Post on 19-Jul-2020
How to Reshape Your Approach to NOWS, Today
Adam Czynski, DOAssistant Professor of PediatricsWarren Alpert Medical School
Brown University Director, Newborn Nursery
Clinical NeonatologistWomen & Infants Hospital
• 8th Largest Birthing Hospital in the Country
• Largest Birthing Hospital in Rhode Island
– 9,100 Births a year
• Pediatric Services include NICU and Newborn Nursery
• 62% of Payer mix is either Self Pay or Medicaid / Medicare Health Plans
Rhode Island’s Opioid Crisis
•Drug overdoses in Rhode Island are a public health crisis. The number of deaths are increasing
•RI ranks 7th in the nation in overdose deaths from prescription drugs (Statistica,2015)
•Between 2009-2015 overdose deaths for women have increased by 63% (RI DOH,2015)
•RI has the nations highest rate of illicit drug use per capita and non-medical use of prescription opioids and ranks far above the national
average
Overdose Deaths In Rhode Island
Overdose Deaths In Rhode Island
Bateman et al, Anesthesiol. 2014
14.4 % of Pregnant women prescribed an opioid during pregnancy
NAS Statistics in Rhode Island
• NAS rates in RI have more than doubled in the last decade
2005 44/10.000 births2010 56/10,000 births2015 95/10,000 births
• 97% of the 95 births in 2015 were born at Women & Infants, of the 97%,
• 98% were managed in the Mother Baby Unit• The average charge is $70,506.00 compared
regionally the average is $93,815.00
Patient Story
• Baby M was born on in February 2016• Involved parents • Both parents on methadone• Total stay was 38 Days• Total morphine need was
– 50.6 mg total– 18.7 mg a day– 2.3 mg /kg/ dose
• Stayed on 4 different hospital units• Parents Felt Judged and Powerless
Support and EmpowermentJudged and Powerless
Knowledge and Understand
Understanding Opioid Addiction
• Understanding the biochemistry helps to better assess NOWS
• Understanding opioid effects on the body is important to understand the need for treatment
Opioids and Pleasure
Kosten et al. Sci Pract Perspect. 2002
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
• Tolerance is the drive to take larger doses of opioids to achieve the same feelings of pleasure
• Dependence is the need for opioids to treat the effects of an upregulated locus ceruleuscausing unregulated norepinephrine release
Tolerance and Dependence
Patient Story
• Baby M was born on in February 2016
• Involved parents
• Both parents on methadone
• Total stay was 38 Days
• Total morphine need was– 50.6 mg total
– 18.7 mg a day
– 2.3 mg /kg/ dose
• Stayed on 4 different hospital units
Problem Identification
• Poor Communication
– Healthcare Provider to Healthcare Provider
– Healthcare Provider to Family
• No Central Treatment Location
• Reduced focus on Discharge
• Flexibility with Protocol “Provider Preference”
• Inconsistency with Rounding
• Families felt judged and powerless
The Journey Begins
Plan
DoStudy
Act
Plan
Develop a new model of care for babies with NAS
1. Centralize our Care
2. Improve Communication Between the Family and Team
3. Create Structure
4. Empower our Patient’s Family
5. Discharge Begins on Day 1
Centralize Location of Care
• Model of care changed from a boarder nursery to a more family centered approach and became centralized
• NAS Task Force initiated• Criteria for “Rooming In” was developed• Education and support for the nursing staff is ongoing• First line of therapy for babies with NAS is non-
pharmacologic , with clustered supportive care• Care is a team approach with parents included every
step of the way• Developed “Cuddler” program
Improve Communication:
“I get 6 different messages from 4 different people”- Every family in a hospital
Team Communication
• Expanded the Team to including all stakeholders
• The Team became the Family Care Team
Family Care Rounds
Family Care
Rounds
Doctors
NP
Nursing
Social Work
Occupational Therapy
Case Management
Chaplin
Community Partners
Family
Family
NP
Nursing
Social Work
Case Management
Chaplin
Community Partners
Doctors
Occupational Therapy
Family Care Rounds
Family
Doctors
NP
Nursing
Social Work
Occupational Therapy
Case Management
Chaplin
Community Partners
• Family Care Rounds Start Every
Day at 13:30
• Conducted in the Patient Room
with entire team
• Family responsible to update
team about previous 24 hours
• Date of Discharge is discussed
everyday
IMPLEMENTATION
Implementation
• May 2016 we went live with our Family Centered Care Model
• Babies kept in the room with the mother
• Nursing and Family partnered to assign NAS Scores
• Families were informed of our new model during prenatal consults
Retrospective cohort study conducted at Women & Infants Hospital (WIH) with infants born between May 2015– April 2017.
• Infants born between May 2015-April 2016 were treated using the WIH standard of care for NAS infants.
• Infants born between May 2016-April 2017 were treated using Family Care Rounds in addition to the WIH standard of care.
• Length of stay (LOS), length of treatment (LOT), and total number of morphine doses were analyzed using generalized linear models with a Poisson distribution.
• Covariates included birth weight, gestational age, and DCYF involvement. Covariates were selected based on conceptual reasons, published literature, characteristics that differed between groups, and were not highly correlated.
Table 1. Caregiver and infant characteristics by type of care
N (%)or Mean (SD)
Family
Care
Rounds
(n = 20 )
WIH
Standard of
Care
(n= 16)
P-
Value
Caregiver Characteristics
Race
White 16 (84.2%) 12 (92.3%) 0.496
Public Insurance 18 (94.7%) 12 (92.3%) 0.780
DCYF Involvement 11 (55.0%) 3 (18.8%) 0.027
Infant Characteristics
Gender (boy) 8 (40.0%) 9 (56.3%) 0.332
Birth weight (g) 3188 (564) 2895 (480) 0.107
Discharge weight (g) 3447 (928) 3239 (616) 0.327
Gestational Age (weeks) 38.7 (1.8) 38.5 (1.5) 0.686
Conclusions
Buprenorphine
Take Home Message