The Colorado Hospitals Substance Exposed Newborn Quality Improvement Collaborative: Standardization of Care for Opioid-Exposed Newborns Shortens Length of Stay and Reduces Number of Infants Requiring Opiate Therapy

Abstract

METHODS:The Colorado Hospitals Substance Exposed Newborn Quality Improvement Collaborative is a consortium of neonatal providers, public health experts, and legislative experts that provides infrastructure and resources for Colorado birthing hospitals to undertake initiatives focused on improving the care of OENs. The Colorado Hospitals Substance Exposed Newborn Quality Improvement Collaborative was started in September 2017 and includes 19 birthing hospitals in Colorado, with 12 contributing data to the centralized database. The interventions were focused on (1) hospital engagement and (2) increasing nonpharmacologic care (by using the Eat, Sleep, Console assessment tool; developing guidelines for breastfeeding eligibility; employing comfort measures before pharmacologic therapy; and administering opiate therapy on an as-needed basis). RESULTS:From April 2017 to December 2019, 787 OENs were identified. Among infants $35 weeks' gestational age without other medical diagnoses (n 5 647), statistical process control charts revealed significant reduction in the primary outcome of interest, average hospital LOS, from 14.8 to 5.9 days. For all OENs, receipt of pharmacologic therapy declined from 61% to 23%. Among OENs who received pharmacologic therapy (and were $35 weeks' gestational age without other medical diagnoses), average LOS also declined from 21.9 to 8.0 days. CONCLUSIONS:Through standardization of OEN care focused on family engagement and nonpharmacologic care, this statewide collaborative reduced average LOS, the percentage of OENs requiring opiate therapy, and average LOS for OENs requiring opiate therapy.

Improving Hospital Care of Opioid-Exposed Newborns: Successes and Remaining Questions

“…The successful QI work described by Hwang et al 4 provides a framework for hospitals to partner together with existing statewide perinatal QI collaboratives to standardize NAS care. Building on this foundation, future groups could add to the collective knowledge by including primary care stakeholders and measuring longer-term postdischarge outcomes important for the health of infants and their families.…”

Current Resources for Evidence‐Based Practice, March/April 2021

“…A similar QI project among just over 200 infants showed a decrease in morphine treatment by half and a 2‐day decrease in length of stay (not statistically significant) but no change in NICU admissions or breastfeeding rates 8 . Since these 2 studies, several states and organizations have undertaken QI initiatives based on these principles showing significant decreases in length of stay and number of neonates treated with morphine 9–11 …”

Neonatal opioid withdrawal syndrome: a review of the science and a look toward the use of buprenorphine for affected infants

“…In addition, the ESC Care Tool is only one component of the ESC care approach for NOWS, which emphasizes the optimization of nonpharmacologic care as a primary intervention (although most health systems that use the FNAST as the primary assessment tool also emphasize education, support, and empowerment of families in the care of their neonate). Quality improvement studies indicate that the ESC approach improves short-term outcomes such as LOS and use of pharmacotherapy [ 16 , 21 – 24 ]. However, it is not clear if these findings are broadly generalizable.…”

“…More recently, symptom-triggered (i.e., “as needed”) dosing regimens of morphine and methadone have been associated with significantly shorter durations of pharmacologic treatment in non-randomized quality improvement investigations, though the safety and neurodevelopmental outcomes of this approach are unknown [ 24 , 29 ]. In one study, neonates started on a symptom-triggered methadone-dosing protocol had fewer methadone treatment days (median 2.5 vs. 11.7 days, P = 0.0001), received a lower overall dose of methadone (0.53 vs. 4.52 mg, P < 0.0001), and had a shorter LOS (median 10.5 vs. 17.0 days, P = 0.003) than neonates started on a fixed-dosing protocol [ 29 ].…”

“…In one study, neonates started on a symptom-triggered methadone-dosing protocol had fewer methadone treatment days (median 2.5 vs. 11.7 days, P = 0.0001), received a lower overall dose of methadone (0.53 vs. 4.52 mg, P < 0.0001), and had a shorter LOS (median 10.5 vs. 17.0 days, P = 0.003) than neonates started on a fixed-dosing protocol [ 29 ]. Implementation of an ESC program and provision of “as needed” opioid therapy was also associated with reductions in mean LOS (from 14.8 to 5.9 days) and in the proportion of neonates receiving pharmacotherapy (from 61 to 23%) in a Colorado hospital network [ 24 ].…”