Collaborative Obstetrics 39-Week Schedule d Deliverie s without medical indicatio n Increas e Birth Data Accurac y& Online module s
Neonatal
Steroids for women at risk for preterm birth (240/7 - 33
6/7
Done Transition to BC Surveillance
Spread to all maternit y hospitals in Ohio
2014:
Blood Stream Infections: High reliability of line maintenan ce bundle
Progesterone to Reduce Preterm Birth Risk
Use of human milk in infants 22-29 weeks GA
2014:
OCHA NAS in 6 CHs
Neonatal Abstinence Syndrome
NAS Participating Sites 2014
Tripoint Medical Center (Lake Mercy Regional Clevelan ProMedi Promedica Medical Center d Clinic HillcrestHealth) ca Bay Toledo Hospital Fairview Lorain Childrens Mercy Park Trumbull Hospital UH Rainbow Elyria Medical Childrens Memorial Center -UH MetroHealthBabies & Hospital Blanchard Mercy Childrens Akron Childrens Summa Valley Akron Akron Childrens Medical OhioHeal Center Nationwi Marion Childrens St. Ritas Lima th Canton de Genera St. Elizabeth Medical Memorial Aultma MedCent Riversid l Health Center Health Nationwide n ral e Center/Maho Nationwide Mt. Carmel St. System Dublin Upper Methodis Mansfiel Anns ning Valley Mt. Carmel West OSU Mt. Carmel East Methodist d Dayton Valley t Nationwide Doctors Licking Memorial Health ChildrensHospital Medical Springfield Regional Good Samaritan System Center Nationwide Medical Center Nationwi Dayton Miami Genesis Healthcare de GrantChildrens Soin Medical Center Valley Southview Medical Center System Kettering Fort Adena Cincinnati Hamilton Atrium Medical Center Regional Childrens ood Samaritan Mercy Hospital Fairfield Medical Hospital Mercy Anderson Center UH Cincinnati Bethesda The Christ Southern Mercy Health North Hospital Ohio Medical West Hospital Center 1/2014 start Level 3 and Level 2 teams 4/2014 start Level 2 teams
Key Driver Diagram
Project Name: OPQC Neonatal NAS 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
non-judgmental support for Narcotic addicted women and infants
Attain high reliability in NAS scoring by nursing staf
Optimize NonPharmacologic 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.
Leader: Walsh INTERVENTIONS All MD and RN staff to view Nurture the Mother- Nurture the Child Monthly education on addiction care
Fulltime RN staf at Level 2 and
3 to complete DApolito 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.
OPQC NAS Project Aim
The aim of the OPQC NAS Project is to increase the identification of and compassionate withdrawal treatment for full-term infants born with NAS, thereby reducing the length of stay for these infants by 20% across participating sites by June 30, 2015.
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 Standardization of protocol bundles Non-pharmacological Bundle Pharmacological Treatment Bundle
Create a culture of compassion, understanding, and
healing for the mother infant dyad affected by the problem of neonatal abstinence syndrome.
Importance of Assessment: what are we assessing?
Neonatal Withdrawal Onset: 24 hours to days Duration: 16 days to months, self limiting
AAP Monitoring Recommendations:
Minimum 2-3 days for any maternal history of drug use 5-7 days if mom on multiple and/or long acting drugs
What is Inter-Rater Reliability?
Inter-rater Reliability= extent to which 2 providers agree when using the same tool. Method= one person scores, while another observes; each independently scores, then compare Goal= 90% inter-rater reliability
NAS Scoring by Clinical Staff Cohort 1
NAS Scoring by Clinical Staff Cohort 2
100% 90%
13%
80% 70%
42% 42%
Not done currently
60%
Planned
50% 40%
29% 13%
30% 20% 10%
13% 33% 17%
0%
All fulltime nursing staff in our NICU complete the DAppolito NAS scoring training video
Implementing Part of our practice
Improve Consistency in Modified Finnegan Scoring All sites use same tool Train RN staff to 90% reliability in scoring using DApolito Training System In Pilot work, we were able to see drop in max score when training completed
Finnegan Scoring DVD &
http://www.neoadvances.com/ Workbook
Finnegan Scoring Tool Erin L. Keels MS, APRN, NNP-BC NAS Taskforce Chair NNP Program Director Nationwide Childrens Hospital Columbus, Ohio ....
Why use an assessment
tool?
2005 study: 81% centers surveyed use assessment
tool, 52% have guidelines (Crocetti, Amin, & Jansonn, 2007) Allows for common language, decrease variability, involve families Based on opiate withdrawal One tool for all substance withdrawal? Confounding factors Term vs. preterm vs. beyond neonatal period Staff training and competency maintenance Subjectivity ....
NAS Assessment Tools
....
Modified Finnegan
Originally developed in 1975; Modified in 1986
200 term, opiate exposed newborns
Assessed from the beginning of one feeding til the beginning of the next feeding, Q 3-4 hrs Challenging with breastfed neonates
Recommended: start scoring at 2 hours of age; if score= 8, continue
to score Q2 hrs until less than 7
OPQC treatment protocol: begin treatment for 2 consecutive scores
Finnegan Training Courses ( March- April 2010) Two half day NAS Workshops Train the trainer format
Implement standardized training of new staff
with commercially produced program (NeoAdvances)
Ongoing competency for all staff
Reliability= extent to which 2 providers agree when using
the same tool. Method= one person scores, while another observes; each independently scores, then compare ....
Goal= 90% inter-rater reliability
Ongoing Inter-rater Reliability
....
Ongoing Inter-rater Reliability 2013 NCH Staff Survey on Finnegan Scoring:
67% of RN staff responded
15.2 % felt somewhat or not comfortable
concerns: scoring of sleep for older babies,
excoriation
37% wanted more education/training
26% of staff were not conducting interrater reliability scoring properly
....
Results
2013 all RNs watched: Assessing signs and
symptoms of Neonatal Abstinence using the Finnegan Scoring Tool video from NeoAdvances NAS Super Users reeducated all staff
Lunch n Learns with 2013 VON iNICQ NAS
Webinars
Dual score minimally once every 12 hours with an
NAS Super User or an NNP
....
2013 reliability scores= 98%
OPQC Resources opqc.net Projects NAS Learning Sessions Archives June 26, 2014 1:10-1:50pm & 1:552:35pm Finnegan Scoring (Keels) 17 minute video of this presentation is on our website
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
What are other hospitals testing?
Steal Shamelessly-Share Seamlessly Have a parent observe and participate when the nurse completes the infants 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.
