Post on 17-Mar-2020
transcript
Neonatal Abstinence Syndrome: Reconsidering the Standard Approach
Matthew Grossman, M.D.Assistant Professor of Pediatrics
Yale School of MedicineQuality and Safety Officer
Yale-New Haven Children’s Hospital
DISCLOSURE
The content of this presentation does not relate to any product of a commercial entity; therefore, I have no relationships to report.
Source: http://familytalk.ca/heroin/Patrick, et al. Journal of Perinatology. 2015; 35:650-655
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
0.0
1.0
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7.0
2000 2003 2006 2009 2010 2011 2012
NA
S p
er
10
00
Ho
sp
ital
Bir
ths
Year
Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to
2012. J Perinatol. Apr 30 2015.
Patrick SW, et. al. Neonatal Abstinence Syndrome and Associated Healthcare Expenditures – United States, 2000-2009. JAMA. 2012 May 9;307(18):1934-40.
Incidence of NAS in the US, 2000-2012
Source: Grossman Family Album
Langenfeld, et al. Drug and Alcohol Dependence 2005;77:31–6.
Source: http://wings.buffalo.edu/aru/preprohibition.htm
Jackson L, et al. Archives of Disease in Childhood 2004;89: F300–4.
Source: http://olivier-dogot.blogspot.com
Coyle MG. Journal of Pediatrics 2002;140:561–4
Source: http://www.bad-drug.net
Source: http://www.projectknow.com
MS Brown et al. Journal of Perinatology 2014; (1-6)
Agthe, et al. Pediatrics 2009;123:e849–56.
Source: http://www.recovery.org
Standard Approach
Medications
NICU
Finnegan Scores
Medication Dosing
Staff cares for the baby
0
5
10
15
20
25
30
2003-June 2006 July 2006-2009
LOS
(da
ys)
Length of Stay: Methadone-Exposed Infants
P <.02
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
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
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
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2003 2004 2005 2006 2007 2008 2009 2010
% T
rea
ted
wit
h M
orp
hin
e
Year
Percent of NAS Patients Treated with Morphine
UCL 47.1
LCL 0.00.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
LE
NG
TH
OF
ST
AY
(D
ay
s)
ADMIT DATE
Mean=22.5
Length of Stay: Methadone exposed infants
The standard approach: why?
Medications
Source: Grossman Family Album
Abraham, et al. J Obstet Gynaecol Can 2010;32(9):866–871
Intervention 1
Focus on non-pharmacologic care
26
UCL
29.1
LCL 0.00.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
LE
NG
TH
OF
ST
AY
(D
ay
s)
ADMIT DATE
Length of Stay: Methadone exposed infants
Standardized non-pharm care
Mean=22.5
Mean=13.2
The standard approach: why?
Medications
NICU
Source: http://medicine.yale.edu
Source: http://adamandsarahcoats.blogspot.com
Intervention 2
Direct transfer to the general inpatient unit
32
UCL
32.5
CL
10.2
LCL 0.00.0
10.0
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60.0
70.0
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/08
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9
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/10
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3/10
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3/10
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8/1
0
2/1
7/11
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/11
4/2
7/11
5/19
/11
7/2
6/1
1
9/1
6/1
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10/7
/11
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/11
12/2
6/1
1
2/1
1/12
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7/12
5/13
/12
6/8
/12
7/16
/12
9/2
7/12
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2
11/1
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/13
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3
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3
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3
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/14
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4
5/10
/14
LE
NG
TH
OF
ST
AY
(D
ay
s)
ADMIT DATE
Direct transferto inpatient unit
Mean=10.2
Length of Stay: Methadone exposed infants
Standardized non-pharm care
Mean=22.5
Mean=13.2
The standard approach: why?
Medications
NICU
Finnegan Scores
“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
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
Intervention 3
Discontinuation of the Finnegan Scoring tool and adoption of a
functional scoring approach
38
1)Can the baby eat?
2)Can the baby sleep?
3)Can the baby be consoled?
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
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
Results
12%
62%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Received Morphine (ESC) Would Have Received Morphine (Finnegan)
Proportion of Infants that Received Morphine
NAS infants (n=50)
p<.001
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
Results
• No readmissions
• No seizures
• No ICU transfers
Source: http://www.mdnews.com
The standard approach: why?
Medications
NICU
Finnegan Scores
Medication Dosing
Intervention 4
Decrease in morphine up to 3 times per day
48
Intervention 5
PRN Dosing
UCL
16.9
LCL 0.00.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1/30
/08
7/2
/08
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0/0
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8
1/13
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5
LE
NG
TH
OF
ST
AY
(D
ay
s)
ADMIT DATE
Direct transferto inpatient unit
Mean=10.2
Mean=7.7
Length of Stay: Methadone exposed infants
Rapid medweaning
Prenatalcounseling
Spread to NICU team
Novel assessment tool on inpatient unit
Standardized non-pharm care
Mean=22.5
Mean=13.2
The standard approach: why?
Medications
NICU
Finnegan Scores
Medication Dosing
Staff cares for the baby
Cleveland, et al., JOGNN;43(3): 318-329
How do moms feel?
Addiction is misunderstood
Guilty
Judged
Mistrusting of nurses
“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.
“…because we’re gonna leave and he’s gonna cry and they’re gonnaleave him crying because they’re gonna be like, ‘you know what? His parents are jerks!’”
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.
Intervention 6
Empowering messaging
Source: http://potomachospital.blogspot.com
Source: http://potomachospital.blogspot.com
Old Protocol New 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
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
UCL
10.8
LCL 0.9
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1/30
/08
7/12
/08
11/1
0/0
8
1/2
1/0
9
4/6
/09
6/1
3/0
9
9/1
8/0
9
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9
3/19
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1
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12
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2
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3
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16
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3/3/
17
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7
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7
6/2
5/17
LE
NG
TH
OF
ST
AY
(D
ay
s)
ADMIT DATE
Standardized non-pharm care
Direct transferto inpatient unit
Rapid medweaning
Prenatalcounseling
Spread to NICU team
Meds as needed
Empoweringmessaging
Novel assessment tool on inpatient unit
Mean=5.9
Mean=7.7
Mean=10.2
Mean=13.2
Mean=22.5
Length of Stay: Methadone exposed infants
0
5
10
15
20
25
30
35
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Ave
rag
e L
en
gth
of
Sta
y (
Da
ys)
Year
Length of Stay (days)
Protocol Change:More aggressive weans
Discontinued FinneganScoring
Transfers directly fromWBN to Floor
NICU includedin effort
Focus on supportivemanagement
More aggressive weans
Average Length of Stay - Methadone Exposed Infants
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
% T
rea
ted
wit
h M
orp
hin
e
Year
Percent of NAS Patients Treated with Morphine
% Treated with Morphine
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2008 2009 2010 2011 2012 2013 2014 2015 2016
Pe
rce
nt
Tre
ate
d
Date
Percent Treated with Morphine
0
0.1
0.2
0.3
0.4
0.5
0.6
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Ave
rag
e m
axim
um
mo
rph
ine
do
se (m
g/d
ose
)
Year
Average Maximum Morphine Dose
Average maximum morphinedose (mg/dose)
p < .001
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
% B
rea
stfe
ed
ing
Year
Breastfeeding Rate
% Breastfeeding
0
10000
20000
30000
40000
50000
60000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
To
tal C
ost
($
)
Year
Total Average Cost of NAS Care
Total Cost ($)
p < .001
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
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
Boston Medical Center – Results
• Use of morphine decreased from 82% to 40%
• Length of stay decreased from 18 days to 10 days
• No readmissions
Additional Spread
Long-Term Outcomes
?
Conclusions
▪ Hugs before drugs
▪ Empower families
▪ Rooming-in
▪ Non-Pharmacologic care as 1st line treatment
▪ ESC approach
▪ PRN meds
▪ Ask why
Source: Grossman Family Album
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