The Neonatal Abstinence Syndrome (NAS) Initiative, the Florida Perinatal Quality Collaborative’s (FPQC) latest infant-focused project, kicked off on Thursday, November 8, 2018.  Teams from 32 hospitals, along with representatives from the Florida Association of Healthy Start Coalitions, Nurse-Family Partnership Florida, Healthy Families Florida, and Florida Hospital Association met in Orlando to learn about the background and clinical significance of the initiative, strategize about implementation, and learn about data collection for the project.

Neonatal abstinence syndrome (NAS), in which infants exhibit postnatal withdrawal symptoms, is most commonly due to chronic in utero exposure to opioids.  The majority of pregnant women taking illicit drugs, using prescribed opioids, or receiving opioid replacement therapy will deliver an infant having withdrawal symptoms, and many of these infants will develop NAS and require pharmacologic management. NAS infants are more likely to have a diagnosis of prematurity, low birth weight, respiratory complications, seizures, and feeding difficulty. Beyond the neonatal period, they are at risk for behavioral problems, learning problems, visual disorders, and psychosocial difficulties (for example, risk for child abuse, foster placement).

With Florida experiencing a ten-fold increase in NAS from 2002-2012, it is important to develop standardized approaches to address variability in NAS management and decrease neonatal length of hospital stay due to NAS. The aim of the initiative is for participating hospitals to have a 20% decrease in average length of stay for infants ≥37 weeks GA diagnosed with NAS.

The meeting began with a welcome from Florida State Senator Kathleen Passidomo who commended the hospitals for agreeing to work on such a complex problem.  After a slide show introducing each hospital and its team, three women who had infants with NAS and now work as peer-educators for the Healthy Start Coalition of Flagler and Volusia talked about their experiences and how hospitals could better understand their perspective.  Their powerful stories set the tone for the rest of the day by emphasizing the importance of compassion and understanding in helping prepare families to care for their NAS infants.  Next, Dr. Maya Balakrishnan, FPQC Associate Director for Clinical and Quality Management and NAS Physician Lead, presented on the background and significance of the project, setting the stage for presentations on the key drivers for the initiative. 

Karen Fugate, NAS nurse and quality consultant led off the presentation of the NAS Initiative key driver diagram with an overview of the diagram and discussion of staff and caregiver education and assessing inter-rater reliability of NAS scoring.  Dixie Morgese from Healthy Start presented on the development of a caregiver survey to assess primary caregiver’s opinions about hospital experiences during the baby’s hospitalization. 

The FPQC’s NAS Initiative is unique among other state efforts in that it will be measuring infant caregiver perceptions of treatment via anonymous survey as a measure for the project.  Presentations by NAS advisory group members Dr. Bill Driscoll (standardized NAS guidelines), Dr. Douglas Hardy (rooming-in and breastfeeding), and Jane Murphy (safe discharge) rounded out the morning portion of the meeting.  

The afternoon sessions began with an interactive panel discussion on barriers to safe discharge care, featuring representatives from DCF Office of Child Welfare, Healthy Start, DCF Office of Substance Abuse and Mental Health, Nurse-Family Partnership, and Healthy Families Florida—this was a great opportunity for hospitals to ask questions about how to better coordinate their efforts with these agencies.   Afterwards, Dr. Estefania Rubio, FPQC Data Manager, presented on the data measures to be reported by the participating facilities, and the day concluded with an exercise in developing a prioritization matrix led by Dr. Balakrishnan and Karen Fugate.

Evaluations were overwhelmingly positive with participants noting:

• I was amazed at the amount of people in the room who were open-minded about new processes that will hopefully create change.
• Thought we were further along in doing the best for our patients. Learned there is so much more—thank you.
• As a nurse, the most helpful speakers were the moms. The moms gave me a different view.

Each hospital has assembled a quality improvement team including physician, nurse, and administrative champions. During the 18 months of the initiative, FPQC will conduct educational webinars, provide monthly quality improvement data reports, an online toolbox with a tool kit, resources and slide sets, and technical assistance. Funding for the NAS Initiative is provided by the Florida Department of Health’s Title V Block Grant.

For more information on the NAS Initiative, visit FPQC.org.