Prevalence of Neonatal Abstinence Syndrome (NAS) and its attendant costs tripled in the past ten years, not only here in the Upper Valley, but nationally. Treating newborns suffering from NAS—withdrawal symptoms from in utero exposure to addictive opioid drugs—is expensive and requires prolonged hospital stays.
To help alleviate the financial burden this care places both on families and the healthcare system, a team of Geisel School of Medicine faculty, students, and pediatric staff at Children’s Hospital at Dartmouth-Hitchcock (CHaD) developed and implemented a new coordinated and standardized care model for treating both opioid-exposed and NAS-affected newborns in January 2013. Their inventive model resulted in lower costs and shorter hospital stays for at-risk infants, while family involvement and satisfaction with care was simultaneously improved.
Earlier this summer, the team’s efforts were rewarded with a 2014-2015 Clinical Care Innovation Challenge Award from the Association of American Medical Colleges (AAMC), which recognizes successfully implemented innovative and transformative initiatives in care delivery to advance quality and improve patient outcomes. The cash award supports one-year pilot projects.
“This is a terrific honor,” says Alison Holmes, MD, MPH, an associate professor of pediatrics and assistant director of pediatric medical student education at Geisel. “We have a lot of newborns with NAS who require a significant amount of care and we were looking for ways to reduce their hospital stay—this integrated care model achieved higher patient satisfaction while lowering costs.
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Perinatal substance use is a growing population health concern for Vermont and New Hampshire communities served by Dartmouth-Hitchcock Medical Center and is associated with long-term health problems for women, infants, and families.
One of the only programs in New England to offer addiction counseling, treatment, group therapy, and perinatal and postnatal care in one clinical setting, the Dartmouth-Hitchcock Perinatal Addiction Treatment Program was initiated in 2013 to provide comprehensive evidence-based treatment and basic obstetric care to pregnant women with substance use disorders and their babies.
“The degree of Geisel medical student involvement should be noted because they made significant contributions to a project that has made a difference,” Holmes adds. “Fourth-year student Emily Carson Atwood assumed an amazing leadership role on this project.”
Working with her mentors was a pivotal experience for Atwood. “The chance to work with families affected by NAS and to be involved in this research project has been invaluable to my medical education,” she says. “I worked with our research team to collect and analyze data and I also conducted the qualitative analysis of the family interview component of the project—I presented our research at the Vermont Oxford Network Annual Meeting last October and then at the Pediatric Academic Societies Meeting this April.
“I also presented the findings from our initiative at the AAMC Integrating Quality Meeting in June along with other Clinical Care Innovation Challenge winners from Duke, Emory, and Oregon Health & Science University,” Atwood says.
New treatment protocols for both opioid-exposed and NAS-affected newborns include consistent symptom scoring, reduced transfers between hospital units, and decreased length of stay for treated babies—pharmacologic treatment of newborns fell from 46 percent in 2012 (baseline year) to 27 percent in 2014. The average length of stay for morphine-treated newborns decreased from 17.9 days to 13.6 days and the average number of transfers between units dropped from 2.1 to 1.5. Average hospital costs per treated infant also decreased from $20,300 to $10,700, and costs per at-risk infant dropped from $11,000 to $5,300.
Prior to implementing the new protocols, which are quite different from the previous model, nearly all of the care that babies at risk for NAS received did not include parents. It was often managed in a neonatal intensive care unit (NICU), but also included other units, resulting in variable, uncoordinated care within the hospital.
“We wanted to change the model so parents could be more involved with their baby’s care while they themselves continued treatment,” Holmes says. “This family-centered approach contributed to the care model’s success.”
Most in utero opioid-exposed babies born at CHaD are to mothers with a history of addiction and who are already in treatment programs. A newborn’s dependence on the drug continues, and because the substance is no longer available the baby shows symptoms of withdrawal—including trembling, excessive crying, and sleep problems—making care a challenge. Initial treatment focuses on parents nurturing, holding, and comforting their newborn. And because cuddled babies thrive, a volunteer cuddler program of community members keeps the babies comfortable while their parents receive treatment.
Another integral component of the hospital’s quality improvement initiative included prenatal education for pregnant women being treated for opioid-dependence with a medication called buprenorphine or methadone. To guide these women and their families in caring for their newborns, both in the hospital and once they returned home, Bonny Whalen, MD, an assistant professor of pediatrics and newborn nursery medical director at CHaD, created educational modules and resources for pregnant women being cared for at the Dartmouth-Hitchcock Perinatal Addiction Treatment Program.
During her group prenatal visits with expectant mothers, Whalen taught them how to prepare for birth, helped them understand what to expect once their babies were delivered, and showed them how to care and comfort their newborns. She also provided this education for expectant mothers at HabitOPCO, a treatment center in West Lebanon, NH, which includes both buprenorphine and methadone treatment for opioid-dependency.
“Working with these women has been one of the most rewarding parts of my clinical practice. These women/mothers are incredibly invested in making sure their babies do as well as they can,” Whalen says. “They feel guilty that their baby may suffer from withdrawal as a result of their needing to be on one of these medications, and they want to do all they can to make sure their baby is as comfortable as possible.”
If comfort measures prove to be inadequate for the management of NAS, an at-risk infant is then treated with morphine, an opioid medication, which leads to a longer hospital stay. Under the new protocols, infants who do not require critical care are able to stay with their mothers in the mother/baby unit or on the Pediatrics Unit if they require treatment, Holmes explains. Infants are transferred to the NICU only if they have an illness or condition requiring a higher level of care than can be provided for in the mother/baby or Pediatrics unit, Whalen notes.
“Educating moms during pregnancy that staying with their babies at all times—or having someone else available to do so if they need to leave their room for any reason—helps reduce the risk of needing treatment for NAS and has helped ensure the success of our program. It has also contributed to the improved outcomes we’ve seen,” Whalen says.
Published averages for length of stay for NAS nationally are closer to a full month—usually in a NICU at significant expense, and in an environment where parents can’t generally live with their newborns during that critical time. As there were no adverse events during the project over two years, Holmes says they are hopeful that other centers will adopt this safe, family-centered, rooming-in model of care. If adopted nationally, it could potentially free up a significant number of NICU beds and lead to tremendous cost savings, while simultaneously improving the family experience of care.
We engaged families in the improvement process, we increased family preparation for and involvement in care, and we trained our clinical teams to better serve those struggling with addiction, Whalen says.
“I learned so much about the quality improvement process by working with a remarkable team of nurses, social workers, residents, undergraduates, and especially under the guidance of my mentors Dr. Alison Holmes and Dr. Bonny Whalen,” Atwood says. “I feel that Dartmouth is a really special place when it comes to prioritizing family-centered care, and I know that I’ll take these lessons with me in my future career in pediatrics.”