2020 Quality




Hospital Quality Improvement Showcase - SSM Health St. Mary’s Hospital, Madison

The Eat, Sleep, Console (ESC) method of caring for infants with neonatal abstinence syndrome.
Reducing Opioids Given to Infants of Mothers with Opioid Use Disorder Using Eat Sleep Console

Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic observed in the general population. Since the year 2000, opioid use disorder (OUD) in pregnant women has increased from 1.19% to 5.63% per 1,000 live births in the United States.1 Consequently, infants with neonatal abstinence syndrome (NAS), which results from intrauterine opioid exposure, has increased five-fold in the past 15 years. These infants traditionally have been treated pharmacologically with additional opioids after being assessed for withdrawal symptoms using the Finnegan Neonatal Abstinence Scoring System (FNASS),2 which assesses for 21 of the most common signs of neonatal drug withdrawal syndrome. However, this scoring tool has never been validated and lacks internal consistency and interrater reliability. Monitoring and treatment of NAS results in prolonged hospitalizations, disrupts infant-parent bonding and leads to a substantial health care burden. 

SSM Health St. Mary’s Hospital’s health care team wanted to reduce pharmacological interventions and wanted a model that focused on non-pharmacologic therapies and a simplified evidence-based, family-centered approach to assessment for infants exposed to opioids prenatally. The team focused on supportive care that included increased skin-to-skin contact, feeding on demand, calming techniques and maintaining a quiet environment. The model of care and assessment implemented is called Eat Sleep Console (ESC). SSM Health St. Mary’s Hospital focused on the mother as the treatment for her baby and let the moms know that they could provide the supportive care that the baby needed. This strategy shifted the goal from reducing withdrawal symptoms by exposing an infant to additional opioids to an approach prioritizing the overall functional well-being of the infant. The ESC model of care, developed by the New England Perinatal Quality Improvement Network, narrows assessments to the infant’s basic functions of eating and sleeping and their ability to be consoled. This led to significant decreases in average length of stay (ALOS) and opioid administration at Yale New Haven Children’s Hospital.2 Eat Sleep Console also seeks to reduce the stigma around neonatal exposure and withdrawal.

Intervention 
Eat Sleep Console replaced Finnegan Neonatal Abstinence Scoring System
(FNASS) as the method of assessment for infants at risk for NAS at SSM St. Mary’s Madison. The multidisciplinary team created an algorithm tool and provided education and training to all members of the healthcare team. Families and caregivers were educated on the new assessment tool and on methods to help console their infants. Educational materials were distributed in the clinic before birth to help the mothers prepare for what will happen in the hospital. Suggestions on how to calm their baby were shared on a poster in the hospital room and mothers were encouraged to be with their babies continuously to help calm and soothe them.

Results
Baseline data from January 2017 to December 2018 identified infants at risk for NAS with length of stays ranging from three to 44 days. The average length of stay (ALOS) was 9.86 days. The average doses of morphine given per month was 40, with a low of 15.5 doses to a high of 132 doses. The percentage of infants who received morphine was 38%.  

Since implementation of the ESC method in April 2019 there have been 52 infants identified to be at risk for NAS through August 2020. The ALOS decreased to 7 days. The percentage of infants receiving morphine decreased to 9%. No infants were readmitted for signs of withdrawal and no adverse events were reported.

Conclusions 
The goal of using the ESC method is not to eliminate the use of opioids to treat NAS, but to assess each infant individually and use other methods of non-pharmacologic treatment before pharmacologic intervention. 

All members of the health care team really appreciate the new scoring method, the interrater reliability improved and the infant does not have to be disturbed to do the assessment. Many families have also noticed the difference. One example is a mother who was on opioid replacement therapy during pregnancy and had her second baby scored with ESC while her first was scored with FNASS. She reported that she was “happy to see that her baby was disturbed less, and she was able to help with the assessment and treatment this time.”

References
1 American College of Obstetricians and Gynecologists (ACOG) 2017. Opioid use and opioid use disorder in pregnancy. Committee opinion 711. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy

2 Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6):e20163360.