Grossman Matthew R, Berkwitt Adam K, Osborn Rachel R, Xu Yaqing, Esserman Denise A, Shapiro Eugene D, Bizzarro Matthew J
Departments of Pediatrics,
Departments of Pediatrics.
Pediatrics. 2017 Jun;139(6). doi: 10.1542/peds.2016-3360. Epub 2017 May 18.
The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%.
In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children's Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts.
There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from $44 824 to $10 289. No infants were readmitted for treatment of NAS and no adverse events were reported.
Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events.
新生儿戒断综合征（NAS）是一组与阿片类药物戒断相关的神经、胃肠和肌肉骨骼功能紊乱症状，其发病率急剧上升，且与住院时间延长有关。在我们机构开展项目之前，宫内接触美沙酮的婴儿平均住院时间（ALOS）为22.4天。我们旨在将NAS婴儿的ALOS降低50%。
2010年，一个多学科团队在耶鲁纽黑文儿童医院启动了几个计划-实施-研究-改进循环。关键干预措施包括非药物治疗的标准化以及向家长传达积极信息、开发一种新的评估方法、按需使用吗啡以及将婴儿直接转入住院病房，绕过新生儿重症监护病房（NICU）。结果指标包括使用统计过程控制图的ALOS、吗啡使用情况和医院成本。
我们项目中有287名婴儿，包括基线期（2008年1月至2010年2月）的55名和实施后时期（2015年5月至2016年6月）的44名。ALOS从22.4天降至5.9天。接受吗啡治疗的宫内接触美沙酮婴儿比例从98%降至14%；成本从44824美元降至10289美元。没有婴儿因NAS再次入院治疗，也未报告不良事件。
针对宫内接触美沙酮婴儿的干预措施聚焦于非药物治疗和简化评估方法，导致ALOS、接受吗啡治疗的婴儿比例和医院成本大幅且持续下降，且无不良事件发生。
