disclosure statement · abortion, growth restriction, placenta previa, abruption 24 to 48 hours...

Disclosure Statement

I have no relevant financial relationships to disclose or

conflicts of interest to resolve

I will discuss unapproved or off-label use of a drug

I will not discuss experimental or investigational use of a

product, drug or device

Between the Devil and the

Deep Blue Sea:

The Challenges of Neonatal

Abstinence Syndrome

Barbara Snapp, DNP, NNP-BC

Neonatal Abstinence Syndrome

Cluster of newborn symptoms

surrounded by social stigma

and parental angst

About women

and the substances

they take

NarcoticsHeroin

Morphine

Codeine

Oxycodone

Hydrocodone

Methadone

Buprenorphine

Fentanyl

Definition of NAS

“Neonatal abstinence syndrome (NAS) is

a group of problems that occur in a

newborn who was exposed to addictive

opiate drugs while in the mother’s womb.”

https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm

Extent of Problem

2000-2009

2 per 1000 births to 6 per 1000 births

Patrick, S. W., Schumacher, R. E., Bennyworth, B. D., Krans, E. E., McAllister, J. M., & Davis, M. M. (2012,

May 9). Neonatal abstinence syndrome and associated health care expenditures United States, 2000-2009.

Journal of the American Medical Association, 307(18), 1934-1940. http://dx.doi.org/10.1001/jama.012.3951

Extent of Problem

2009-2012

7 per 1000 births to 27 per 1000 births

Veeral N. Tolia, M.D., Stephen W. Patrick, M.D., M.P.H., Monica M. Bennett, Ph.D., Karna Murthy, M.D.,

John Sousa, B.S., P. Brian Smith, M.D., M.P.H., M.H.S., Reese H. Clark, M.D., and Alan R. Spitzer, M.D.

N Engl J Med 2015; 372:2118-2126. May 28, 2015. DOI: 10.1056/NEJMsa1500439

Extent of Problem

Average delivery service:

2000 60 NAS infants

Extent of Problem

2000 60 NAS infants

5000 150 NAS infants

Extent of Problem

2000 60 NAS infants

Average LOS: 15-21 days

Extent of Problem

2000 60 NAS infants

Average LOS: 15-21 days

Average Costs: $4-9,500,000

$1.5 billion dollars

81% paid by

Medicaid

http://www.salon.com/2014/04/30/tennessee_just_became_the_first_state_that_will_jail_women_for_their_pre

gnancy_outcomes/

Gov . Bill Haslam signs SB 1391

making Tennessee the first state to

jail women for their pregnancy

outcomes

Katie Mcdonough April 30, 2014

http://www.theatlantic.com/health/archive/2015/05/into-the-body-of-another/392522/

History of Women and Opiates

Early 1800’s:

Sigmund Freud

published “The

Interpretation of

Dreams” describing

cocaine use for

female “hysteria”

http://www.pbs.org/wgbh/aso/databank/entries/dh00fr.html

Mid 1800’s:

2/3 of prescriptions for

opioids were for

“Fussy” newborns given:

Morphine

Paregoric

Harrison Narcotic

Tax Act 1914

“bring the domestic

traffic in narcotics into

the open under a

licensing system, so that

the sloppy dispensing

practices of the day

could be checked”

King, R. B. (1953, April). The narcotics bureau and the Harrison Act: Jailing

the healers and the sick. The Yale Law Journal, 62(5), 784-787

Harrison Narcotic Tax

Act 1914

Curb recreational

drug use by limiting

prescribing of

narcotics to

physicians within a

physician-patient

relationship

Addiction was unrecognized and

women were suddenly left adrift

Beginning

of criminal

journey of

narcotic addiction

When Addiction Became a Problem

Congressmen

Robert Steele (CT)

and Morgan

Murphy (IL)

traveled to Vietnam

When Addiction Became a Problem

soldiers

addicted to

heroin

Methadone Becomes

Treatment for Addiction

Methadone

• Created 1930’s in Germany

Methadone

• 1960’s:

NY Physicians studying metabolic disorders

-Obesity and addictive behavior

Methadone

• 1960’s:

-Enrolled heroin addicts

Methadone

• 1960’s:

studied on morphine

Methadone

• 1960’s:

studied on morphine

weaned using methadone

Methadone

Morphine Methadone

Watching

television

Went back to

school

Methadone

Morphine Methadone

Watching

television

Went back to

school

Facing prison Living

independently

Methadone

Morphine Methadone

Watching

television

Went back to

school

independently

Costing society Contributing to

society

Methadone

Morphine Methadone

Watching

television

Went back to

school

independently

Costing society Contributing to

society

Methadone influenced quality of life behaviors

Until 1990’s

addiction treatment

focused on men

selling

narcotic

reliever

http://www.drphil.com/articles/article/225

http://prohttp://programs.ccm-ct.org/Plugs/discount-prescription-cards.aspx

2014: 200 MILLION opiate

prescriptions written

Prescription Drug Monitoring

Programs

37 states have PDMP

11 are planning PDMP

CDC Guideline for Prescribing Opioids for Chronic

Pain — United States, 2016

Recommendations and Reports / March 18, 2016

/ 65(1);1–49

Why is substance use

such a problem?

Photo by Katie Nesling/Thinkstock

• endogenous opiate-like substances

• enkephalins, endorphins, endomorphins,

and dynorphins

• endogenous opiate-like substances

• enkephalins, endorphins, endomorphins,

and dynorphins

• neuropeptides used as neurotransmitters

send chemical messages

throughout body

http://www.faim.org/neurotransmitters-and-the-brain-denver-colorado

Chemical

messengers

Neurotransmitters associated with pain

perception bind with opioid receptors:

mu (μ), delta (δ), kappa (κ)

Reduces perception of pain

by inhibiting firing of nerve cells

Limbic system

is loaded with

opiate receptors

https://en.wikipedia.org/wiki/Mesolimbic_pathway#/media/File:Mesolimbic_pathway.svg

Limbic system associated with:

• Emotions: fear, anxiety, pleasure, anger

Limbic system associated with:

• emotions: fear, anxiety, pleasure, anger

• drives: sex, food, maternal behaviors

https://en.wikipedia.org/wiki/Mesolimbic_pathway#/media/File:Mesolimbic_pathway.svg

Mesolimbic

dopamine

pathway

originates

in ventral

tegmental

area (VTA)

Opiates in the Brain

Connects to

nucleus

accumbens:

Area associated

with motivation

and reward

http://imgur.com/gallery/IpXaQBc

Dopamine is

neurotransmitter

“love molecule”

Associated with:

Attention-seeking behavior

Motivation

Addiction

http://www.livescience.com/18079-women-feel-pain-intensely-men.html

We don’t produce enough endogenous

opiates for severe pain

Exogenous opiates (heroin, morphine) • react with same receptors (mu, delta, kappa)

• reduces excitability of neurons

• produces feelings of euphoria

• inhibits neurons that control breathing

• slows signals in the digestive tract

• “dulling” of neurons requires drug increase

Opiates block GABA

(Gamma Amino Butyric Acid)

Gamma Amino Butyric Acid (GABA)

• acts as a neurotransmitter

• inhibits nerve transmission

• reduces nerve excitability

• limits dopamine release

https://www.cnsforum.com

http://allisonfriese.com/tag/dopamine/

Attention-seeking

behavior

MotivationAddiction

Opioids in the Brain

• Drowsiness

• Mental confusion

• Nausea

• Constipation

• Depress respiration

• Euphoria

https://www.drugabuse.gov

Definitions

• Addiction

• Dependence

• Abuse

Addiction

• Neuronal adaptation in the brain to the chemical influence of certain drugs

Addiction

• Changes brain composition and operation

Addiction

• Addict has cravings and inability to properly manage their drug use

Addiction

• Addict has cravings and inability to properly manage their drug use

• Will continue despite grave personal consequences

Dependence

• Similar to addiction except the user requires increasing amounts of their drug

Dependence

• Recognition of the desire to stop using or the preoccupation with quitting

Dependence

• Recognition of the desire to stop using or the preoccupation with quitting

• Continue to use large quantities of their drug despite damaging outcomes or results

Ongoing use of a drug despite what can be

catastrophic consequences

• Legal

• Social

• Legal

• Social

• Risk to their own safety

http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html

Drug use associated

•Intimate partner abuse

Drug use associated

•Sexual assault

Drug use associated

•Sexual assault

•Physical violence

Drug use associated

•Sexual assault

•Dysfunctional families

Drug use associated

•Sexual assault

•Dangerous environment

Drug use associated

•Sexual assault

•Dangerous environment

•Unstable relationships

Mental health

issues:

http://cambridgecitizen.ca/correctional-services-women-and-mental-health/

Mental health

issues:

• Depression

Mental health

issues:

• Depression

• Anxiety

Mental health

issues:

• Depression

• Anxiety

• Eating disorders

Mental health

issues:

• Depression

• Anxiety

• Emotional abuse

Mental health

issues:

• Depression

• Anxiety

• Emotional abuse

• Unstable housing

Affects all

income levels

NEUROBEHAVIORAL DISORDER

http://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf

Alcohol

dependence

Conduct

disorder

Antisocial

personality

disorder

Disorder

-specific

Genes influencing

externalizing

psychopathy

Disorder

-specific

geneshttp://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf

Women and Substance Use

• Women are more susceptible to

opiates

• Go more quickly from use to abuse

opiates

• Go more quickly from use to abuse

• More women suffer from multiple

influences

Words Not to Use

• Addict

Words Not to Use

• Addict

• Abuser

Words Not to Use

• Addict

• Abuser

• Substance abuser

Words Not to Use

• Addict

• Abuser

• Substance abuser

• Chronic pain med abuser

Words Appropriate to Use

• Substance use disorder

• Addictive disorder

• Addictive disease

• Chemical dependency

Chemical Dependency

and Pregnancy

Commonly Used Substances

• Opiates

• Cocaine

• Methamphetamines

• Selective Serotonin Reuptake Inhibitors (SSRI’s)

(Zoloft, Paxil, Prozac)• Benzodiazepines

(Ativan, Valium, Xanax)

• Nicotine

• Alcohol

• Marijuana

Drug Prenatal Effects Withdrawal Time Postnatal Effects

Cocaine Growth restriction,

prematurity,

abruption

48-72 hours Mild behavioral

changes

Methamphetamines Abruption,

prematurity, growth

restriction, heart and

brain malformations

48-60+ Neuro-

developmental

changes

SSRI’s No documented

effects

Hours to days Initial hypotonia,

weakness, feeble cry

then hypertonia,

irritability

Benzodiazepine Prematurity, low birth

weight

Variable Mild withdrawal

symptoms

Nicotine Displaces fetal

oxygen,

spontaneous

abortion, growth

restriction, placenta

previa, abruption

24 to 48 hours Irritability, high

pitched cry,

jitteriness, overall

fussiness, poor

feeding, low

threshold for stress

Marijuana Brain development Not evident in

prenatal period

High pitched cry,

jitteriness, poor

sleep patterns

prematurity,

abruption

changes

prematurity, growth

brain malformations

48-60+ hours Neuro-

developmental

changes

effects

then hypertonia,

irritability

weight

symptoms

oxygen,

spontaneous

abortion, growth

previa, abruption

pitched cry,

fussiness, poor

feeding, low

prenatal period

High pitched cry,

jitteriness, poor

sleep patterns

prematurity,

abruption

changes

prematurity, growth

brain malformations

48-60+ hours Neuro-

developmental

changes

effects

then hypertonia,

irritability

weight

symptoms

oxygen,

spontaneous

abortion, growth

previa, abruption

pitched cry,

fussiness, poor

feeding, low

prenatal period

High pitched cry,

jitteriness, poor

sleep patterns

prematurity,

abruption

changes

prematurity, growth

brain malformations

48-60+ hours Neuro-

developmental

changes

effects

then hypertonia,

irritability

weight

symptoms

oxygen,

spontaneous

abortion, growth

previa, abruption

pitched cry,

fussiness, poor

feeding, low

prenatal period

High pitched cry,

jitteriness, poor

sleep patterns

prematurity,

abruption

changes

prematurity, growth

brain malformations

48-60+ hours Neuro-

developmental

changes

effects

then hypertonia,

irritability

weight

symptoms

oxygen,

spontaneous

abortion, growth

previa, abruption

pitched cry,

fussiness, poor

feeding, low

prenatal period

High pitched cry,

jitteriness, poor

sleep patterns

prematurity,

abruption

changes

prematurity, growth

brain malformations

48-60+ hours Neuro-

developmental

changes

effects

then hypertonia,

irritability

weight

symptoms

oxygen,

spontaneous

abortion, growth

previa, abruption

pitched cry,

fussiness, poor

feeding, low

Marijuana Brain development No timeframe in

postnatal period

High pitched cry,

jitteriness, poor

sleep patterns

Opiates

Morphine, codeine, oxycodone,

hydrocodone, heroin, opium, methadone,

buprenorphine, fentanyl

Abrupt cessation of

opiate use during

pregnancy is

detrimental to fetus

Treat pregnant women

using opiates

Women and Opiates

Treatment:

• methadone (Schedule II)

Women and Opiates

Treatment:

• methadone (Schedule II)

• buprenorphine (Schedule III)

Subutex

Suboxone:

(buprenorphine + noloxone)

Women and Opiates

Methadone:

• Decreases cravings

Women and Opiates

Methadone:

• Delays withdrawal

Women and Opiates

Methadone:

• Promotes healthy behaviors

Women and Opiates

Methadone:

• Promotes healthy behaviors

• Improves overall quality of life

Women and Opiates

Buprenorphines:

• Binds with opiate receptors

Women and Opiates

Buprenorphines:

• Mimics opiates but to lesser degree

Women and Opiates

Buprenorphines:

• Less respiratory suppression

Women and Opiates

Buprenorphines:

• Less respiratory suppression

• Alleviates withdrawal symptoms

Women and Opiates

Buprenorphines + noloxone

decreases risk of IV use

treats the withdrawal without the “high”

Screening for Substance Use

No ID, no liquor - and

wrinkles don't count

http://www.timesfreepress.com/news/local/story/2014/jul/29/no-id-no-liquor-and-wrinkles-dont-count-universal

Screening Mothers

Universal toxicology screening of all

pregnant women

http://www.naofficesolutions.com/setting-gold-standard/

Toxicology Screening

Maternal urine drug screen (UDS):

• Amphetamines, cocaine, opiates

activity within 2 to 3 days

Maternal urine drug screen (UDS):

• Amphetamines, cocaine, opiates

activity within 2 to 3 days

• Marijuana

activity with several weeks

Screening Mothers

Universal screening

1st prenatal visit

Screening Mothers

Universal screening

1st prenatal visit

-diabetes

Screening Mothers

Universal screening

1st prenatal visit

-diabetes

-hypertension

Screening Mothers

Universal screening

1st prenatal visit

-diabetes

-hypertension

-neurobehavioral disorders

Screening Mothers

Mothers identified with neurobehavioral

issues can be referred to appropriate

community services

Screening Mothers

Hospital admission lacking universal

screening:

Maternal history may help screen for

neurobehavioral disorders

Screening Mothers

Maternal history:

• Late or no PNC

Screening Mothers

Maternal history:

• Late or no PNC

• Admitted drug use

Screening Mothers

Maternal history:

• Late or no PNC

• Partner violence

Screening Mothers

Maternal history:

• Late or no PNC

• Partner violence

• Poor quality environment

Screening Mothers

Obstetrical history:

• Repeated spontaneous abortions

Screening Mothers

• Placental abruptions

Screening Mothers

• Precipitous delivery

Screening Mothers

• Myocardial infarction

Screening Mothers

• Myocardial infarction

• Cerebral vascular accidents (CVA)

Screening Mothers

Significant chronic pain:

• Motor vehicle accident (MVA)

• Surgical procedures

• Arthritis

https://www.psychologytoday.com/blog/neuronarrative/201106/how-we-know-youre-lying

Neonatal Abstinence

Syndrome

NewbornToxicology Screening

Infant urine drug screen (UDS)

Positive Urine Toxicology Screens

•Alcohol (Ethanol) •3 to 10 hours

•Hydromorphone (Dilaudid)•1 to 2 days

•Amphetamine Methamphetamine •1 to 2 days

•Methaqualone (Quaaludd)•2 weeks

•Barbiturates•2 to 6 weeks

•Methadone (Dolophine)•2 to 3 days

•Benzodiazepines•Moderate use: 3 to 5 days•Heavy abuse: 3 to 6 weeks

•Morphine•1 to 2 days

•Cocaine•Direct: 5 hours

•PCP (Phencyclidine)•2 to 8 days

•Codeine•1 to 2 days

•Propoxyphene (Darvon)

•Direct: 6 hours•Metabolites: 6 to 48 hours

•Heroin (detected as Morphine)1 to 2 days

•http://childabusemd.com/laboratory/toxicology.

•Marijuana (THC metabolite)Urine: Use of one joint: 2 days

Newborn Toxicology Screening

Infant meconium drug screen

- formed in very early 2nd trimester

- takes days to collect

Meconium

Results are presumptive for a positive

UDS or meconium drug screen

until confirmed with further testing

Cord sampling

Positive Urine Toxicology Screens

•Alcohol (Ethanol) •3 to 10 hours

•Hydromorphone (Dilaudid)•1 to 2 days

•Amphetamine Methamphetamine •1 to 2 days

•Methaqualone (Quaaludd)•2 weeks

•Barbiturates•2 to 6 weeks

•Methadone (Dolophine)•2 to 3 days

•Benzodiazepines•Moderate use: 3 to 5 days•Heavy abuse: 3 to 6 weeks

•Morphine•1 to 2 days

•Cocaine•Direct: 5 hours

•PCP (Phencyclidine)•2 to 8 days

•Codeine•1 to 2 days

•Propoxyphene (Darvon)

•Direct: 6 hours•Metabolites: 6 to 48 hours

•Heroin (detected as Morphine)1 to 2 days

•Marijuana (THC metabolite)Urine: Use of one joint: 2 days

Cord sampling

• Always available

http://www.usdtl.com/testing/umbilical-cord-tissue-drug-test-labs

• 48 hour turn around time

• Higher sensitivity for detection

• Simple collection

• Should be covered by insurance

Symptoms of NAS

Neurologic

Hypertonicity

Exaggerated Moro

Constant crying

High pitched cry

Grossly altered

sleep state

Sneezing

Excoriated skin

Symptoms of NAS

Neurologic Autonomic

Hypertonicity Tremors

Exaggerated Moro Mottling

Constant crying Nasal stuffiness

High pitched cry Tachypnea

Grossly altered

sleep state

Sneezing Sweating

Excoriated skin

Symptoms of NAS

Neurologic Autonomic Gastrointestinal

Hypertonicity Tremors Frequent, loose

watery stools

Exaggerated Moro Mottling Frantic sucking

Constant crying Nasal stuffiness Poor feeding skills

High pitched cry Tachypnea Frequent

spitting/vomiting

Grossly altered

sleep state

Sneezing Sweating

Excoriated skin

Symptoms of NAS

NAS Scoring Tools

• Modified Finnegan Neonatal Abstinence

• Lipsitz Neonatal Drug-Withdrawal

• Neonatal Withdrawal Inventory

• Neonatal Narcotic Withdrawal Index

NAS Scoring Tools

• Modified Finnegan Neonatal Abstinence

• Lipsitz Neonatal Drug-Withdrawal

• Neonatal Withdrawal Inventory

• Neonatal Narcotic Withdrawal Index

NAS Scoring Tools

Modified Finnegan Lipsitz

High interrater reliability Does not address

interrater reliability

Comes with commercial

educational materials

No commercial materials

available

Screens, monitors and

manages

Screening tool only

(transport decisions)

21 point scale 11 point scale

NAS Scoring Tools

available

manages

Screening tool only

NAS Scoring Tools

available

manages

Screening tool only

NAS Scoring Tools

available

manages

Screening tool only

NAS Scoring Tools

available

manages

Screening tool only

Score after a feed every 3 – 4 hours

Observation for NAS

Opiates: 24 to 48 hours

Methadone: 24 to 72 hours

Buprenorphine: 12 to 70 hours

Observation for NAS

Or as long as 5 to 7 days

Observation for NAS

Or as long as 5 to 7 days

If withdrawal is going to occur

majority in 1 week

Observation for NAS

Medication Half Life Time to

Observe

Hydrocodone 4 hours Discharge after 3

Methadone 10-60 hours Discharge after 7

Observation for NAS

• Depends upon medication, half life of

drug, and infant’s metabolism of drug

Observation for NAS

– Heroin withdrawal is earlier and shorter

Observation for NAS

– Heroin withdrawal is earlier and shorter

– Buprenorphine is up to 9 months

Observation for NAS

Cofounders may increase length of

observation:

• tobacco

• benzodiazepines

• SSRI’s

• poly drug use

Non-Pharmacologic Care

• Quiet, calm environment

• Soft voices

• Slow movement, gentle handling

• Soft voices

• Cluster care

• Soft voices

• Cluster care

• Tight swaddling

• Soft voices

• Cluster care

• Tight swaddling

• Skin to skin holding

• Dark environment

• Non-nutritive sucking

• Frequent feeds

• Massage therapy, music therapy

• Frequent feeds

• Vertical rocking (not side to side)

• Frequent feeds

• Vertical rocking (not side to side)

• Use of cuddlers

Cuddlers

can be

important

care team

members

The Challenge of Nutrition

Nutrition:

Breastfeeding is recommended

• mother enrolled in program, monitored

• HIV negative

• not a poly drug or current user

Nutrition:Breastfeeding and marijuana

• Heavy user, regular medical, occasional user

• Deposited in brain, adipose tissue

• Stored for weeks to months

• Long half life (60 hours)

• Possible infant sedation

• Impaired mother

• ???

BREASTFEEDING MEDICINE Volume 10, Number 3, 2015

Nutrition:

• Additional nutrition via formula

Nutrition:

• Hydrolyzed formula

Nutrition:

• Fortified with additional calories

Nutrition:

• Gavage feeds

Nutrition:

• Gavage feeds

• Small frequent feedings

Nutrition:

• Gavage feeds

• Small frequent feedings

• Monitor weight gain

Pharmacologic Care

Morphine and Methadone most common

Buprenorphine and clonidine gaining but studies needed

Treat with same classification of drugs

Pharmacologic Care

Adherence to protocol more important

than drug selection

Pharmacologic Care

Standardizing care improves outcomes for infants born with neonatal abstinence

syndrome

April 16, 2016www.sciencedaily.com/releases/2016/04/160416094756.htm>.

NAS Scoring

Pharmacologic treatment initiated

3 consecutive scores >8

or 2 scores >12 within 24 hour period

NAS Scoring

• Score after a feed every 3 to 4 hours

• Wean for average score over 24 hours

NAS Scoring

• Score after a feed every 3 to 4 hours

• Wean for average score over 24 hours

• Medications are given as prescribed

– Methadone q 6 hours

– Morphine q 3-4 hours

Pharmacologic Care

NAS Protocol:

Once captured, weaning takes days to weeks

NAS Scoring

Infants >28 days of age:

awareness of more awake time

Add two to score for weaning

(<11 instead of <8)

NAS Metrics

Medication Treated Treatment

Methadone 11 11-23 14-27

+ Pb 4 28-50 31-53

+Clonidine 1 35 39

Pharmacologic Care

Discharge Planning

Child Protective Services

Virginia Department of

Social Services January

Child and Family Services

Manual C. Child Protective

Services

10.2 Mandated reporting of

substance-exposed infants

Reportable conditions:

• Positive toxicology results

• Finding by healthcare provider that infant was

born dependent upon a controlled substance

• Finding by healthcare provider that infant was

born dependent upon a controlled substance

• Child has an illness, disease, or condition which

is attributable to in utero exposure

Unless the controlled substance was

prescribed by a physician for the mother

Unless the controlled substance was

prescribed by a physician for the mother

Or the mother sought treatment or

counseling

Discharge Planning

• Appropriate referrals in place for mother

Discharge Planning

• Community healthcare follow-up can follow NAS

infant (including weaning medications)

Discharge Planning

• Infant is eating and gaining weight

it is not necessary for all symptoms to

disappear

Discharge Planning

disappear

• Caretakers have been taught to score infant

Discharge Planning

disappear

• Caretakers have been taught to score infant

• Caretakers are comfortable with newborn

Quality Improvement Metrics

Education:

Prenatal instruction for Ob/Peri

Staff education

Appropriate family education

Screening:

Adequate maternal screening

Screening of infant as indicated

Initiation of scoring per protocol

Non-pharmocologic interventions:

Family driven care

Comfort strategies

Cuddler program

Medical management:

Initiation of medications per protocol

Weaning per protocol

Discharge Planning:

Multidisciplinary preparation

Appropriate follow-up

Supportive discharge education

Follow up appointments made

Team approach to care

Discharge plan in place

Timely use of medications

Strict adherence to

protocol

Family supported to care for infant

Comfort strategies successful

Reduced nursing care required

Mothers/infants appropriately screened

Scoring initiated in timely manner

Family education initiated prenatally

Mother’s aware of NAS plan of care

and importance of participation

Reduce pharmocologic

intervention

Reduce length of stay

Decrease hospital costs

Improve parent/infant

relationship

Supportive discharge plan of

Safe discharge of family

NAS Key Driver Diagram

Aims Primary Drivers Process/Interventions

Thank you for your time and interest

• http://www.nbcnews.com/video/disturbing-video-shows-baby-undergoing-withdrawal-581562435940

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