765 - Implementation of eat, sleep, console protocol in a rural community hospital: a success story

The opioid epidemic in United States resulted in an increased number of infants with neonatal abstinence syndrome (NAS). The traditional method of treating NAS with pharmacological management led to prolonged NICU stay and extensive exposure to medications. We adopted the family centered, non-pharmacological approach, “eat, sleep, console (ESC)” with as-needed use of morphine. Implementation of such projects could be challenging in resource-limited settings.

Objective:

To successfully implement ESC guidelines for NAS management, reduce length of stay (LOS) to < 7days, and decrease medication use by >80% within 1 year. 

Design/Methods: We conducted a quality improvement project at a level II and a level III NICU from Oct 2021-Dec 2022. Retrospective quarterly data were collected from Jan 2020-Oct 2021. Infants born at ≥35 weeks of gestational age who were exposed in utero to opiates were included; infants requiring NICU admissions for other reasons and transferred out were excluded. A multidisciplinary team was created, and extensive education was provided to all clinical providers. Multiple interventions were performed during the study period (Fig 1). Historically, all patients requiring medical management for NAS were admitted to the NICU; however, with ESC implementation, most patients were managed in non-NICU locations.

Results: A review of retrospective data revealed that ~60% of the patients with in-utero exposure to opiates required medical management, and ~40% of them were observed (Table 1). After implementation of ESC protocol, there was a significant reduction in the proportion of patients requiring medical treatment (3%, Fig 2). Only 1 of 36 patients received medical management; none of the patients required adjuvant therapy. The LOS for NAS patients decreased substantially from an average of 14.5 days to 5.5 days (62% reduction, Fig 3). Days of therapy (DOT) reduced from ~9 days to 0.5 days, and number of morphine doses reduced from an average of ~70 doses to 4 doses per exposed patient (Table 1). None of these patients required readmission within 30 days of discharge. Considering ~$12,000/day of estimated NICU cost, ESC implementation reduced the hospital cost by >$3 million in less than 1 year.

Conclusion(s):

A multidisciplinary approach can lead to successful implementation of an ESC program. This value-based care initiative helped reduce LOS, NICU admissions, and medication exposure for infants born with in-utero exposure to opiates and led to a huge cost reduction in our health care system.