Background: In utero opioid exposure can result in neonatal abstinence syndrome (NAS). NAS is a serious condition characterized by central nervous system hyperirritability and autonomic nervous system and gastrointestinal tract dysfunction. Newborns with NAS may require pharmacological management, have increased hospital costs, and have a prolonged hospital length of stay (LOS). NAS incidence has increased five-fold in the last decade. Opioid use disorder (OUD) in pregnant women and NAS are now considered a public health crisis, with detrimental clinical outcomes and increased healthcare expenditures.Several large studies at tertiary care centers have demonstrated that non-pharmacologic interventions and care bundles decrease the severity of symptoms, need for primary and adjunctive pharmacologic treatment, cost of care, and LOS in NAS. Variation in care is prevalent, and there is little known about whether the application of similar methodology could improve the care of high-risk children with NAS in a smaller safety net community hospital with limited addition, NAS initiatives have been discussed as part of direct patient care, but to our knowledge, no study has been published demonstrating improved clinical and financial outcomes from incorporating NAS initiatives as major part of a larger population health management program.

Methods: We created a multidisciplinary team to improve the quality of care for our NAS infants with aims of decreasing LOS by 20% and cost of care by 10% over a 24 month period. The primary drivers and implementation strategies included expanding education in NAS care, maximization of non-pharmacologic interventions, standardized nursing care and development of care bundles, care management and patient navigation, community outreach and stigma awareness and sensitivity training. Care bundles and educational modules on non-pharmacologic treatments were created and implemented using PDSA cycles. Prospective patient data was collected during the intervention period.This work was supported by a Massachusetts Health Policy Commission grant.

Results: Median rate of pharmacologic treatment for opioid-exposed infants monitored for NAS decreased from 87% in the pre-intervention period to 40% post (Figure 1). Use of adjunctive medication (phenobarbital or clonidine) also decreased from 16% to 4% (p = 0.05).The median LOS decreased from 17.5 days in the pre-intervention period to 8 days post-intervention (Figure 2). Median LOS was 6 days, both pre- and post- intervention, for infants not pharmacologically treated. Hospital costs for all infants decreased from $23,025 to $8876 (p < 0.001).

Conclusions: Implementation of standardized evidence-based strategies demonstrated decreased use of pharmacotherapy, use of adjunctive medications, LOS, and cost of care for NAS at a safety-net community hospital. The average cost savings of this intervention is $14,149 per infant, or an estimated $778,000 over the 28-month intervention period. Because more than 70% of pediatric hospitalizations occur outside of freestanding children’s hospitals, the impact of expanding interventions in community hospitals could be dramatic.These findings support growing evidence that a multi-disciplinary, population health approach to improving clinical care in NAS is effective in community hospital settings and has the potential to offer improvement in health care resource utilization.

IMAGE 1: Figure 1. Percent of Infants Treated With Pharmacotherapy. Figure 2. Median Length of Stay for Infants Hospitalized with NAS.

IMAGE 2: Figure 3. Key Driver Diagram