Length of Treatment with non-opiate drugs Record the number of days the infant was treated with nonopiate medications (phenobarbital or clonidine) for NAS Day of start of non-opiate drug treatment is day number 1
Question #8: Length of stay in the hospital Record the number of days the infant was in the hospital Day of admission = day 1 Question #9: Was baby discharged on drug Record whether the baby was discharged on pharmacologic therapy for the treatment of NAS If YES indicate the drug in Question #9a Check unable to determine if appropriate
OPQC IRB Update The OPQC Progesterone and NAS projects received IRB approval in early 2014 by Cincinnati Children's Hospital Medical Center's Committee on the Protection of Human Subjects. Institutions vary in how they approach participation in multisite collaborative improvement efforts. We encourage each participating charter site to review and ensure compliance with its institutional policies for IRB and Data Use Agreements. The IRB protocol (IRB protocol) can be adapted for your institution if needed.
Additional Questions? Please click on the raised hand icon on the right of your screen to ask a question OR type it into the chat box.
Next Month s Focus Key Driver: Improve recognition and non-judgmental support for Narcotic addicted women and infants Intervention: All MD and RN staff to view Nurture the Mother- Nurture the Child VON DVD Monthly education on addiction care All teams will take the Attitude Measurement Survey 90 days post kick off
Save the Date! The OPQC Summer 2014 Learning Session will be on Thursday, June 26 th in Columbus. Please mark your calendars!
Follow us on Twitter! @OhioPQC Next Steps Continue to collect monthly NAS data; electronic data submission will start first week of May. VON Infection Data (sustain mode) for March was due 4/5; % of teams submitted that data Monthly Progress Report Will be sent out 4/25; due 5/5 Includes PDSA results (needed for MOC) Next Action Period Call: May 20th
The OPQC NAS Project is funded by The Ohio Department of Medicaid