Eat, Sleep, Console (ESC) Overview

Tuesday, September 11, 2018 12 – 1 PM

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Mission

Maine Quality Counts is a nonprofit located in Manchester, Maine.

We are working to improve the health of all Maine people (and beyond) by transforming

the way healthcare is delivered.

QC Brings Together the People Who Give, Get and Pay for Healthcare to Address Shared Priorities:

• Improve the alignment of healthcare systems to transform health for all Maine people

• Provide quality improvement assistance to practices

• Engage consumers in healthcare

• Promote the integration of physical and behavioral health

Priorities

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CME • Disclosure: Today’s speakers do not have any relevant financial

relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

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Funding

Funding for this webinar is provided by: The Maine Health Access Foundation (MeHAF)

Objectives • Discuss use of the ESC Care Tool as a means to decrease need for

pharmacologic treatment for opioid-exposed newborns through optimization of non-pharmacologic care and use of function-based NAS assessments

• Highlight perinatal quality improvement work happening through the Northern New England Quality Improvement Network (NNEPQIN).

• Provide an overview on Eat Sleep Console (ESC) Work at Dartmouth and work to improve care for substance exposed infants.

• Discuss initial data from sites that are doing Eat Sleep Console project and the potential impact of the quality improvement work.

• Provide an overview of the Oct 30th ESC training in Maine and discuss responsibilities of interested hospital teams.

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Today’s Speakers Bonny Whalen, MD Dr. Bonny Whalen is an Assistant Professor of Pediatrics at the Geisel School of Medicine at Dartmouth and is a newborn hospitalist and Medical Director of the Newborn Nursery at the Children’s Hospital at Dartmouth-Hitchcock (CHaD). Dr. Whalen is a general pediatrician who received her MD from the University of Vermont College of Medicine, trained in residency at Massachusetts General Hospital in Boston, MA, then practiced newborn and pediatric medicine in Madison, WI for 6 years before moving back to New England to join CHaD in 2005. Dr. Whalen specializes in the care of opioid-exposed newborns and breastfeeding support for new mothers. She leads quality improvement (QI) efforts in her hospital and Northern New England to improve care for newborns at risk for and with Neonatal Abstinence Syndrome (NAS) due to in-utero opioid exposure. Her work focuses on increasing baby- and family-centered care, improving neonatal outcomes and mother-baby bonding through rooming-in couplet care, empowering families to best care for their newborns through prenatal education and in-hospital support, and increasing breastfeeding for newborns through education of mothers and health care providers. Dr. Whalen is co-developer of the “Eating, Sleeping, Consoling (ESC) Care Tool”, a new assessment and care tool for in-hospital care of opioid-exposed newborns. She is leading efforts to study its effectiveness and safety in a regional QI/learning collaborative in Northern New England, as well as co-leading efforts to improve safe transitions to home for these newborns.

Kelley Bowden, MS, RN Kelley Bowden is the Perinatal Outreach Nurse Educator for the state of Maine. After graduating from the University of Southern Maine with her Bachelor’s degree in nursing, she joined the Maine Medical Center NICU staff. Kelley then went on to earn a certificate from Georgetown University as a Neonatal Nurse Practitioner. After working in the NICU for 18 years, she left to become a chart abstractor for the Maine Birth Defects Program and assumed the outreach position in 2004. Kelley completed her master’s degree in nursing at USM in 2005. Alan Picarillo, MD Dr. Picarillo is a specialist in Neonatal-Perinatal Medicine at MaineHealth. Previously, he practiced Neonatal-Perinatal Medicine in Richmond, VA. Dr. Picarillo graduated from University of Massachusetts Medical School in 1998 and has been in practice for over 20 years. He completed a residency at UMASS Medical School. Dr. Picarillo also specializes in Pediatrics.

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Today’s Speakers

Using the Eating, Sleeping, Consoling (ESC) Care Tool to Improve Care of Infants with In-utero Opioid Exposure in Northern New England

Bonny Whalen, MD Sept 11, 2018

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April 2013

October 2014

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1. RN scoring training/ reliability

6. Standardize score interpretation + modify Rx criteria

3.Baby-centered scoring & care

7. Rooming-in pilot

5. Parent symptom diary

8. “Cuddlers”

9. Full rooming–in

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2. Family interviews

4. Prenatal education

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10. Working with families with addiction training

Jan 2013: Formed Multi-D VON NAS QI team April 2013 - Oct 2014: 11 PDSA cycles

11. Transfers

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Decreased Need for Pharm Rx

46% 51%

27%

0%

10%

20%

30%

40%

50%

60%

70%

Baseline InterventionYear 1

InterventionYear 2

% Opioid-exposed Newborns Receiving Morphine

13%

7%

2% 0%2%4%6%8%

10%12%14%16%18%

Baseline InterventionYear 1

InterventionYear 2

N = 54 3/1/12-2/28/13

N = 61 3/1/13-2/28/14

N = 48 3/1/14-2/28/15

N = opioid-exposed infants per year

N = 54 3/1/12-2/28/13

N = 61 3/1/13-2/28/14

N = 48 3/1/14-2/28/15

% Opioid-exposed Newborns Receiving Adjunctive Agents

Holmes et al. Pediatrics. 2016.

Decreased Length of Stay

Holmes et al. Pediatrics. 2016.

Healthy Moms / Healthy Babies:

A Regional QI / Learning Collaborative to Improve Outcomes for Women and Infants with Perinatal Opioid Exposure

2015 NH 7 Level 1 3 Level 2 3 Level 3

VT 4 Level 1

NNEPQIN NAS “BUNDLE” Prenatal education Maternal presence and rooming-in Breastfeeding if no concerning maternal substance use Baby-centered care / scoring

Care / score based on infant’s waking & feeding schedule Skin-to-skin & feed before scoring Skin-to-skin / hold during scoring

Involve family in care & scoring Bedside huddle for Finnegan scores 8 x 3, 2 x 12

Optimize non-pharm rooming-in care further, as able Consider treatment if …

MODIFIED NAS RX CRITERIA Traditionally Rx for: 3 NAS scores ≥ 8 or 2 scores ≥ 12 Given experience of other centers using physiologic criteria to

guide Rx (Vancouver, Yale, CHaD), recommended moving to individualizing treatment for infants who demonstrate significant physiologic distress due to NAS as demonstrated by: Inability to 1) Eat, 2) Sleep, or 3) Console Other significant physiologic disturbance (e.g., apnea, seizures,

excessive weight loss or poor weight gain) felt related to NAS * No treatment in first 24+hr (unless mom missed Rx dose day prior)

May 2016: Collaboration b/w Drs. Bonny Whalen (CHaD), Elisha Wachman (Boston Medical Center), and Matt Grossman (Yale)

June 2016: Drs. Whalen and Grossman invited to speak at BMC on Dartmouth / Yale approaches to optimizing NAS care through rooming-in, optimal non-pharm care, parental presence, and modified NAS assessments and Rx criteria

YALE’S ESC APPROACH

Morphine Rx decreased: 98% → 14% LOS decreased: 22.4 days → 5.9 days Hospital costs decreased: $44,824 → $10,289

Mean = 96%

DEVELOPMENT & PRE-TESTING OF ESC CARE TOOL

Summer - early winter 2016: Formal development of ESC Care Tool with definitions: CHaD (Drs. Bonny Whalen / Kate MacMillan), BMC (Drs. Elisha Wachman, Sue Minear), Yale (Matt Grossman)

June-Dec 2016: ESC Care Tool – Pre/pilot-tested at

Wachman et al. Journal of Perinatology. 2018.

DEVELOPMENT & DISSEMINATION OF ESC CARE TOOL

Jan – Feb 2017: Refined / expanded ESC Care Tool to include Non-Pharm Care Interventions

Feb – May 2017: monthly ESC educational webexes

REFINEMENT / TESTING OF ESC CARE TOOL Spring 2017: ESC Instructional Manual, video tutorial & case dvlp

May 2017: Revised ESC Care Tool based on collaborative feedback

June 2017 - present: Pilot testing at

Eating, Sleeping, Consoling (ESC) Training Day # 1 June 14, 2017

NNEPQIN COLLABORATIVE ESC ROLL-OUT

Monthly ESC Non-pharm Care webinars: Challenging ESC cases Brainstorming barriers/strategies Data sharing Needs-based topics (e.g., cuddler

programs, safe sleep) Approaches to ESC staff/provider

education & unit roll-out EPIC builds

1st NNEPQIN hospital

June 2017:

NEED FOR PHARMACOTHERAPY- P-CHART

NEED FOR PHARMACOTHERAPY- RARE EVENTS G-CHART

LENGTH OF STAY- XBARS STATISTICAL PROCESS CONTROL CHART

NNEPQIN NAS QI/LEARNING COLLABORATIVE INITIATED IN 2015

ESC Care Tool Rollout 30 NNEPQIN hospital teams trained using standardized mothers: 15 NH,

11 VT, 4 ME hospitals Since roll out of ESC Care Tool: Need for pharm Rx has decreased from

36% (6/16-6/17) to 24% (7/17-7/18) in hospitals contributing data, below national average of 50%

Monthly Webinars – data sharing, challenging cases, needs-based topics NNEPQIN Breastfeeding Guidelines for Women with a Substance Use

Disorder NNEPQIN Parent educational materials

• Marijuana use in pregnancy and lactation pamphlet • NAS parent education booklet, NAS ESC pamphlet, video in production

NAS Inpatient Management QI Toolkit

Gold star rater: 6/6 = 100% Bedside RN: 5/6 = 83%

QUESTIONS

Eat Sleep Console Initiative Data (it’s not that scary!)

Alan Picarillo, MD Division of Neonatology The Barbara Bush Children's Hospital Maine Medical Center

Data requirement

Data requirement

• Important to understanding the impact of change concepts – “Not all change is good”

• Learning process with quality improvement • Can be time consuming • Balance too much versus too little data • 30 separate items

– ~15 minutes per patient to abstract and enter data – MaineHealth hospitals

Data sheet

Data sheet

Data from single site experience

Timeline

Sept 2017 meeting started

Sept-December structure of teams

Jan 2018 CHaD training

Feb 2018 Gold star trainers

Mar 2018 Staff training

April 2018 ESC go live

Implementation

Contact Information • Amy Belisle, MD, MBA, Senior Medical Director

abelisle@mainequalitycounts.org • Kayla Cole, Project Manager kcole@mainequalitycounts.org • Jackie Tiner, Administrative Coordinator

jtiner@mainequalitycounts.org QC Website: https://mainequalitycounts.org/

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Upcoming Webinars! • October 23, 2018, 12-1 pm, Delivering Compassionate &

High Quality Care for Hospitalized Individuals with SUD/OUD, Zoom Registration

• Tues, November 20, 2018, 12-1 pm, Caring For ME Webinar: Urine Drug Screening: Jonathan Fellers- Registration