IN BRIEF

Improving Medication Dosing Consistency for Infants With Neonatal Abstinence Syndrome

December 2, 2019
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A quality improvement initiative effectively increases the percentage of infants dosed according to birth weight.

From 2000 to 2009, prenatal maternal opiate use increased from 1.2 to 5.6 per 1,000 births, with up to 80% of in utero exposed infants requiring pharmacotherapy for neonatal abstinence syndrome (NAS). In Ohio, home of Nationwide Children’s Hospital, the exposure rate surpasses national averages. In 2015, 15.4 of every 1,000 infants born in Ohio developed NAS.

At Nationwide Children’s Hospital, infants with NAS in the NICU are treated based on the NAS Protocol, which emphasizes nonpharmacologic care and has been shown to reduce the length of stay, even when medication is needed.

In a new study, published in Pediatric Quality and Safety, researchers from Nationwide Children’s show how quality improvement methodology further improved this care by increasing the percentage of NAS medication orders based on birth weight from 29% to 90%. 

“Because most infants requiring pharmacologic therapy are below birth weight at the time of treatment initiation, we use birth weight as the infant’s dosing weight for the treatment,” explains Thomas Bartman, MD, PhD, neonatologist and associate chief medical officer at Nationwide Children’s. “The rationale for not adjusting the dosing weight is two-fold. First, using birth weight ensures consistency, as entering an incorrect dosing weight may lead to prolonged suffering, prolonged medication weans, or potential overdose. Second, as the infant grows, continuing medication dosing based on birth weight allows the infant to ‘auto-wean’ in addition to weaning per protocol.”

Interventions for the project centered on the electronic health record and clinical decision support tools, in addition to provider education. Nurses and pharmacists were also utilized as change agents during the ordering and administration process.

As the team implemented the interventions, they saw an increase in the use of birth weight for medication orders. They also saw a decrease in variation in length of stay for the infants.

“This improvement in length of stay variation proves that using the birth weight for medication orders is a good thing to do,” says Dr. Bartman. “We suspect that this decrease is due to gaining control of symptoms faster, as the majority of these infants were underdosed before the interventions.”

While the project was initially successful, sustainability was a challenge. According to the study, the use of workarounds in the electronic health record had a potentially detrimental effect.

“Moving forward, we are looking to use a ‘human factors engineering approach’ to design further clinical decision supports,” says Dr. Bartman. “As a next step, we’re working toward enhancing the use of order sets through behavioral economic principles and moving toward indication-based ordering. Our ultimate goal is to make changes sustainable to continue to improve outcomes for infants.”

 

Reference:

Bertoni CB, Prusakov P, Merandi J, Bartman T. Clinical decision support to improve dosing weight use in infants with neonatal abstinence syndrome. Pediatric Quality and Safety. 2019 Jun 28;4(4):e184.

Photo credit: Nationwide Children’s