Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Quality Improvement Article
  • Published:

A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts’ PNQIN collaborative

Journal of Perinatology volume 40, pages 1560–1569 (2020)Cite this article

Subjects

Abstract

Objective

To support hospitals in the Massachusetts PNQIN collaborative with adoption of the ESC Neonatal Opioid Withdrawal Syndrome (NOWS) Care Tool© and assess NOWS hospitalization outcomes.

Study design

Statewide QI study where 11 hospitals adopted the ESC NOWS Care Tool©. Outcomes of pharmacotherapy and length of hospital stay (LOS) and were compared in Pre- and Post-ESC implementation cohorts. Statistical Process Control (SPC) charts were used to examine changes over time.

Results

The Post-ESC group had lower rates of pharmacotherapy (OR 0.35, 95% CI 0.26, 0.46) with shorter LOS (RR 0.79, 95% CI 0.76, 0.82). The 30-day NOWS readmission rate was 1.2% in the Pre- and 0.4% in the Post-ESC cohort. SPC charts indicate a shift in pharmacotherapy from 54.8 to 35.0% and LOS from 14.2 to 10.9 days Post-ESC.

Conclusions

The ESC NOWS Care Tool was successfully implemented across a state collaborative with improvement in NOWS outcomes without short-term adverse effects.

Access through your institution
Buy or subscribe

This is a preview of subscription content, access via your institution

Access options

Access through your institution

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Percent of opioid-exposed newborns ≥35 weeks receiving pharmacotherapy, Pre- and Post-ESC implementation.
Fig. 2: Length of hospital stay (LOS) for opioid-exposed newborns ≥35 weeks, Pre- and Post-ESC implementation.

Similar content being viewed by others

References

  1. Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and costs of neonatal abstinence syndrome among infants with medicaid: 2004–2014. Pediatrics 2018;141. https://doi.org/10.1542/peds.2017-3520.

  2. Milliren CE, Gupta M, Graham DA, Melvin P, Jorina M, Ozonoff A. Hospital variation in neonatal abstinence syndrome incidence, treatment modalities, resource use, and costs across pediatric hospitals in the United States, 2013 to 2016. Hosp Pediatr. 2018;8:15–20.

    Article  PubMed  Google Scholar 

  3. Mehta A, Forbes KD, Kuppala VS. Neonatal abstinence syndrome management from prenatal counseling to postdischarge follow-up care: results of a national survey. Hosp Pediatr. 2013;3:317–23.

    Article  PubMed  Google Scholar 

  4. Tolia VN, Patrick SW, Bennett MM, Murthy K, Sousa J, Smith PB, et al. Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. N. Engl J Med. 2015;372:2118–26.

    Article  PubMed  Google Scholar 

  5. Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015;35:667.

    Article  CAS  PubMed  Google Scholar 

  6. Bogen DL, Whalen BL, Kair LR, Vining M, King BA. Wide variation found in care of opioid-exposed newborns. Acad Pediatr. 2017;17:374–80.

    Article  PubMed  Google Scholar 

  7. Snowden JN, Akshatha A, Annett RD, Crawford MM, Das A, Devlin LA, et al. The ACT NOW clinical practice survey: gaps in the care of infants with neonatal opioid withdrawal syndrome. Hosp Pediatr. 2019;9:585–92.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Schiff DM, Grossman MR. Beyond the Finnegan scoring system: novel assessment and diagnostic techniques for the opioid-exposed infant. Semin Fetal Neonatal Med. 2019;24:115–20.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2:141–58.

    CAS  PubMed  Google Scholar 

  10. Jones HE, Seashore C, Johnson E, Horton E, O’Grady KE, Andringa K, et al. Psychometric assessment of the Neonatal Abstinence Scoring System and the MOTHER NAS Scale. Am J Addict. 2016;25:370–3.

    Article  PubMed  Google Scholar 

  11. Grossman MR, Berkwitt AK, Osborn RR, Xu Y, Esserman DA, Shapiro ED, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics 2017;139. https://doi.org/10.1542/peds.2016-3360.

  12. Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hosp Pediatr. 2018;8:1–6.

    Article  PubMed  Google Scholar 

  13. Wachman EM, Grossman M, Schiff DM, Philipp BL, Minear S, Hutton E, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. J Perinatol. 2018;38:1114–22.

    Article  PubMed  Google Scholar 

  14. Whalen BL, Grossman MR, Whatley C. Inter- and intra-rater reliability of the Eating, Sleeping, Consoling (ESC) Care Tool for Neonatal Abstinence Syndrome (NAS). In: Proceedings from the 2018 Annual Meeting of the Pediatric Academic Societies; May 5–8, 2018; Toronto, Canada.

  15. Whalen BL, MacMillan KD, Flanagan VA, Picarillo A. NNEPQIN NAS initiative: implementation of the eat, sleep, console care tool across a regional neonatal quality improvement network. In: Proceedings from the 2019 Annual Meeting of the Pediatric Academic Societies; April 27–30, 2019; Baltimore, MD.

  16. Achilles JS, Castaneda-Lovato J. A quality improvement initiative to improve the care of infants born exposed to opioids by implementing the eat, sleep, console assessment tool. Hosp Pediatr. 2019;9:624–31.

    Article  PubMed  Google Scholar 

  17. Blount T, Painter A, Freeman E, Grossman M, Sutton AG. Reduction in length of stay and morphine use for NAS with the “eat, sleep, console” method. Hosp Pediatr. 2019;9:615–23.

    Article  PubMed  Google Scholar 

  18. Parlaman J, Deodhar P, Sanders V, Jerome J, McDaniel C. Improving care for infants with neonatal abstinence syndrome: a multicenter, community hospital-based study. Hosp Pediatr. 2019;9:608–14.

    Article  PubMed  Google Scholar 

  19. Dodds D, Koch K, Buitrago-Mogollon T, Horstmann S. Successful implementation of the eat sleep console model of care for infants with NAS in a community hospital. Hosp Pediatr. 2019;9:632–8.

    Article  PubMed  Google Scholar 

  20. MacMillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Volpe Holmes A. Association of rooming-in with outcomes for neonatal abstinence syndrome: a systematic review and meta-analysis. JAMA Pediatr. 2018;172:345–51.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wachman EM, Schiff DM, Silverstein M. Neonatal abstinence syndrome: advances in diagnosis and treatment. JAMA. 2018;319:1362–74.

    Article  PubMed  Google Scholar 

  22. Howard MB, Schiff DM, Penwill N, Si W, Rai A, Wolfgang T, et al. Impact of parental presence at infants’ bedside on neonatal abstinence syndrome. Hosp Pediatr. 2017;7:63–69.

    PubMed  Google Scholar 

  23. Massachusetts Perinatal Neonatal Quality Improvement Network (PNQIN) Perinatal Opioid Project. http://www.pnqinma.org/perinatal-opioid-project. Accessed 16 March 2020.

  24. Kilo CM. A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement’s Breakthrough Series. Qual Manag Health Care. 1998;6:1–13.

    Article  CAS  PubMed  Google Scholar 

  25. Gupta M, Kaplan HC. Using statistical process control to drive improvement in neonatal care: a practical introduction to control charts. Clin Perinatol. 2017;44:627–44.

    Article  PubMed  Google Scholar 

  26. Baby Friendly USA. http://www.babyfriendlyusa.org. Accessed 16 March 2020.

  27. Wachman EM, Warden AH, Thomas Z, Thomas-Lewis JA, Shrestha H, Nikita FNU, et al. Impact of psychiatric medication co-exposure on Neonatal Abstinence Syndrome severity. Drug Alcohol Depend. 2018;192:45–50.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge the Massachusetts PNQIN perinatal opioid project leadership team, the ESC leadership team, and ESC NOWS Care Tool creators (Bonny Whalen, Elisha Wachman, Kathryn MacMillan, Susan Minear, Matthew Grossman). We would like to thank the numerous people at each hospital who participated in the multi-disciplinary teams needed to implement the ESC NOWS Care Tool.

Funding

This study was supported by grant funding from the Massachusetts Health Policy Commission and the Massachusetts Department of Public Health (CDC Grant no. NU58DP006371).

Author information

Authors and Affiliations

  1. Department of Pediatrics, Boston Medical Center, Boston, MA, USA

    Elisha M. Wachman, Breanna C. Isley & Susan Minear

  2. Newborn Medicine, Beth Israel Deaconness Medical Center, Boston, MA, USA

    Mary Houghton & Munish Gupta

  3. Center for Applied Pediatric Quality Analytics, Children’s Hospital Boston, Boston, MA, USA

    Patrice Melvin

  4. Department of Pediatrics, Lowell General Hospital, Boston, MA, USA

    Jennifer Murzycki

  5. Department of Pediatrics, Baystate Children’s Hospital, Springfield, MA, USA

    Rachana Singh

  6. Department of Pediatrics, MassGeneral Hospital for Children, Boston, MA, USA

    Kathryn Dee L. MacMillan

  7. South Shore Hospital, Weymouth, MA, USA

    Debra Banville

  8. Cooley Dickinson Hospital, Northampton, MA, USA

    Amy Walker

  9. Department of Pediatrics, Mercy Medical Center, Springfield, MA, USA

    Teresa Mitchell

  10. Milford Regional Medical Center, Milford, MA, USA

    Rose Galimi-Hayes

  11. Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA

    Selena Jorgensen

  12. Department of Neonatology, Boston Children’s Hospital, Boston, MA, USA

    Daphne Remy Gomes

  13. Massachusetts Health Policy Commission, Boston, MA, USA

    Fran Hodgins

  14. Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock, Lebanon, NH, USA

    Bonny L. Whalen

  15. Massachusetts Department of Public Health, Boston, MA, USA

    Hafsatou Diop

Authors
  1. Elisha M. Wachman
    View author publications

    Search author on:PubMed Google Scholar

  2. Mary Houghton
    View author publications

    Search author on:PubMed Google Scholar

  3. Patrice Melvin
    View author publications

    Search author on:PubMed Google Scholar

  4. Breanna C. Isley
    View author publications

    Search author on:PubMed Google Scholar

  5. Jennifer Murzycki
    View author publications

    Search author on:PubMed Google Scholar

  6. Rachana Singh
    View author publications

    Search author on:PubMed Google Scholar

  7. Susan Minear
    View author publications

    Search author on:PubMed Google Scholar

  8. Kathryn Dee L. MacMillan
    View author publications

    Search author on:PubMed Google Scholar

  9. Debra Banville
    View author publications

    Search author on:PubMed Google Scholar

  10. Amy Walker
    View author publications

    Search author on:PubMed Google Scholar

  11. Teresa Mitchell
    View author publications

    Search author on:PubMed Google Scholar

  12. Rose Galimi-Hayes
    View author publications

    Search author on:PubMed Google Scholar

  13. Selena Jorgensen
    View author publications

    Search author on:PubMed Google Scholar

  14. Daphne Remy Gomes
    View author publications

    Search author on:PubMed Google Scholar

  15. Fran Hodgins
    View author publications

    Search author on:PubMed Google Scholar

  16. Bonny L. Whalen
    View author publications

    Search author on:PubMed Google Scholar

  17. Hafsatou Diop
    View author publications

    Search author on:PubMed Google Scholar

  18. Munish Gupta
    View author publications

    Search author on:PubMed Google Scholar

Contributions

All authors reviewed and edited the manuscript, and approved the final submitted version. EMW wrote the first draft of the manuscript, developed the concept for the project and led the project; MG supervised the project, helped develop the concept, and provided key resources and data coordination; MH was a key project lead involved in site, conference, data collection coordination; PM performed the data analysis, table and figure creation; EMW, JM, SM, KDLM, and BLW created the ESC Care Tool training materials, led workshops and webinars, and provided site support; BCI wrote portions of the first draft of the manuscript and assisted with data collection; EMW, JM, RS, DB, AW, TM, RG, SJ, and DRG were site leads who supervised implementation and data collection at their hospitals; HD and FH provided overall project leadership and resources.

Corresponding author

Correspondence to Elisha M. Wachman.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wachman, E.M., Houghton, M., Melvin, P. et al. A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts’ PNQIN collaborative. J Perinatol 40, 1560–1569 (2020). https://doi.org/10.1038/s41372-020-0733-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue date:

  • DOI: https://doi.org/10.1038/s41372-020-0733-y

This article is cited by

Search

Advanced search

Quick links