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EVOLUTION OF NAS

The spectrum of NAS has changed over time.

Before 1970, NAS was generally secondary to either morphine or

heroin use

Today, NAS may be secondary to the use of morphine, heroin,

methadone buprenorphine, prescription opioid analgesics,
antidepressants, anxiolytics,
and/or other substances

Increase in the use of opioids

Simultaneous use of multiple opioids

Concurrent use of multiple other licit and illicit substances

NAS is now more common, more complex with social, economic,

and health care cost implications

NASReportable Disease
Maternal Source of Exposure
Substance exposure
unknown
4.0%

Only illicit or
diverted
substances
33.4%

Only substances
prescribed to mother
41.7%

Mix of prescribed
and nonprescribed
substances
20.9%

Data source: Tennessee Department of Health, Neonatal Abstinence Syndrome Reporting Data. Data through 10/26/2013.

TNs Prescription Drug Problem

51 pills
per every
Tennessean
over age 12
275.5 Million Hydrocodone Pills

116.6 Million Xanax Pills

113.5 Million Oxycodone Pills

Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

22 pills
per every
Tennessean
over age 12
21 pills
per every
Tennessean
over age 12

NAS is a reportable condition to

TN Dept of Health

Effective Jan 1, 2013

Used for public health surveillance
Data collection was modeled after TIPQC
Individual data is not reported to law
enforcement
or DCS
49 hospitals enter data at discharge or monthly
for the previous month discharges
Stats are reported on the website and updated
weekly

Neonatal Abstinence Project

Development teams: Vanderbilt, East TN Childrens
Hospital, UTMC Knoxville
Project Kickoff Feb 24, 2012; 9 teams
AIM: to minimize the impact of NAS on mothers,
babies and society by optimizing our inpatient
management. We will attain high reliability (>90%)
processes for NAS scoring, NAS treatment initiation
and weaning (pharmacologic and nonpharmacologic), and
post-NAS discharge preparation by December 2013.

Menu of Potentially Better Practices Overview

1. Review and assess current NAS management approach in your unit
2. Establish/refine a standardized NAS management approach

detection/screening
non-pharmacological management
behavioral
environmental

pharmacological management
scoring system
transition to outpatient follow-up

3. Monitor evidence implementation

outcome and QI measures

consistent scoring system- inter-observer reliability and frequency
consistent responses to scores

4. Engage upstream and downstream stakeholders

5. Monitor environment, caregivers, and families

Forming NAS team

Physician champion
Pharmacist
Staff nurses
Nurse educator
Nurse manager
NP/PA
Case managers
Physical therapist/Speech therapist

DETECTION AND SCREENING

Maternal urine drug screen
Infant urine drug screen
Meconium drug screen (with confirmation)
Case management consult
Standing orders on admission for mother
and baby
if positive history or risk factors for
substance abuse
Monthly audits > 90% compliance

DETECTION AND SCREENING:

CHALLENGES
Maternal urine drug screen: collection after medications given
falsification of sample by patient
Infant urine drug screen: known 50-60% false negatives,
collection close to time of birth, panel of drugs being tested,
occasional false positive UDS for cocaine/PCP
Meconium drug screen (with confirmation): prenatal passage,
delay in collection of an adequate sample, QNS if positive for
multiple drugs needing confirmation, meconium already passed
when baby becomes symptomatic, turn around time,
chain of custody
Considering umbilical cord testing
Case management consult: not routinely available on weekends

NONPHARMACOLOGIC TREATMENT

NONPHARMACOLOGIC TREATMENT

Initial treatment in all infants

Gentle handling

Minimal stimulation (dim lighting, quiet environment, single room)

Careful avoidance of waking the sleeping infant

Swaddling

Skin-to-skin care, holding, rocking, cuddling

(parents, family members, nurses, volunteers)

Pacifiers, hands to midline for self-soothing

Non-lactose feedings, frequent feedings, increased caloric density

feeds

Breastfeeding (if appropriate)

Boundaries may be used during escalation and stabilization, convert

to safe sleep environment when tapering

INTER-RATER RELIABILITY
Developed by Karen DApolito, PhD, NNP-BC Vanderbilt School of Nursing
Precise definitions of scoring items
Example: How do you differentiate between mild, moderate and severe tremors?
Example: How do you differentiate between a hyperactive and a markedly hyperactive
Moro
reflex?
Example: What is excessive crying?
Watch a video of a NAS infant being examined/scored for NAS: demonstrates technique
Establish reliability by scoring infant on the video
Test inter-observer reliability
One nurse examines the baby while the other nurse watches
Both nurses score baby independently
Compare scoring on each item
Goal is > 90% agreement
Zero items disagree = 100%
One item disagree = 95%
Two items disagree = 90%

UTMC KNOXVILLE
AUDIT OF PBP 2D CLINICAL SCORING
Nurses recorded paired Finnegan scores on NAS infants using
the inter-rater reliability tool
(21 items per paired observation) for each audit
10 audits per month
98% correlation in Sept 13
94% correlation in Oct 13
99% correlation in Nov 13
99% correlation in Dec 13
98% correlation in Jan 14
97% correlation in Feb 14
99% correlation in March 14

Reached high reliability; plan to continue but decrease ~ 5

audits per month to reinforce

PHARMACOLOGIC TREATMENT

TREATMENT PROTOCOL UTMCK

Dosing weight: _________grams
INITIATION AND ESCALATION THERAPY:
1. Finnegan score every 3 hours
2. If two consecutive Finnegan scores are greater than or equal to
10
OR if one is
greater than 12, then start the following orders:
3. Oral

morphine sulfate solution (0.4 mg/mL)

_________mL (0.05 mL/kg) PO every 3 hours
(round to the nearest 0.05 mL)
4. If a period of at least 6 hours has elapsed since the last
dosing increase AND consecutive Finnegan scores remain
greater than or equal to 10, increase oral morphine by 0.05 ml
until a maximum dose of 0.5 mL (0.2 mg) is reached

NAS PATHWAY: Morphine initiation

Initiate monotherapy with oral morphine

(weight based) 0.05 ml/kg for consecutive
scores of 10 or higher or single score greater
than 12
Increase dose by 0.05 ml every 6 hours for
consecutive scores of 10 or higher to a
maximum dose of 0.5 ml (0.2 mg) q 3 hours
Protocol/nurse driven. Nurse will write the order
for increase in dose per protocol and scan to
pharmacy
Goal is to capture symptoms more quickly

ORAL MORPHINE TAPER

When symptoms are stable for 48-72 hours - begin taper

Reduce dose by 0.05 ml every 24-48 hours as tolerated,

monitoring Finnegan

If weaning fails, increase dose by 0.05 ml and wait until

scores stabilize

After 48 hours of stable symptoms, begin taper as before

If fails morphine taper x 2, add phenobarbital

When a minimum dose of 0.05 ml q 3 hours has been given

for 48 hours
with stable symptoms discontinue

Observe for 48 hours after discontinuation of morphine

before discharge.

NAS PATHWAY: ADJUNCTIVE RX

Consider addition of phenobarb

morphine dose exceeds 0.4 ml q 3

if infant fails weaning x 2 after initial stabilization
If polysubstance exposure

Consider addition of clonidine

if unable to control symptoms with oral morphine

0.5 ml q 3 hours plus theraputic phenobarb
(25-30 mg/dl)
if fails morphine wean with theraputic phenobarb
levels (25-30 mg/dl)

ADJUNCTIVE THERAPY
PHENOBARBITAL

Consider when there is history of poly-substance abuse

Consider when symptoms are not controlled with 0.4-0.5 ml q 3 hrs oral
morphine

Consider when morphine wean has failed twice

Loading dose 10 mg/kg PO q 12 hours x 2

Maintenance dose 5 mg/kg/day divided BID

Check trough level 5 days after a dose change (long half-life)

Goal level is 25-30 mg/dl

When symptoms are stable for 48-72 hours, begin morphine wean

When stable off morphine for 48 hours, discharge on phenobarbital

Taper phenobarb dose weekly over 4 weeks (outpatient) and discontinue

NAS Pathway:
Discharge on Phenobarbital

Discharge with target phenobarb level

of 25-30 mg/dl
Taper off phenobarb over a 4 week period
as an outpatient
Prescription written with instructions for taper
(standardized)
Single prescription; no refills
Pharmacy teaching prior to discharge
Weekly outpatient follow up with primary care
until off phenobarbital

ADJUNCTIVE THERAPY
CLONIDINE

Consider when symptoms are not controlled with 0.5 ml q 3 oral

morphine and phenobarbital at target level of 25-30 mg/dl

1.5 mcg/kg/dose q 6 hours

Monitor for hypotension

When symptoms are stable for 72 hours, begin morphine wean

When symptoms are stable 48 hours off morphine, begin clonidine

taper.

Taper clonidine dose 25% every 48 hours until off

Monitor for rebound hypertension as clonidine is tapered and for 48

hours after discontinuation

Discharge on phenobarbital with taper

0% (beginning) 15% (current) treated with adjunctive clonidine

Standardized Medication Initiation Orderset Use

120%

100%

80%

60%

40%

20%

0%
41487.0

41518.0

41548.0

41579.0

41609.0

41640.0

UTMCK NICU NAS ADMISSIONS

CASES PER MONTH

NAS LENGTH OF STAY (LOCAL VS

STATE)

NAS LENGTH OF STAY: UTMC

NAS TIPQC WEBINAR 1/15/15

UTMC KNOXVILLE
NAS infants enrolled: 335
Redcap data current through Jan 14
13 NAS infants discharged in December
Accounts for 20% of 2014 discharges
100% required pharmacologic treatment
100% oral morphine
61% adjunctive phenobarb
15% adjunctive clonidine
61% seropositive Hepatitis C
Status of project IHI 4.5

POSITIVES AND NEGATIVES

Opportunities for improvement:

Increase

in randomly elevated Finnegan scores:

Instituted validation of score with second observer
Increase in outlier LOS (2 patients with LOS of 68 and
75 days). Case review: Clonidine added late.
Re-educate providers re: algorithm for adjunctive
therapy. Improved: last 6 discharges clonidine added at
22 days, 32 days, 22 days, 19 days, 13 days, and 17 days
Added standardized clonidine taper (25% QOD) to preprinted orderset (with parameters to notify for high BP
and/or high Finnegan)

Hardwired: maintained high reliability during

sustained period of high census (2-3 months) and
discharge co-ordinator also on sick leave

WORK IN PROGRESS

PBP 5: Monitor Families, Caregivers,

Environment
Staff

survey regarding perceived stressors involved

with care of NAS infants in our NICU-done
Remodeling a Quiet Room for nurses
(using United grant) in process
Plan to repeat survey after room is in use
to measure impact
Staff education: Developing script for handling
difficult conversations with parents

PBP 2e: Transition to outpatient

Phone

follow-up with patients discharged on

phenobarbital to identify problems in process

CHALLENGES

HIPPA FINAL RULE

Compliance required by 9/23/13

Business associate: other than a member of

a covered entitys workforce, a person who:
(i) On behalf of a covered entity creates,
receives, maintains, or transmits protected
health information, including claims
processing or administration, data analysis,
processing or administration, utilization
review, quality assurance, patient safety
activities, billing, benefit management,
practice management, and repricing;

Tennessee State Law PC 820

Effective 4/24/14

Tennessee State Law PC 820

Effective 4/24/14
Tennessee
Arrests First Mother Under Its New Pregnan
cy Criminalization
Law July 6, 2014
a woman may be prosecuted for assault
for the illegal use of a narcotic drug while
pregnant,
if her child is born addicted to or harmed
by the narcotic drug.

Tennessee State Law PC

820
a woman can be charged with a misdemeanor (assault) if she
illegally uses narcotics during pregnancy and if the baby is harmed as
a result (ex. NAS)
intent of PC 820 is to give law enforcement and district attorneys a
tool to address illicit drug use among pregnant women, through
treatment programs including drug courts
sunset provision in 2 years (automatically expires)
Reporting:
Prenatal care providers do not report to law enforcement
Care provider for infant reports to DCS after birth
Child Protective Team Investigation determines whether case is
prosecuted
Prosecution
It is an affirmative defense to a prosecution...that the woman
actively enrolled in an addiction recovery program before the child is
born, remained in the program after delivery, and successfully
completed the program, regardless of whether the child was born
addicted to or harmed by the narcotic drug.

Public Chapter 820 vs Safe Harbor Act

PS 820 (2014), is a criminal statute concerning

the prosecution of women who give birth to
infants who are harmed by the womens
prenatal drug use and does not specifically deal
with a mothers parental rights.

The Safe Harbor Act (2013) deals with services

for pregnant women referred for prescription
drug use/misuse and the parental rights of
pregnant women abusing/misusing drugs.