P0127 - Evaluation of Safety and Cost Effectiveness of Use of a Higher Threshold for Morphine Therapy in Neonatal Opioid Withdrawal Syndrome (NOWS)

The Finnegan Neonatal Abstinence Scoring System (FNASS) is the most widely used tool for quantifying Neonatal Opioid Withdrawal Syndrome (NOWS) severity and identifying which infants require medication for symptom relief. Three consecutive FNASS scores of 8 or two scores of 12 has typically been used as the threshold for pharmacologic treatment (low threshold). We present a single-center QI initiative aimed at reducing hospital length of stay (LOS) and morphine treatment in NOWS patients by standardizing scoring method and utilizing a new treatment threshold of 3 serial scores of 12 or 2 serial scores totaling 28 or more (high threshold). We present outcomes of 201 children with prenatal opioid exposure born between 2016-2018. All FNASS scores were reviewed to determine whether patients met the low versus high pharmacologic treatment threshold, along with birth demographics and substance exposure history. To explore safety as a balancing measure of using a higher threshold for pharmacotherapy and possible decreased LOS, EMR data was reviewed for hospital readmissions, emergency room visits, post-discharge foster care placement, non-accidental trauma, failure to thrive, and/or seizure. Outcomes were compared across three groups: high threshold, low threshold, and a group that did not meet the low threshold. Group outcomes that were dichotomized were compared using chi-square analyses. Continuous outcomes (e.g., LOS) were analyzed using univariate analyses of variance (ANOVAs). Using the high FNASS threshold, 47 patients (23%) did not receive pharmacologic NOWS treatment, and an additional 12 patients could have avoided morphine treatment if compliance with the higher treatment threshold had been 100%. There was a 9-day reduction in average LOS with use of the high threshold. Hospital readmission within 30 days of discharge remained infrequent across groups (4% to 6% of patients). Foster care placement and failure to thrive occurred most frequently in patients who did not meet the low or high threshold for NOWS treatment, but differences across groups were not significant with respect to any post-discharge outcome. Utilization of 3 serial scores of 12 or 2 scores totaling 28 did not result in greater healthcare utilization in infants who were spared pharmacotherapy for NOWS. Additional resources may be needed to address growth and nutrition given the increased diagnosis of failure to thrive in groups with low FNASS scores, who transitioned more quickly to outpatient care. The 9-day decrease in hospital LOS would reduce the cost of NOWS care by $10,548 per patient, and saved $495,756 for the entire QI cohort. Additional PDSA cycles should focus on improving provider compliance with the treatment algorithm and standardizing nutrition plans for transition to the outpatient setting.