September 2014 - Ohio Perinatal Quality Collaborative

Welcome to the OPQC NAS
September Action Period Call
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Welcome!
Neonatal Abstinence
Syndrome Project
Action Period Call
Ohio Perinatal Quality Collaborative
September, 2014
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Agenda
Time
Topic
Presenter
3:00 pm
Welcome, Agenda Review, roll call/sign in
Susan Ford
3:05 pm
Data Overview – August Results
Michele Walsh, MD
3:15 pm
Universal Screening and Testing
•What our teams are doing
•The difference between Screening and Testing
•Site presentation using Screening
Questionnaire
•Site presentation using Universal Testing
•Legal Issues Surrounding Screening & Testing
•Discussion amongst all teams
Poll for all teams
Michele Walsh, MD
Presenter A
Presenter B
Jonathan Fanaroff, MD
All teams
3:55 pm
Next Steps
•Data Submission Review
•Monthly Progress Report
Susan Ford
Roll Call:
Please sign in with your hospital affiliation and the
names of your team members on the call in the
Question box
NAS Participating Sites 2014
Tripoint Medical
Center (Lake Health)
Mercy Regional Medical Cleveland
Center Lorain
Clinic
Hillcrest Hospital
Fairview Hospital
Trumbull
UH Rainbow Babies
Elyria Medical
Memorial
MetroHealth & Children’s
Center -UH
Blanchard
Mercy Medical
Akron Children’s Summa
Valley
Akron Children’s Center Canton Akron Children’s
OhioHealth
Nationwide
St. Elizabeth
St. Rita’s
Lima Memorial Marion
MedCentral
Riverside
General
Health
Medical Center
Health System
Aultman
Mansfield
Methodist
Center/Mahoning
Nationwide
Valley
Nationwide Mt. Carmel St. Ann’s
Upper Valley Dublin Methodist
OSU Mt. Carmel East
Mt. Carmel West
Dayton Children’s
Medical Center
Nationwide Doctor’s
Licking Memorial Health System
Springfield Regional
Good Samaritan Hospital Dayton
Medical Center Nationwide Nationwide
Miami Valley
Genesis Healthcare System
Children’s
Grant
Soin Medical Center
Southview Medical Center
Kettering
Fort Hamilton
Adena
Cincinnati Children’s
Atrium Medical Center
Regional
Good Samaritan
Mercy Hospital Fairfield
Medical Center
Hospital
Mercy Anderson
UH Cincinnati
Bethesda North
The Christ Hospital
Southern Ohio
Mercy Health
Hospital
Medical Center
West
ProMedica
Promedica
Bay Park
Toledo Children’s
Mercy Children’s
Hospital
1/2014 start Level 3
and Level 2 teams
4/2014 start
Level 2 teams
Key Driver Diagram
Project Name: OPQC Neonatal NAS
GLOBAL AIM
To reduce the number of
moms and babies with
narcotic exposure, and
reduce the need for
treatment of NAS.
KEY DRIVERS
Prenatal Identification of Mom
Implement Optimal Med Rx Program
Improve recognition and nonjudgmental support for Narcotic
addicted women and infants
Attain high reliability in NAS
scoring by nursing staff
SMART AIM
By increasing
identification of and
compassionate
withdrawal treatment for
full-term infants born with
Neonatal Abstinence
Syndrome (NAS), we will
reduce length of stay by
20% across participating
sites by June 30, 2015.
Optimize Non-Pharmacologic Rx
Bundle
Standardize NAS Treatment
Protocol
Connect with outpatient support
and treatment program prior to
discharge
Partner with Families to Establish
Safety Plan for Infant
Partner with other stakeholders
to influence policy and primary
prevention.
Leader: Walsh
INTERVENTIONS
•All MD and RN staff to view “Nurture the
Mother- Nurture the Child”
•Monthly education on addiction care
Fulltime RN staff at Level 2 and 3 to
complete D’Apolito NAS scoring training
video and achieve 90% reliability.
•Swaddling, low stimulation.
•Encourage kangaroo care
•Feed on demand- MBM if appropriate or
lactose free, 22 cal formula
• Initiate Rx If NAS score > 8 twice.
•Stabilization/ Escalation Phase
•Wean when stable for 48 hrs by 10% daily.
• Establish agreement with outpatient program
and/or Mental Health
•Utilize Early Intervention Services
Collaborate with DHS/ CPS to ensure infant
safety.
Engage families in Safety Planning.
Provide primary prevention materials to sites.
OPQC NAS Project - 2014 Q2
Collaborative Aggregate
Non-Pharmacologic Care Elements Received BEFORE Drug Treatment
Note: 96% of forms had more than one element recorded as completed.
100%
80%
60%
Breast Milk Feeds OR Low Lactose Feeds
Swaddling
Low Stimulation OR Rooming In
40%
22 kcal/oz Feeds
Clothed Cuddling
Other
20%
0%
(1) Breast Milk/Low Lactose Feeds, (2) Swaddling, and (3) Low Stimulation/Rooming In are ALL required to be in compliance with
the bundle. 22 kcal/oz feeds, Clothed Cuddling, and Other are all optional treatment.
Median
15.61
Median
19.93
Site specific data is in
folders in SharePoint!
Each data point
represents 5 babies
Universal Screening and Testing
• Site presentation using Screening Questionnaire
• Site presentation using Universal Testing
• What are our teams are doing?
• What is the difference between Screening and Testing
• Legal Issues around Screening & Testing
• Discussion amongst all teams
Screening for Drugs of
Abuse
Michele Walsh, MD MSc
I work on a statewide collaborative funded to study NAS in Ohio
by the Ohio Dept of Jobs and Family Services.
Screening versus Testing
• ACOG recommends that every woman is
screened at beginning of prenatal care
with a questionnaire.
• Testing is performed in a subset who
screen positive for at risk status, or for a
limited set of behaviors- no pnc, appears
intoxicated.
Screening For Drugs of Abuse
• Best practice:
• ACOG: Screen everyone with a short questionnaire
asked at first prenatal visit and on admission to L&D.
• Hospital has standard policy applied to ALL
admissions that specifies triggers for sending a
maternal urine drug test.
• Specifies historical triggers (no prenatal care, prior
positive tox screen) and/or observed behaviors that
will lead to a screen.
• Some advocate universal screening to prevent biased
assessments
• Person should be informed that it is being sent.
Maternal Tox Screen Options
• Urine: most rapid screens are done on
urine using immunoassays.
• Advantage:
– Fast and relatively inexpensive screen.
• Disadvantage:
– Detects only exposures in the prior 24-48 hrs.
– All positives require confirmation with GC/MS
– False positives and false negatives.
False Negatives and
False Positives
• False Negatives:
– If urine is too dilute
– Deliberate attempts to adulterate tests:
added nitrites, or Visine, or using “clean” urine, water
• False Positives:
– Immunoassays cross react with similar molecules
– Infant urines higher false positives (esp THC) than
adults
– Amphetamines highest false-positive rates- 4%
– PCP – 1.5% false positive
– Opiates- cross react with Levofloxin
Structural Similarities
From: Krasowski MD, BMC Emergency Medicine 2009: 9: 5.
Universal Screening for Maternal Drug
Use
Presenter A
How To Ask
• Ask to ALL patients
– Disclose that everyone is asked
– Non-judgmental
– Confidential
– Adequate care for mother and fetus
– Illicit and prescribed substances
Tools
• 5Ps1
– parents, peers, partner, past, pre-pregnancy
• CRAFFT2
– 16-26 yo
– 6 items measuring use of
substances/concerns
• SURP-P3 (Substance Use Risk ProfilePregnancy Scale)
– 3 questions
1Adapted
from Watson E. Institute on Health and Recover, Integrated
Screening Tool, 2014
2Knight, et al. and Chang et al. 2011
3Yonkers KA, et al. Screening for prenatal substance use:
development of a substance use risk profile-pregnancy scale. 2010
Our Approach
• All women screened early and when arrive
to L&D
– General admission consent includes consent
for testing
• Must disclose to woman that test is being sent 
she can refuse
– Situations where testing is indicated
•
•
•
•
+ screen
+ toxicology screen in the past 2 years
Referral from outside social services or social work
Clinical indications
When Testing Is Indicated…
• Document indication and disclose to
mother
– If she declines  document and discuss with
pediatric team
• Test infant
– Mother declines testing and there is concern
– Mother has a positive toxicology screen
– Exhibits signs/symptoms of withdrawal
Do We Miss Babies?
• No readmissions for NAS in past 6 months
Universal Testing
Presenter B
Maternal Risk Based Screen
ACOG Committee Opinion 524, May 2012.
Recommends universal screening.
Recommends obtaining consent prior to testing.
Maternal Risk Based Screen
• Documented, suspected, or acknowledged maternal history of drug use
• Insufficient prenatal care, defined as starting care after 12 weeks of
gestation
• Placental abruption
• Admission from a justice center.
• Positive for Human immunodeficiency virus
• Positive for Hepatitis B Surface Antigen
• Positive for Hepatitis C virus
• Maternal history of Gonorrhea or Syphilis
Universal Testing
Started Universal Testing on Sept 1st.
Encourage consent
Recommend DAU 13 for mother and infant
Poll #1– Screening of Mothers
Do you have a policy for screening
pregnant women for drugs at your
hospital?
•
•
•
•
Yes, we screen ALL pregnant women for drug
use
Yes, we screen, but only with a hx of drug use
No, we do not screen pregnant women for
drug use
N/A; we do not provide care to pregnant
women
Poll #2 – Testing of Babies
Do you have a policy for testing
babies at your hospital?
•
•
•
Yes, we test all babies for drugs
Yes, we test only babies with a
maternal hx of drug use
No, we do not routinely test our
babies for drugs
Legal Implications for
Testing in Ohio
OPQC Webinar
September 2014
Jonathan Fanaroff, MD, JD
Disclaimer
Balancing Considerations
Medical
Legal
Ethical
Maternal Drug Use


Rights of the mother versus the rights
of the child
Rights of the mother versus the
parens patriae duty of the State
Scene at the Signing of the Constitution – Howard Chandler Christy
Bill of Rights
①Religion, Speech, Press, Assembly
②Bear arms
④No unreasonable searches and seizures
⑤Right to due process of law
⑥No Cruel and Unusual Punishment
⑨Other rights of the people
⑩Powers reserved to the states
Schloendorff v. Society of
NY Hospital
“Every human being of adult
years and sound mind has a
right to determine what shall
be done with his own body.”
Justice Cardozo
4th
Amendment
“The right of the people to be secure in their
persons, houses, papers, and effects, against
unreasonable searches and seizures, shall not
be violated, and no Warrants shall issue, but
upon probable cause, supported by Oath or
affirmation, and particularly describing the
place to be searched, and the persons or
things to be seized.”
Ferguson v. City of Charleston
532 U.S. 67 (2001)





Staff at MUSC concerned about
increase in “crack babies”
Began testing  refer for counseling
No change in incidence
Began to work with law enforcement
New program implemented
Ferguson v. City of Charleston
532 U.S. 67 (2001)

Pregnant women tested if met criteria
– Poor prenatal care
– Birth defects or poor fetal growth
– Placental abruption
– History of drug or alcohol abuse
– Intrauterine fetal demise
Gordon Wiltsie / National Geographic Image Collection
Ferguson v. City of Charleston
532 U.S. 67 (2001)



Opinion by Justice Stevens
Ruled in favor of the pregnant women
“The reasonable expectation of privacy
enjoyed by the typical patient
undergoing diagnostic tests in a
hospital is that the results of those
tests will not be shared with
nonmedical personnel without her
consent.”
Criminal
charges




Felony child
endangerment
Corruption of a
minor
Chemical
endangerment
Assault with a
deadly weapon
Punitive measures are
ineffective
“Drug enforcement policies that deter
women from seeking prenatal care are
contrary to the welfare of the mother
and fetus. Incarceration and the threat
of incarceration have proved to be
ineffective in reducing the incidence of
alcohol or drug abuse.”
ACOG Committee Opinion Substance Abuse Reporting and Pregnancy:
The Role of the Obstetrician-Gynecologist, January 2011
Parens Patriae


Children are not property
Government has the power and duty
to protect the safety and well-being of
children
Child Abuse Prevention and
Treatment Act (CAPTA)


Healthcare providers must have policies and
procedures in place to notify Child Protective
Services of all infants born and identified as
affected by illegal substance abuse, withdrawal
symptoms resulting from prenatal drug
exposure, or a Fetal Alcohol Spectrum Disorder
and to establish a plan of safe care for these
newborns
Reports of prenatal substance exposure shall not
be construed to be child abuse or neglect and
shall not require maternal prosecution
CAPTA Reauthorization Act of 2010
Medical Practice is mainly
regulated by the State
States vary widely in their
approach to pregnant women
who use drugs




One state allows assault charges to be filed
against a pregnant woman who uses certain
substances
18 states consider substance abuse during
pregnancy to be child abuse
15 states require health care professionals to
report suspected prenatal drug abuse
4 states require prenatal drug testing for
suspected abuse
Ohio Department of
Health Approach


Substance abuse during pregnancy is
not automatically considered
– Criminal act
– Child abuse
– Grounds for civil commitment
A $4.2 million, three year targeted drug
treatment program for pregnant women
supported by the Ohio Department of
Health is promising
Drug Testing Mothers and
Newborns
1.
2.
Obstetricians, Pediatricians, and
Administration should develop policies
to be followed consistently.
Hospital counsel should ensure
compliance with state and federal
laws
Stanton E. NAS and the Law for the Non-Lawyer
Drug Testing Mothers and
Newborns
3.
Maternal and infant drug testing should be
based on specific evidence-based criteria
and medical indicators to avoid
discriminatory testing. Open-ended criteria
such as “clinical suspicion” are inadequate.
Stanton E. NAS and the Law for the Non-Lawyer
Drug Testing Mothers and
Newborns
4.
5.
All mothers should be informed about proposed
drug testing prospectively and the rationale for
testing should be documented in the medical
record. The discussion should include the nature
and purpose of the test and how testing will guide
care.
If a woman refuses testing, document the refusal
and do not test over her objection.
Stanton E. NAS and the Law for the Non-Lawyer
Drug Testing Mothers and
Newborns
6.
When medically necessary for the proper and safe
care of the infant, testing may be done without
specific informed consent of the mother. This
includes
–
–
–
Newborns who exhibit signs and symptoms of drug
exposure
Newborns whose mothers have been identified as
probable substance users
Newborns whose mothers have signs and symptoms of
drug use
Drug Testing Mothers and
Newborns
7.
Remember that under Ohio law all healthcare
providers are mandated reporters of child
abuse/neglect are required to report when there is
reasonable cause to suspect that a child “has
suffered or faces a threat of suffering any physical
or mental wound, injury, disability, or condition of
a nature that reasonable indicates abuse or neglect
of the child”
Ohio Revised Code Chapter 21 - 2151.421
Stanton E. NAS and the Law for the Non-Lawyer
Discussion and Questions
• What method do you use at your
hospital? Why was this method chosen?
• What challenges have you had
regarding maternal screening or testing?
How did you overcome them?
• Questions for our panel?
OhioHealth NAS
Conference this Friday!
• A full day conference to help doctors, nurses,
and social workers learn about addiction in
pregnant women and neonatal abstinence
syndrome in their newborns.
• Speakers will discuss skills that promote
effective communication between hospital
staff and these families and share methods
for supporting mothers in the care of their
withdrawing newborns.
• In person registration is full, but OhioHealth is
offering attendance via live-streaming on the
web free of charge!
Next Steps
• Continue testing small tests of change (PDSA)
• Please return Data Participation Agreement to OPQC.
• Please submit NAS Data. Remember to please
submit and check “No Eligible Babies for the
Month” if there were no NAS patients at your site.
• Monthly Progress Report
• Will be sent to Key Contacts on 9/25; due 10/5
The OPQC NAS Project is
funded by The Ohio
Department of Medicaid