P2D194: Difficulties Implementing a NOWS QI Project in a Large Urban Center

Purpose/Objectives: There is a rising incidence of infants diagnosed with neonatal opioid withdrawal syndrome (NOWS) in the United States. Our unit’s heterogenous approach to the pharmacologic management of patients admitted with NOWS led to this quality improvement project. The objectives of this project were to: 1) standardize NOWS pharmacological management , and 2) reach 50% physician adherence to guidelines within 6 months.

Design/Methods: This project was conducted in a single center 96-bed level IV NICU within an urban hospital, Miller Children’s and Women’s Hospital.  The patients targeted were neonates born at greater than 35 weeks gestation with confirmed intrauterine opioid exposure through positive urine drug screen admitted to the NICU . Process measures include appropriate initiation of pharmacologic treatment, escalation of treatment, and de-escalation of treatment. Outcome measures include the patient’s length of treatment and length of stay. Balancing measures include re-initiation of pharmacologic treatment and readmission for NOWS treatment.

The first PDSA cycle included a chart review of infants treated for NOWS in 2021 to highlight our heterogenous approach. Our second PDSA cycle included a literature review on NOWS and suggested guidelines for our group of 15 neonatologists and hospitalists in April 2022. Thirteen of the fifteen physicians participated in a survey to achieve consensus on the pharmacological treatment, escalation, and de-escalation of treatment. The agreed upon protocol was disseminated to all physicians in June 2022.

Results: Nine months of review of electronic medical records from July 2022 through March 2023 were completed to assess physician adherence to the newly implemented protocol. Seven infants were admitted with confirmed intrauterine opioid exposure with NOWS symptoms requiring pharmacologic treatment. There was 100% adherence to the appropriate choice of medication for initiation of treatment, 60% adherence to escalation of treatment, and 14% adherence to de-escalation of treatment per protocol. There were modest decreases in length of treatment (16 vs 10 days) and length of stay (22 vs 19 days), though these were not statistically significant. Similar to our preintervention data, there were no readmissions or re-initiations of treatment.

Conclusion/Discussion: Creating a NOWS pharmacological guideline among a large group of physicians can lead to a more unified approach to management and a modest decrease in length of treatment and length of stay. Despite reviewing the protocol and disseminating the protocol among all physicians, overall physician adherence was 14%. Future work includes multidisciplinary meetings with nursing and pharmacy teams to increase awareness of our guidelines, as well as physician surveys regarding adherence challenges with the goal to increase future adherence.