How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th...
Transcript of How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th...
![Page 1: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/1.jpg)
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
![Page 2: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/2.jpg)
![Page 3: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/3.jpg)
• 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
![Page 4: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/4.jpg)
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
![Page 5: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/5.jpg)
Overdose Deaths In Rhode Island
![Page 6: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/6.jpg)
Overdose Deaths In Rhode Island
![Page 7: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/7.jpg)
![Page 8: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/8.jpg)
![Page 9: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/9.jpg)
Bateman et al, Anesthesiol. 2014
14.4 % of Pregnant women prescribed an opioid during pregnancy
![Page 10: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/10.jpg)
![Page 11: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/11.jpg)
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
![Page 12: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/12.jpg)
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
![Page 13: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/13.jpg)
Support and EmpowermentJudged and Powerless
Knowledge and Understand
![Page 14: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/14.jpg)
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
![Page 15: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/15.jpg)
Opioids and Pleasure
Kosten et al. Sci Pract Perspect. 2002
![Page 16: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/16.jpg)
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
![Page 17: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/17.jpg)
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
![Page 18: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/18.jpg)
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
![Page 19: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/19.jpg)
Kosten et al. Sci Pract Perspect. 2002
Opioids and Physical Dependence
![Page 20: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/20.jpg)
• 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
![Page 21: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/21.jpg)
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
![Page 22: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/22.jpg)
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
![Page 23: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/23.jpg)
The Journey Begins
Plan
DoStudy
Act
![Page 24: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/24.jpg)
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
![Page 25: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/25.jpg)
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
![Page 26: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/26.jpg)
Improve Communication:
“I get 6 different messages from 4 different people”- Every family in a hospital
![Page 27: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/27.jpg)
Team Communication
• Expanded the Team to including all stakeholders
• The Team became the Family Care Team
![Page 28: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/28.jpg)
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
![Page 29: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/29.jpg)
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
![Page 30: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/30.jpg)
IMPLEMENTATION
![Page 31: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/31.jpg)
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
![Page 32: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/32.jpg)
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.
![Page 33: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/33.jpg)
• 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.
![Page 34: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/34.jpg)
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
![Page 35: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/35.jpg)
![Page 36: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/36.jpg)
![Page 37: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/37.jpg)
![Page 38: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/38.jpg)
Conclusions
![Page 39: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/39.jpg)
Buprenorphine
![Page 40: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/40.jpg)
![Page 41: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/41.jpg)
![Page 42: How to Reshape Your Approach to NOWS, Today Conference/W… · Women & Infants Hospital •8th Largest Birthing Hospital in the Country •Largest Birthing Hospital in Rhode Island](https://reader034.fdocuments.in/reader034/viewer/2022042917/5f58b5789c74795d0f172a43/html5/thumbnails/42.jpg)
Take Home Message