Background: Neonatal abstinence syndrome (NAS) occurs when an infant is exposed to chemical substances in utero and consequently withdrawals from the substance(s) after birth. The long-term impact of NAS remains unclear due to confounding by other factors that impact infant health and development, but literature suggests that infants with NAS have motor and cognitive delays associated with shorter attention spans and behavioral problems. In 2004 under Part C of the Individuals with Disabilities Education Act (IDEA), infants with NAS qualified for federally funded therapies to support development through Early Intervention (EI) programs. To qualify for EI, the diagnosis must be properly documented by clinicians and communicated to EI programs. When this diagnosis is not communicated with an EI referral, qualifying is more difficult as the child must then either exhibit developmental delay or the family must meet a minimum of 4 social risk criteria. A recent study at our institution showed fewer than half of eligible patients with NAS were enrolled in EI. Babies most at risk for not receiving EI referrals included infants discharged into foster care and those with shorter hospital stay who were not admitted to neonatal intensive care unit.
Purpose: • To increase rates of appropriate inpatient documentation of NAS in the EMR, based on standardized criteria established, to >90% over a 12-month period (process)• To increase rates of transfer of NAS documentation to EI programs to >90% over a 12-month period (outcome)• To maintain rates of appropriate documentation of hepatitis B vaccination >90% over a 12-month period (balancing)
Description: All discharges of newborns will be identified using a billing database. These will be analyzed for process and balancing measures by manual review initially until an automated system of querying the BMC CIS database on a monthly basis is completed. Data will be entered into a HIPAA compliant database. Aggregate level EI referral rates will be provided from the Massachusetts Department of Public Health (MDPH). Data provided by the UMMS NAS research group and later by the BMC IT query report will be reviewed monthly. Proposed interventions include:• Develop standardized criteria for diagnosis of NAS through meetings with stakeholders• Provide education to attending physicians and residents via online educational module or academic half-day; 70% score required measured by a 10-question NAS Post-Education Assessment Tool (NASPEAT)• Revise newborn nursery resident data collection sheet to include reminders to document NAS• Revise Cerner CIS Dynamic Documentation note template for newborn nursery to remind author to document NAS and to transfer discharge summary to EI program • Place background reminders on computers used by physicians to include standardized criteria for NAS diagnosis and reminders for appropriate documentation• Run monthly report in Cerner to identify babies discharged with NAS diagnosis codes; review EMR to ensure referral made to EI after discharge. If referral not made, remind provider via email.
Conclusions: Improving referral rates of babies with NAS will require optimizing the transfer of documentation from inpatient to outpatient settings through establishing a learning health system. This will not only improve care in the newborn nursery setting, but also build an infrastructure that establishes a model for ongoing quality improvement in the newborn nursery.