WisPQC Eat, Sleep, Console Webinar for NAS/NOWS Initiative December 6, 2018 12:00-1:00 p.m. GoToWebinar®

ESC Development Developed by a collaborative effort between faculty at Yale, Children’s Hospital at Dartmouth-Hitchcock and Boston Medical Center

Key Elements of Eat, Sleep, Console Care Tool First treatment should be non-pharmacologic All opioid-exposed infants should be monitored in the hospital for 4-7 days for signs of withdrawal – per AAP Some infants may require pharmacologic treatment (replacement opioids)

Rationale for Pharmacologic Treatment Finnegan Scale: most commonly used to foNAS symptoms Typically, Finnegan scores consecutively of 8 or greater are used to initiate and titrate pharmacologic treatment Rationale for using a score of 8 for medication has never been scientifically established or validated Recent studies: Finnegan scoring poor psychometric properties New research suggests pharmacologic treatment should be based on function-based assessments (how well the infant is eating, sleeping, and infant comfort).

Pharmacologic Treatment If non-pharmacologic care has been optimized and the infant continues to have poor eating, sleeping, or consoling, then pharmacologic treatment should be considered After a team huddle and After maximal optimization of non-pharmacologic care 10 – 40 % of infants will require pharmacologic treatment: Usually initiating treatment at 3 – 4 days of life for methadone and buprenorphine-exposed infants Usual rate of 50 – 80 % pharmacologic treatment when using a numerical, score based approach

ESC Primary Focus The ESC method’s sole principle is that treatment of infant (both non-pharmacologic and pharmacologic treatment) should be based on infant function and comfort, rather than reducing signs and symptoms of withdrawal. Focus on the parent as primary caregiver.

Timing and Location of ESC Assessments Assessments should be initiated within 4-6 hours of birth Assessments should continue for 4-7 days for infants exposed to long-acting opioids (i.e. Buprenorphine, Methadone) Assessments should continue for a minimum of 48 hours for shorter-acting opioids (i.e. Oxycodone, Codeine) Assessments should be performed every 3-4 hours at the time of other routine infant care (i.e. feeding, assessment of vital signs) Should incorporate input from all infant caregivers who interacted with infant during the time period assessed (i.e. mother, other parent, nurse, cuddler) Do not need to remove infant from mother/other parent/caregiver if being held

Implementation Expertise Copyrighted material that we had to get written permission to use and add to Epic. We will also need to share data with the authors as part of copyright permission. Grossman, M. et al., Hospital Pediatrics. 2018;8(1):1-6

The Eat, Sleep and Console (ESC) Approach Grossman, M. et al., Hospital Pediatrics.

Outcomes Outcomes Using the ESC Approach Predicted Outcomes Using the Finnegan’s Approach p - value Infants with NAS receiving morphine, n (%) Hospital Days, n (%) No Morphine Increased Morphine Dose Decreased Morphine Dose Same Morphine Dose 6 (12) 258 (87.2) 8 (2.7) 21 (7.1) 9 (3.0) 31 (62) 156 (52.7) 76 (25.7) 35 (11.8) 29(9.8) < 0.001 The ESC approach limits pharmacologic treatment (98% to 12%) and may lead to reductions in length of stay (22.5 days to 5.9 days). Grossman, M. et al., Hospital Pediatrics. 2018;8(1):1-6

Balancing/Safety Measures Key Drivers Interventions Overall Goal Improve the family-centered care of Infants with NAS Decrease the LOS of Infants with NAS Nonpharmacologic Interventions Standardized non pharmacologic care Prenatal counseling of parents Parental/Volunteer presence Simplified assessment of infants Implementation of the ESC Approach Decreased use of Morphine Rapid Morphine weans Education of Caregivers Empowering messaging to parents Train Nurses and Pediatricians in ESC Approach Primary Aim Balancing/Safety Measures 30-day readmission rates adverse clinical events/NICU transfers weight change during readmission

Key Interventions: Education of Nurses and Physicians on recent NAS literature and ESC Approach Revised Scoring System for NAS using the ESC Approach Revised Pharmacotherapy Guideline for NAS Revised EPIC NAS order set including workflow sheet for ESC approach

Who is Scored? All Infants suspected of Prenatal Exposure to Narcotics (Positive drug screen for mother or baby, H/O substance use during pregnancy, inadequate prenatal care) will be screened. Screening to be completed using the ESC Scoring with the Finnegan tool every 2-4 hours and only when patient is awake.

When/Where/How is Infant Scored? ESC assessments should be performed every 2-4 hours at the time of routine cares or feedings. Initial assessment should be completed within 2 hours of birth and continues based on the length of time required for the type of infant exposure. (See Neonatal Abstinence Policy) All assessments should reflect the interval timeframe since last ESC assessment. Assessments should be completed in their own room and remain with their mother (or visiting caregiver) as much as possible.

When/Where/How is Infant Scored? ESC assessments are documented in the EMR ESC flow sheet until discontinued by physician. Continue to use ESC & Finnegan Scoring when receiving pharmacological treatment in SCN. If receiving pharmacologic treatment, should continue ESC assessments for 24 hours following treatment discontinued.

Documentation in Epic MUST ADD: ESC found under Neuro in the NB PCS Body System Flowsheet

Define Newborn: EAT…… Yes No Poor feeding due NAS symptoms (fussiness, tremors, uncoordinated or excessive suck) Unable to coordinate feeding within 10 minutes of hunger cues Unable to sustain suck/latch within 10 minutes of initiating feeding Any excessive spitting up or emesis with feeding Breast feeding or Bottle feeding well Breast: latches deeply with comfortable latch for mother and sustains active suckling with only brief pauses Bottle: effectively coordinates suck and swallow without gagging or excessive spitting up Eating 10 ml of finger or bottle feeding each feeding Indicated if clearly a non- NAS related issue (prematurity, spittiness or sleepy first 24 hours, or inability to latch/suck due to infant/maternal anatomical factors) If unclear if poor feeding is due to NAS, continue to monitor infant while using non-pharm interventions

Define Newborn: Sleep …… No Sleeps < 1 hour due to NAS symptoms ( fussiness, restlessness, increased startle reflex, tremors) Yes Able to sleep for 1 hour or longer after feeding Indicate if sleeps <1 hour is clearly related to non-NAS factors (cluster feeding, interruptions for routine newborn care, symptoms in first day likely due to nicotine or SSRI withdrawal) If unclear if sleep < 1 hour is due to NAS, continue to monitor infant while using non-pharm interventions

Define Newborn: Console …… Yes Infant consoles easily with 10 minutes using CSIs. CSIs: (Consoling Support Interventions) Caregiver begins softly & slowly talking to infant and uses his/her voice to calm infant. Caregiver looks for hand-to-mouth movements and facilitates by gently bringing infant’s hand to mouth. Caregiver continues talking to infant while placing hand firmly but gently on infant’s abdomen. Caregiver continues softly talking to infant while bringing arms & legs to the center of their body. Caregiver picks up infant, holds skin-to-skin or swaddled, and gently rocks or sways infant. Caregiver offers a finger or pacifier for infant to suck, or a feeding if infant is showing hunger cues. Indicate if inconsolable due to hunger, difficulty feeding, or non-NAS source of discomfort. If unclear if the inability to console is due to NAS, continue to monitor infant while using non-pharm interventions No Infant inconsolable within 10 minutes of caregivers providing comfort & supporting interventions Excessive crying and restlessness for over 10 minutes with interventions provided

Non-Pharm Interventions include… Rooming-in with parent throughout the hospital stay Ensuring parental presence at the bedside as often as possible during the hospital stay Encouraging skin-to-skin contact Swaddling/flexed positioning Ensuring optimal feeding quality including encouraging breastfeeding for mother without concerns for continued concerning substance use or other medical contraindication Non-nutritive sucking with pacifier or finger (ensuring baby is well fed first) Ensuring a quiet environment with low light stimulation in the room. Limiting visitors to one at a time (and to those that will be quiet/supportive) Providing uninterrupted periods of sleep/clustering infant’s care May use noise machine at infant bedside not within infant’s crib. Use of swing only during daytime and when caregiver is awake. Caregiver must be continuously observing infant while in swing. (Swing must be removed when not in use or at night time.)

NAS Rooming-In and Visiting Caregiver Guidelines/Expectations Infants exposed/withdrawing require close observation and some special care. A great way to help them is to room-in with them as much as possible and provide them loving care and support. We understand that there may be a times, you may need to step away from your infant for appointments or other childcare responsibilities. The follow are the guidelines to establish a visiting caregivers list in your absence. Rooming-in strongly encouraged at all times. All caregivers will use safe sleep practices. All caregivers will use good hand hygiene.

NAS Rooming-In and Visiting Caregiver Guidelines/Expectations Rooming-in strongly encouraged at all times. All caregivers will use safe sleep practices. All caregivers will use good hand hygiene. Banded parents may only be gone for 4 hours per day unless medically indicated. ONLY banded parents may room in overnight with infant.

NAS Rooming-In and Visiting Caregiver Guidelines/Expectations A banded parents or Verified visiting caregiver should be present with infant at all times. Visiting caregiver is responsible to attend to infant’s needs until parents return. Banded parent MUST notified RN when leaving unit for visiting caregiver to be verified and given proper badge. Visiting caregiver must have photo ID to assume cares. Once banded parent returns RN to be notified. Visiting caregivers list will be established once mother is medically discharged. Maximum of 4 adults can be on the list.

Nursing Workflow Identify NAS Infant. Initiate NAS protocol. Educate Parents on ESC & Finnegan Scoring Tools. Begin Scoring at 2 hours of age. Then every 2-4 hours to follow while infant is awake until discontinued or discharged home. Follow ESC Algorithm for appropriate interventions and when to notify Healthcare provider. (ESC Algorithm to follow and laminated in all baby charts) RN should accompany physician when rounding for accurate continuity of infant’s care with parents. RN should write a progress note after two scoring assessment with ESC with answers of “no” or when any update of physician is completed. Rounding: Should be done minimally of every hour by RN, more frequent check ins and observations of feeds and cares required for NAS support and education of caregivers. ( would be great to have NAS patient placed in rooms 2506,2507, or 2509 for better observation and workflow) Initiate Substance exposed/Neonatal abstinence care plan.

EAT, SLEEP AND CONSOLE (ESC) ALGORITHM FOR NURSES Start ESC Scoring together with Finnegan Scoring every 2-4 hours and only when patient is awake Continue to monitor ESC Scoring together with Finnegan Scoring every 2-4 hours and only when patient is wake until physician discontinues the order ESC Scoring involves documenting an answer of “YES” or “NO” to the following questions: Can an infant breastfeed well or eat > 10ml per feeding (finger or bottlefeeding) Can an infant sleep > 1 hour? Can an infant be consoled within 10 minutes? “YES” to all three questions “NO” to any question “NO” to any question “YES” to all three questions Start the nonpharmacologic intervention that may include the following: Feeding on demand Swaddling and holding Low stimulation environment Parental/Volunteer presence Call Healthcare provider or Pediatrician On-Call for increase in pharmacotherapy Two consecutive ESC scoring documentations of any “NO”

EAT, SLEEP AND CONSOLE (ESC) ALGORITHM FOR NURSES (continued) Any two consecutive ESC scoring documentations of any “NO” Once on pharmacotherapy, admit to SCN, place on CR monitor and pulse oximeter Call Healthcare provider or Pediatrician On-Call for pharmacotherapy “YES” to all three questions Continue to monitor ESC Scoring together with Finnegan Scoring every 2-4 hours and only when patient is wake until physician discontinues the order Discontinue CR monitor and pulse oximeter once off pharmacotherapy Discontinue scoring 24 hours after pharmacotherapy is discontinued If Patient falls outside of the algorithm, questions, or concerns, consult Healthcare Provider or On-Call Pediatrician for further care instructions.

EAT, SLEEP AND CONSOLE PARENT EDUCATION Eat, sleep and console is a way to watch your baby for signs of substance withdrawal. The nurse watches your baby closely for the recommended stay advised by your doctor. The nurse will score your baby every 2 to 4 hours while baby is awake. The nurse scores “yes” or “no” for eat, sleep and console. The nurse is watching baby for the following signs of withdrawal. EAT Baby will be scored for poor eating if: Baby can’t eat within 10 minutes of acting hungry Baby can’t eat at the breast well AND/OR with a bottle/syringe/finger of 10 mL because baby is fussy, shaking, or is sucking extra GOOD FEEDINGS: Baby eating early with hunger signs without any limit on how long baby eats or the amount Breastfeeding: Baby can latch deep and with a comfortable latch for mother. Baby is actively sucking only taking small breaks. If you need help with breastfeeding please ask for help from lactation or nurses. Bottle Feeding: Baby can eat without gagging, drooling or spitting up. If you need help with bottle feeding please ask for help from the nurses. Nurses can help and see if baby needs a different bottle position or type of nipple. SLEEP Baby will be scored for poor sleeping if: Baby sleeps less than 1 hour after eating because baby is fussy, shaking and uneasy or is easily scared The nurses can help provide hints for helping baby sleep safely CONSOLE Baby will be scored if they are not able to be comforted if: Baby continues to cry and be fussy for 10 minutes or more and can’t be comforted by the person caring for the baby A great way to help your baby be comfortable in its new world is to have baby in the room with you as much as possible and give them loving care and support.

Parental Education ESC Scoring: Rooming In: We are scoring based on infant’s ability to function. Is the infant able to eat, sleep, and be comforted? Infant is scored every 2-4 hours while awake only. Do not wake infant to score. Infant will be scored using ESC and Finnegan scoring tools. Infant will be treated based off the ESC scoring tool. If infant scores a “no” for two consecutive ESC scoring assessments then Healthcare Provider is contacted to discuss pharmacotherapy treatment. If pharmacotherapy treatment is ordered, infant is admitted into SCN. Non-pharmacologic interventions should be initiated, taught, and reinforced with parents/caregivers. Rooming In: Parental involvement is strongly recommend to provide the best comfort & support for the infant. Once mother is discharged, a Visiting Caregivers list can be established and utilized in times when a parent can not be present. Parents can not be absent for more than 4 hours in a day. Only 4 adults (greater than 18 years old) can be placed on Visiting Caregivers list. Visiting Caregiver must have a ID with them and be validated by Birth Center RN prior to assuming cares and parent leaving. Must obtain a badge identifying them as the Visiting Caregiver. Visiting Caregiver must remain in patient room caring for infant at all times. May call RN for assistance as needed or if needs to leave before parents return. NO Visiting Caregivers allowed to overnight stay. Only Parents!! Parents must keep Identification bracelets on until infant is discharged. Reinforce Safe Sleep Practices & Guidelines for parents/caregivers to follow.

WAYS TO HELP COMFORT BABY Picks up baby Holds baby skin-to-skin or swaddled in blanket Gently rocks baby Talking softly and slow to calm baby down Keep talking calmly to infant and place hand firm but softly on baby’s belly Gives pacifier or finger for baby to suck on Person caring for baby looks for hunger signs and helps bring infant’s hand to mouth to help calm baby Feeding baby if they are acting hungry Sound machine in room Hospital swing use in room only during the day when baby is being watched  If your baby can not eat, sleep and console easily for more than one scoring the nurse will contact your baby’s doctor to talk about possible changes in care. Page 2 Page 1

**** Found in SCN drawer **** NAS Rooming-In and Visiting Caregiver Guidelines/Expectations Infants that are exposed and withdrawing from drugs require close observation and some special care. A great way to help them is to room-in with them as much as possible and provide them loving care and support. We understand that there may be a times, you may need to step away from your infant for appointments or other childcare responsibilities. The follow are the guidelines to establish a visiting caregivers list in your absence. Rooming-in strongly encouraged at all times. All caregivers will use safe sleep practices. All caregivers will use good hand hygiene. Banded parents may only be gone for 4 hours per day unless medically indicated. ONLY banded parents may room in overnight with infant. A banded parent or a verified visiting caregiver should be present with infant at all times. Visiting caregiver is responsible to attend to infant’s needs until parents return. Banded parent MUST notified RN when leaving unit for visiting caregiver to be verified and given proper badge. Visiting caregiver must have photo ID to assume cares. Once banded parent returns RN to be notified. Visiting caregivers list will be established once mother is medically discharged. Maximum of 4 adults can be on the list. Infant’s Name___________________________ Parents (Banded Caregivers) 1.______________________ 2.______________________ Visiting Caregivers: 1.____________________________ 2.____________________________ 3.____________________________ 4.____________________________ **** Found in SCN drawer ****

Challenges How to educate patients/families on the process How to accommodate mom’s longer stays Will ESC replace the Finnagen tool? How do we focus on ESC while keeping safe sleep

Learning Collaborative Sessions: Schedule & Format Upcoming WebinarMeetings: Invite your team of opioid project champions to gather together Weekday Date Time Topic Wed Dec 12 12:00– 1:00 pm Learning Collaborative Sessions: Schedule & Format Nursing

Thank you. For additional information, contact Sue Kannenberg at kannenberg@perinatalweb.org or 608-285-5858 ext. 205