Massachuse(s

NAS project

Alan Picarillo, MD, FAAP

On Behalf of MassNeoQIC
12 February 2015

Disclosures
I have no nancial conicts to disclose
I will be discussing o-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
aliated 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 eorts and improve
newborn outcomes in Massachuse;s

NeoQIC Hospitals

UMass
Baystate

BWH TuAs
Childrens
MGH
BIDMC
BMC
St. Elizabeths
South Shore

Nosocomial InfecMon Project

Launched in 2006 (rst NeoQIC project)

ComparaJve data reports
Local QI eorts
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 idenJed 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
ocials, 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. Vincents Emerson
BWH TuAs
MGH Spaulding
UMass
Melrose-Wakeeld
Holyoke
Berkshire
Metrowest
BIDMC BMC
St.
E
lizabeths
Baystate
Newton-Wellesley
Mt. Auburn
Brockton
Mercy Harrington
South Shore
Good Samaritan
Milford
Jordan
Sturdy Charlton
Cape Cod
St. Lukes
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

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

26

Non-pharmacologic treatment of i nfants with signs of NAS

14

12

Pharmacologic treatment of i nfants with signs of NAS

27

Use of breastmilk i n i nfant with NAS

15

10

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
Specic aims
Outcome and process measures
Changes for improvement
PDSA to test changes
Key driver diagrams,
process ow diagrams

Local Improvement

Make an improvement team

Select areas of focus
Dene SMART aims
Dene 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

Specic 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 sta from OB and pediatrics will amend
simulaJon session exploring dicult 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

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

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 dierence?

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 eecJve 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

Sta 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

Sta 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.doseounny.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