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OPQC

Ohio Perinatal Quality
Collaborative

The Ohio Perinatal Quality
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 CH’s

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
Children’s Mercy Park
Trumbull
Hospital
UH Rainbow
Elyria
Medical
Children’s
Memorial
Center -UH MetroHealthBabies &
Hospital
Blanchard
Mercy
Children’s
Akron Children’s Summa
Valley
Akron
Akron Children’s Medical
OhioHeal
Center
Nationwi
Marion
Children’s
St. Rita’s
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 Ann’s
ning Valley
Mt.
Carmel West OSU Mt. Carmel
East
Methodist
d
Dayton
Valley
t
Nationwide Doctor’s
Licking Memorial Health
Children’sHospital Medical
Springfield Regional
Good Samaritan
System
Center
Nationwide
Medical Center Nationwi
Dayton
Miami
Genesis
Healthcare
de GrantChildren’s
Soin Medical Center
Valley
Southview
Medical Center
System
Kettering
Fort
Adena
Cincinnati
Hamilton
Atrium Medical Center
Regional
Children’s
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 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.

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
D’Apolito
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 Children’s 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
of ≥8 or one score ≥12.

………………..……………………………………………………………………………………………………………………………………..

Finnegan Scored Items
Central Nervous
Autonomic Nervous
System
System
Sweating (1)
Excessive Crying (2-3)
Fever (1-2)
Sleep (1-3)
Frequent Yawning (1)
Hyperactive Moro (2-3)
Mottling (1)
Tremors (1-4)
Nasal Stuffiness (1)
Increased muscle tone
Sneezing (2)
(2)
Nasal Flaring (2)
Resp rate (1-2)
Excoriation (1)
Myoclonic jerks (3)
Convulsions (5)

Gastrointestinal
System
Excessive sucking (1)
Poor
feeding (2)
Regurgitation (2)
Projectile
Vomiting (3)
Stools (2-3)

………………..……………………………………………………………………………………………………………………………………..

NCH Finnegan Training
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 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?