Yale-New Haven Children's Hospital demonstrated the importance of challenging traditional approaches to pediatric disease management, resulting in better care for babies born with neonatal abstinence syndrome.
For a baby with NAS, mom's presence and touch can be a powerful healing tool. That's what team members at Yale-New Haven Children's Hospital (YNHCH) learned after observing moms in the NICU. Prior to 2006, the standard approach for babies with NAS at YNHCH was to admit them directly from the delivery room to the NICU. But over time, team members noticed these babies' symptoms subsided when their moms held them as much as possible—something that can be a challenge in the NICU.
But with encouragement from the care team, mothers learned to swaddle their babies and reduce stimuli around them. And when Mom stayed close, the baby was calm and ate and slept better. “We started to think our focus on medication wasn't the right way to go,” says Matthew Grossman, M.D. In reality, bypassing the NICU and having the parents involved as the primary caregivers and the primary method of treatment made the biggest impact.
This allowed the baby to slowly come off medication, and over time, instead of these patients staying at the hospital for four weeks, they were going home after about a week.
Here's how the 2015 Pediatric Quality Award winner, YNHCH decreased length of stay (LOS) for methadone-exposed infants by 50 percent—lower than any published data—and decreased the use of morphine by 50 percent over a five-year period.
6 changes for improvement
YNHCH focused changes on a population with consistent withdrawal symptoms: patients born to mothers on methadone maintenance treatment of at least 30 milligrams per day.
Change morphine weaning protocol. YNHCH's NAS weaning guideline initially allowed for morphine weans every 48 hours if the Finnegan Neonatal Abstinence Scoring Tool (FNAST) scores (a tool that scores the clinical signs of withdrawal in newborn infants) were consistently below eight. The team adjusted the guideline to allow for weaning every 24 hours if scores remained below eight.
Focus on non-pharmacological care. The care team kept rooms dark and quiet to create a low-stimulation environment. Providers encouraged parents to be in the room with the baby as much as possible and to respond to the infant quickly if he or she became irritable. Team members also taught parents to swaddle, coached them on soothing techniques, and encouraged their involvement as the most important treatment for the infant.
Discontinue the use of FNAST scores. While this tool is useful in describing withdrawal symptoms, it doesn't describe how well the patient is functioning. YNHCH's guidelines on the inpatient units were changed to focus on more functional guidelines, particularly whether the infant could be soothed, fed and slept.
Transfer patient from well-baby nursery directly to the general inpatient unit. The team stopped transferring opiate-exposed babies to the NICU immediately after birth in an effort to keep the mother-baby bond intact and help the focus on parental involvement continue. The NICU houses infants in rooms with as many as 12 patients, making it impossible for parents to room-in, and this limits the ability to provide a low-stimulation environment.
Instead, the team kept babies with their mothers in the nursery and transferred them to the inpatient unit when FNAST scores rose to eight or higher. Babies were transferred from the nursery to the NICU if they had additional medical problems, or if beds were unavailable on the inpatient unit.
Include NICU staff members in improvement efforts. At the end of 2013, the team working on the NAS improvement project shared the results and approach with NICU staff members in an effort to expedite the transfer of NAS infants to the general unit and to encourage transfers prior to starting medication.
Aggressively wean infants started on morphine in the NICU. When it became clear that non-drug therapies were effective, infants transferred from the NICU to the general inpatient unit had their morphine weaned as many as three times a day, if tolerated.
The therapeutic effects of a mother soothing her child were much more powerful than anything medical teams could offer in an intensive care setting. The team also learned it can:
- Decrease LOS below published data by following a bundle of interventions mostly geared toward baby and family-centered care.
- Challenge traditional approaches to pediatric disease management.
- Respect the power of nonpharmacological approaches to disease management.
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