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Massachuse(s  NAS  project  

Alan  Picarillo,  MD,  FAAP  
On  Behalf  of  MassNeoQIC  
12  February  2015  

Disclosures  
•  I  have  no  financial  conflicts  to  disclose  
•  I  will  be  discussing  off-­‐label  use  of  mediaJons  to  
treat  Neonatal  AbsJnence  Syndrome  (NAS)  
•  I  will  not  longer  be  menJoning  the  recent  Patriots  
Superbowl  win  

On  to  Raleigh!  

Outline  
•  Brief  review  of  NeoQIC  
•  Background  on  NAS  
•  Statewide  improvement  project  
 

Massachuse(s  NAS  project    
•  PopulaJon  6.7  million  
•  High  urban  density  
•  Large  academic  
medical  faciliJes  or  
affiliated  insJtuJons  
•  Approximately  72k  
births  (2012)  
•  Unknown  number  of  
NAS  infants  
 

NeoQIC  Mission  Statement  
Use  the  open  sharing  of  data  and  prac/ces  
to  support  local  and  collabora/ve  quality  
improvement  efforts  and  improve    
newborn  outcomes  in  Massachuse;s  

NeoQIC  Hospitals  

UMass  
Baystate  

BWH   TuAs  
Children’s  
MGH  
BIDMC  
BMC  
St.  Elizabeth’s  
South  Shore  

Nosocomial  InfecMon  Project  
• 
• 
• 
• 
• 

Launched  in  2006  (first  NeoQIC  project)  
ComparaJve  data  reports  
Local  QI  efforts  
Discussion  of  best  pracJces  
2011:  inserJon  and  maintenance  checklists  

Gov.  Patrick  declares  emergency  

Coordinated  Recovery  IniMaMve  for  Babies  (CRIB  Act)  

•  Another  new  clipping  

By  Brian  MacQuarrie    Boston  Globe  January  29,  2015  

Outline  
•  Brief  review  of  NeoQIC  
•  Background  on  NAS  
•  Statewide  improvement  project  
 

Neonatal  AbsMnence  Syndrome  
Neonatal  absJnence  syndrome  (NAS)  
 
•  Newborns  with  in-­‐utero  drug  exposure  
•  CessaJon  of  drug  supply  at  delivery  
•  Withdrawal  syndrome  
•  Physiologic  and  behavioral  signs  
•  Respiratory,  gastrointesJnal,  central  nervous  system  

Patrick  et  al,  JAMA,  2012;  307(18):1934-­‐1940  

Past  Month  and  Past  Year  Heroin  Use  among  Persons  Aged  12  or  Older:  
2002-­‐2012  

SAMHSA,  2012  NaJonal  Survey  on  Drug  Use  and  Health  (NSDUH),  Summary  of  NaJonal  Findings

All  Poisoning  and  UnintenMonal  Opioid-­‐Related  Overdose  Deaths,    
MA  Residents,  2000-­‐2012    

Source: Registry of Vital Records and Statistics, MDPH, IIHS

All  Poisoning  and  UnintenMonal  Opioid-­‐Related  Overdose  Deaths,    
MA  Residents,  2000-­‐2012    

349  MVA  deaths  (2012)  

Source: Registry of Vital Records and Statistics, MDPH

Mass  DPH,  2014  

Outline  
•  Brief  review  of  NeoQIC  
•  Background  on  NAS  
•  Statewide  improvement  project  
 

Goals  

Improve  the  care  of  infants  impacted    
by  NAS,  and  their  families  
Develop  a  system  to  support  structured  approaches  to  
local  and  collabora/ve  quality  improvement  projects  
among  Massachuse;s  neonatal  providers  

Massachuse(s  NAS  project  
•  NAS  was  idenJfied  by  state  leaders  as  a  potenJal  area  
for  an  improvement  project  
•  Local  hospital  and  providers  felt  “overwhelmed”  by  the  
sheer  number  of  NAS  infants  at  their  facility  
•  No  naJonal,  regional  or  local  guidelines  on  how  to  best  
care  for  these  infants  and  their  families  
•  Goal  

–  Develop  a  community  of  pracJce  in  the  state  around  NAS  
–  Engage  all  hospitals,  providers,  professionals,  state  government  
officials,  payors  and  families  
–  Have  each  hospital-­‐based  team  parJcipate  in  iNICQ  2013/4  and  
create  a  local  project  to  improve  some  facet  of  NAS  care  
–  ParJcipate  in  VON  quality  audits  and  state  NAS  meeJngs    

Project  Timeline  
2013  

2014  

Webinar  Series  

Webinar  Series  

Project  proposal  
Hospital  recruitment  

First  statewide  
meeJng  

Second  statewide  
meeJng  

Third  statewide  
meeJng  

Fourth  statewide  
meeJng  
Sharepoint  site  
REDCap  
database  

ParMcipaMng  Centers  
Holy  Family  
Lawrence  General  
Health  Alliance  
Anna  Jaques  
Baystate  Franklin  
Lowell  General   Beverly  
Heywood  
North  Shore  
Winchester  
Cooley  Dickinson   St.  Vincent’s   Emerson  
BWH   TuAs  
MGH   Spaulding  
UMass  
Melrose-­‐Wakefield  
Holyoke  
Berkshire  
Metrowest  
BIDMC   BMC  
St.  
E
lizabeth’s  
Baystate  
Newton-­‐Wellesley  
Mt.  Auburn  
Brockton  
Mercy   Harrington  
South  Shore  
Good  Samaritan  
Milford  
Jordan  
Sturdy   Charlton  
Cape  Cod  
St.  Luke’s  
Falmouth  
Nantucket  

Components  

Knowledge  
Awareness  
CollaboraMon  
Improvement  

Knowledge  
•  Webinar  series:    Vermont-­‐Oxford  Network  (iNICQ)  
–  Started  2013,  consisJng  of  webinars,  NAS  and  QI  methods  
–  Capturing  the  family  voice  
–  2015  series  planned  
•  Local  experts  
–  Mara  Coyle:    Do  newborns  really  care  what  drug  their  
mother  took?  
–  Elisha  Wachman:    Breaskeeding  in  the  selng  of  maternal  
drug  abuse  
–  James  Moses:    Quality  improvement  tools  and  techniques  
for  NAS  improvement  work  

Components  

Knowledge  
Awareness  
CollaboraMon  
Improvement  

Awareness  
•  Epidemiology  and  trends  
–  Partnership  with  DPH  
–  Baseline  data  audits  
•  Resources  
–  Partnership  with  BSAS  
–  Partnership  with  DCF  
–  Partnership  with  Early  IntervenJon  

Components  

Knowledge  
Awareness  
CollaboraMon  
Improvement  

CollaboraMon  
•  Sharing  of  tools  and  resources  
–  Share  freely,  borrow  shamelessly  
•  Learn  from  variaJon  
•  Review  your  current  policies  and  guidelines  
–  Any  guidelines  that  need  updaJng?  
–  Any  new  guidelines  that  are  needed?  
–  Any  new  resources  that  could  be  useful?  

Written  Policies  or  Guidelines
Yes

No  

Not  Sure

Screening  for  maternal  substance  abuse

21

5

2

Screening  of  i nfants  at  risk  for  or  showing  signs  of  NAS

26

2

0

Non-­‐pharmacologic  treatment  of  i nfants  with  signs  of  NAS

14

12

2

Pharmacologic  treatment  of  i nfants  with  signs  of  NAS

27

1

0

Use  of  breastmilk  i n  i nfant  with  NAS

15

10

3

Baystate NAS
Consult Template

Components  

Knowledge  
Awareness  
CollaboraMon  
Improvement  

Massachuse(s  NAS  project  methods  
•  VON  iNICQ  parJcipaJon  
–  Webinars  
–  VON  quality  audits  

•  Massachusems  NAS  meeJng  
– 
– 
– 
– 

Face-­‐to-­‐face  meeJngs  twice/year  
NaJonal  and  regional  experts  
Hospital-­‐based  project  presentaJons  
Data  (surveys,  ICD-­‐9,  etc.)  

•  Partnerships  
– 
– 
– 
– 

Massachusems  Department  of  Public  Health  
Bureau  of  Substance  Abuse  
Early  IntervenJon,  Department  of  Children  and  Families,  MassHealth  
Substance  abuse  providers/treatment  centers  

Massachuse(s  NAS  project  measures  
•  42  delivery  hospitals  parJcipated  in  the  2012/3  VON  
iNICQ  series  and  submimed  data  for  at  least  1  quality  
audit  
•  Hospitals  provided  ICD-­‐9    data  for  2012  and  2013  to  
allow  for  an  esJmate  of  the  impact  of  NAS  on  the  
Commonwealth  
•  Hospitals  were  invited  to  present  their  local  projects  
at  biannual  Massachusems  NAS  meeJngs  and  at  the  
VON  Annual  Quality  meeJng    

Improvement  
•  Model  for  Improvement  
–  Specific  aims  
–  Outcome  and  process  measures  
–  Changes  for  improvement  
–  PDSA  to  test  changes  
•  Key  driver  diagrams,    
process  flow  diagrams  

Local  Improvement  
• 
• 
• 
• 
• 
• 
• 
• 

Make  an  improvement  team  
Select  areas  of  focus  
Define  SMART  aims  
Define  outcome  &  process  measures  (baseline  data!)  
IdenJfy  possible  changes  
Use  key  driver  diagram  to  structure  project  
Test  changes  with  PDSA  cycle  
Monitor  data  over  Jme  

Number  of  People  on  Improvement  Team  

Disciplines  Represented  on  Improvement  Team  

Care  Areas  Represented  on  Improvement  Team  

Other:    LactaJon,  Obstetrics  

What  projects  were  team  working  on?  
 P roject  Topic
NAS  s coring
Guidelines  on  management  of  infants  with  NAS
Prenatal  education  or  outreach
Breast  feeding  in  infants  with  NAS
Maternal  s creening
Staff  education
Communication  among  care  teams
Non-­‐pharmacologic  therapy  for  infants  with  NAS
Parent  information  or  education
Perinatal  excoriation  in  infants  with  NAS
Management  of  preterm  infants  with  NAS
Improve  patient  experience
Total

#  of  Hospitals
6
3
2
2
2
2
1
1
1
1
1
1
23

Specific  Aims:    Examples  
•  We  will  improve  the  quality  of  reliability  of  NAS  
scoring  among  health  care  providers  from  48%  to  
80%  by  September  15,  2013.  
•  Provide  90%  of  women  in  Project  RESPECT  with  
pediatric  prenatal  consult  by  Dec  2014;    ensure  that  
90%  of  women  in  Project  RESPECT  are  seen  for  iniJal  
post-­‐natal  OB  consult  by  Dec  2014.  
•  100%  of  staff  from  OB  and  pediatrics  will  amend  
simulaJon  session  exploring  difficult  conversaJons  
with  NAS  families  by  December  2014  

Data  for  Improvement  
•  VON  data  audits  
–  Audit  1:    October  to  December  2012  
–  Audit  2:    May  to  July  2013  
–  Audit  3:  October  to  December  2013  
–  Audit  4:  May  to  July  2013  

•  Local  data  
•  Statewide  data  –  REDCap  database  
 

NAS  Incidence  by  Zip  Code  (2013)  

Slide  courtesy  of  Urbano  Franco  and  Michael  McManus  

Massachuse(s  NAS  incidence  (2004-­‐2013)  

Slide  courtesy  of  Urbano  Franco  and  Michael  McManus  

Massachuse(s  NAS  Incidence,  per  1000  births  
(2012-­‐2013)  
80  

Incidence  of  NAS  per  1000  births  

70  

2012  
60  

2013  
2012  MA  

50  

2013  MA  

40  

30  

2013:    17.8  
20  

2012:    16.7  
10  

0  

1  

2  

3  

4  

5  

6  

7  

8  

9  

10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26   27   28   29   30  

Massachuse(s  NAS  infants/1000  births  (1/2014-­‐6/2014)  
80  

Incidence  of  NAS/1000  live  births  

70  

60  

50  

40  

30  

2014:  18.2  

20  

10  

0  
1  

2  

3  

4  

5  

6  

7  

8  

9   10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26   27   28  

VON  data  audits  
•  Over  the  course  of  4  audits:  
–  38  hospitals  submimed  data  
–  766  infants  
–  >15,000  paJent  days  
–  ~30%  of  total  number  of  infants  in  VON  audit  

Have  we  made  a  difference?  
100  

Audit  1  

90  

Audit  4  

80  
70  
60  
50  
40  
30  
20  
10  
0  
Pharmacologic  treatment  for  
NAS  

Non-­‐pharmacologic  
treatment  for  NAS  
P  <  0.05  

Encourages  provision  of  
human  milk  

Breastmilk  use  at  discharge  
30  
25  
20  

22  
20.1  
17.3  

16.8  

Audit  1  

Audit  2  

15  
10  
5  
0  
Audit  3  

Audit  4  

Percent  infants  discharged  to  guardian/foster  parent  
40  
34.7  

35  
30  

26.6  
24.3  

25  
20  
15  

15.4  

10  
5  
0  
Audit  1  

Audit  2  

Audit  3  

Audit  4  

Pharmacologic  management  
100  
90  
80  

Morphine  

70  

Phenobarbital  

60  
50  

Clonidine  

40  

DDTO/Paregoric  

30  
20  
10  
0  
Audit  1  

Audit  2  

Audit  3  

Audit  4  

Pharmacologic  management  
100  
90  
80  

Morphine  

70  

Phenobarbital  

60  
50  

Clonidine  

40  

DDTO/Paregoric  

30  
20  
10  
0  
Audit  1  

Audit  2  

Audit  3  

Audit  4  

Pharmacologic  management  
100  
90  
80  

Morphine  

70  

Phenobarbital  

60  
50  

Clonidine  

40  

DDTO/Paregoric  

30  
20  
10  
0  
Audit  1  

Audit  2  

Audit  3  

Audit  4  

MedicaMons  at  Discharge  
45  
40  

38.2  

38.1  

35  
28.8  

30  
25  
20  
15  
10  
5  
0  
Audit  1  

Audit  2  

Audit  3  

Audit  4  

Length  of  treatment/Length  of  stay  
30  

Audit  1  
Audit  4  

24  

25  
21  

20  

20  
16  

15  
10  
5  
0  
DuraJon  of  pharmacologic  treatment  

P<  0.05  

Length  of  stay  

What  Percent  of  Massachuse(s  NAS  Infants  
Required  Pharmacologic  Management?  
A. 
B. 
C. 
D. 
E. 
F. 

50%  
60%  
70%  
80%  
90%  
100%  

NeoQIC  Neonatal  AbsMnence  Syndrome  Improvement  Project  
Primary  Aims  

Overall  Project  Goal  
 

Improve  the  care  and  
outcomes  of  newborns  
impacted  by  NAS  

Primary  Drivers  
Increase  and  improve  parJcipaJon  of  
MA  hospitals  in  improvement  project  
Measure:    %  of  MA  birth  hospitals  
engaged  in  project  

Secondary  Drivers  
Increase  number  of  hospitals  that  have  
structured  and  effecJve  NAS  improvement  
projects  in  place  
Measure:    %  of  hospitals  in  project  with  
acJve  NAS  QI  project  by  end  of  2015  

PotenJal  Change  Concepts  
1) 
2) 
3) 

Outreach  to  all  MA  hospitals  
QI  educaJon  and  project  
facilitaJon  
Database  development  
including  compleJon  of  Data  
Use  Agreements  

Measure:    %  of  hospitals  in  project  reporJng  
data  to  state  database  by  end  of  2015  
Improve  non-­‐pharmacologic  care  
Reduce  post-­‐natal  exposure  to  opiates  
Outcome  Measure:    %  of  newborns  at  
risk  for  NAS  needing  pharmacologic  Rx  

1.    Improve  the  hospital-­‐based  care  of  
infants  at  risk  of  NAS.  

Outcome  Measure:    total  post-­‐natal  
opiate  exposure  

2.    Improve  childhood  outcomes  of  
infants  born  at  risk  for  NAS.      

Increase  family  involvement  in  care  

Process  Measure:  %  of  newborns  at  risk  for  
NAS  receiving  non-­‐pharmacologic  care  

1) 
2) 
3) 

Development  of  local  protocols  
Staff  educaJon  
Family  educaJon  

Increase  use  of  human  milk  
Process  Measure:  %  of  newborns  at  risk  for  
NAS  receiving  any  human  milk  by  discharge  

Process  Measure:  %  of  parJcipaJng  
hospitals  with  appropriate  local  
policies  or  guidelines  

Increase  antenatal  consults  for  families  at  
risk  for  NAS  

1) 
2) 

Development  of  local  protocols  
Staff  educaJon  

1) 

Consider  innovaJve  approaches  
to  rooming-­‐in  in  context  of  
physical  space  limitaJons  

1) 

Real-­‐Jme  EI  referral  rate  
reports  to  hospitals  

1) 

Improve  case-­‐load  of  DCF  case  
workers  

1) 

Develop  system  of  community-­‐
based  care  coordinators  
Maximize  use  of  exisJng  
community-­‐based  support  
programs  

Measure:    %  of  families  at  risk  for  NAS  
receiving  antenatal  consultaJon  
Associated  Measures  
1)  Percent  of  live  births  in  MA  where  
infants  are  at  risk  for  NAS  
2)  Percent  of  live  births  in  MA  where  
infants  have  NAS  

Increase  rooming-­‐in  
Improve  discharge  process  for  infants  
with  NAS  

Improve  referrals  to  Early  IntervenJon  (EI)  
Measure:    %  of  infants  with  NAS  referred  to  
EI  by  Jme  of  hospital  discharge  
Improve  coordinaJon  with  DCF  

Maximize  ability  to  maintain  safe  and  
intact  family  structure  
Measure:  %  of  infants  with  NAS  living  
with  biologic  or  adopJve  family  at  one  
year  of  age  

Increase  support  systems  following  
discharge  

2) 

January  13,  2015  

Next  steps  
•  2015  goals:  
–  Reduce  post-­‐natal  opiate  
exposure  by  opJmizing  non-­‐
pharmacologic  therapy  
–  Increase  use  of  human  milk  in  
NAS  infants  
–  Increase  antenatal  
consultaJons  for  families  at  
risk  for  NAS  
–  Improve  rates  of  Early  
IntervenJon  referrals  for  NAS  
infants  
hmp://www.doseoffunny.com/funny-­‐gifs-­‐people-­‐falling/  

Many  Thanks…  
•  Bureau  of  Substance  
Abuse  Services  
•  Department  of  Children  
and  Families  
•  Early  IntervenJon  
•  Department  of  Public  
Health  
•  March  of  Dimes