Welcome to the OPQC NAS September Action Period Call

Transcription

1 Welcome to the OPQC NAS September Action Period Call Thank you for joining; our webinar will start shortly! In the mean time; please sign in the chat box the names of all webinar participants and full name of hospital affiliation.

2 Welcome! Neonatal Abstinence Syndrome Project Action Period Call Ohio Perinatal Quality Collaborative September, 2014

3 Please don t put us on HOLD! If you need to step away: Use the MUTE button on your phone or You can use *6 to place the call on MUTE and *6 to come off of MUTE

4 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 3:55 pm Next Steps Data Submission Review Monthly Progress Report Poll for all teams Michele Walsh, MD Presenter A Presenter B Jonathan Fanaroff, MD All teams Susan Ford

5 Roll Call: Please sign in with your hospital affiliation and the names of your team members on the call in the Question box

6 NAS Participating Sites 2014 Promedica ProMedica Toledo Children s Bay Park Mercy Children s Hospital St. Rita s Medical Center Blanchard Valley Lima Memorial Health System Marion General Nationwide Upper Valley Dublin Methodist Dayton Children s Medical Center Mt. Carmel West Nationwide Doctor s Good Samaritan Hospital Dayton Springfield Regional Miami Valley Medical Center Southview Medical Center Soin Medical Center Fort Hamilton Kettering Cincinnati Children s Atrium Medical Center Good Samaritan Mercy Hospital Fairfield Hospital Mercy Anderson UH Cincinnati Bethesda North The Christ Hospital Hospital Mercy Health West Nationwide Riverside Methodist Nationwide Grant Mercy Regional Medical Cleveland Center Lorain Fairview Hospital Clinic Hillcrest Hospital Elyria Medical UH Rainbow Babies Center -UH MetroHealth & Children s Akron Children s Summa Mercy Medical Akron Children s Center Canton OhioHealth MedCentral Mansfield Aultman OSU Nationwide Children s Adena Regional Medical Center Southern Ohio Medical Center Nationwide Mt. Carmel St. Ann s Mt. Carmel East Licking Memorial Health System Genesis Healthcare System Tripoint Medical Center (Lake Health) Trumbull Memorial Akron Children s St. Elizabeth Health Center/Mahoning Valley 1/2014 start Level 3 and Level 2 teams 4/2014 start Level 2 teams

7 Key Driver Diagram Project Name: OPQC Neonatal NAS Leader: Walsh GLOBAL AIM To reduce the number of moms and babies with narcotic exposure, and reduce the need for treatment of NAS. 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, 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 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. 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.

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11 100% OPQC NAS Project Q2 Collaborative Aggregate Non-Pharmacologic Care Elements Received BEFORE Drug Treatment Note: 96% of forms had more than one element recorded as completed. 80% 60% 40% Breast Milk Feeds OR Low Lactose Feeds Swaddling Low Stimulation OR Rooming In 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.

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14 Median 15.61

15 Median 19.93

16 Site specific data is in folders in SharePoint! Each data point represents 5 babies

17 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

18 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.

19 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.

20 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.

21 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 hrs. All positives require confirmation with GC/MS False positives and false negatives.

22 False Negatives and False Negatives: False Positives 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

23 Structural Similarities From: Krasowski MD, BMC Emergency Medicine 2009: 9: 5.

24 Universal Screening for Maternal Drug Use Presenter A

25 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

26 Tools 5Ps 1 parents, peers, partner, past, pre-pregnancy CRAFFT yo 6 items measuring use of substances/concerns SURP-P 3 (Substance Use Risk Profile- Pregnancy Scale) 3 questions 1 Adapted from Watson E. Institute on Health and Recover, Integrated Screening Tool, Knight, et al. and Chang et al Yonkers KA, et al. Screening for prenatal substance use: development of a substance use risk profile-pregnancy scale. 2010

27 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

28 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

29 Do We Miss Babies? No readmissions for NAS in past 6 months

30 Universal Testing Presenter B

31 Maternal Risk Based Screen ACOG Committee Opinion 524, May Recommends universal screening. Recommends obtaining consent prior to testing.

32 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

33 Universal Testing Started Universal Testing on Sept 1 st. Encourage consent Recommend DAU 13 for mother and infant

34 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

35 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

36 Legal Implications for Testing in Ohio OPQC Webinar September 2014 Jonathan Fanaroff, MD, JD

37 Disclaimer

38 Balancing Considerations Medical Legal Ethical

39 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

40 Scene at the Signing of the Constitution Howard Chandler Christy

41 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

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43 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

44 4 th 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.

45 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

46 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

47 Gordon Wiltsie / National Geographic Image Collection

48 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.

49 Criminal charges Felony child endangerment Corruption of a minor Chemical endangerment Assault with a deadly weapon

50 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

51 Parens Patriae Children are not property Government has the power and duty to protect the safety and well-being of children

52 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

53 Medical Practice is mainly regulated by the State

54 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

55 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

56 Drug Testing Mothers and Newborns 1. Obstetricians, Pediatricians, and Administration should develop policies to be followed consistently. 2. Hospital counsel should ensure compliance with state and federal laws Stanton E. NAS and the Law for the Non-Lawyer

57 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

58 Drug Testing Mothers and Newborns 4. 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. 5. 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

59 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

60 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 Stanton E. NAS and the Law for the Non-Lawyer

61 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?

62 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!

63 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

64 The OPQC NAS Project is funded by The Ohio Department of Medicaid