PC1064: Chasing Equity in Toxicology Testing in the Newborn Nursery

Purpose/Objectives: The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend that all infant-mother dyads be screened in an equitable manner for Neonatal Opioid Withdrawal Syndrome (NOWS). Screening approaches vary and may be influenced by socioeconomic status, race, and marital status of the birth parent. Our Level I&II newborn nursery (NBN) uses universal questions to screen all birth parents and then obtains toxicology testing (TOX) for infants if risk factors are identified. We aimed to align the accuracy of this screening process across demographic groups to achieve >90% accuracy in 1 year without inhibiting detection of symptomatic NOWS.

Design/Methods: Included infants were admitted to the NBN between January 1, 2019 and January 28, 2022 and identified using I2B2 with data extraction using Honest Broker and manual chart review. A Pareto chart of baseline data prioritized high-impact intervention opportunities (Fig 1). Percentage of each demographic group receiving TOX and corresponding screening process accuracy were tracked on P charts. Process measures of TOX obtained for solely prenatal cannabinoid exposure and TOX obtained without a documented reason were tracked on C charts. Balancing measures followed on U charts included rate of NOWS diagnosis and NOWS diagnosis without TOX obtained. Montgomery rules defined special cause variation (SCV). PDSA#1 occurred in July 2021 with discontinuation of TOX for infants born to parents with solely prenatal cannabinoid use. PDSA#2 in December 2021 provided standardized EMR documentation of risk factors warranting TOX.

Results: 6892 infants met inclusion criteria during the baseline study period and 1795 infants met inclusion criteria after PDSA#1 implementation. Infants of birth parents who self-identified as black received 60% of the toxicology testing despite being only 26.8% of the total NBN population and only 17.5% of the NOWS diagnoses during the baseline period. No infants whose toxicology testing was obtained solely due to prenatal cannabinoid exposure developed NOWS or had toxicology testing positive for opioids. PDSA#1 was followed by downward SCV in TOX by 50% and improved accuracy of the screening process across demographic groups (Fig. 2). Accuracy most improved for infants of black birth parents (82.8% to 91.3%) after PDSA#1, although infants of black birth parents remained more frequently tested and less frequently diagnosed with NOWS in comparison to infants of white birth parents. Balancing measures did not show SCV. Toxicology testing without accompanying documentation of indication for testing stopped occurring prior to PDSA#2.

Conclusion/Discussion: Prenatal cannabinoid exposure was a low yield “risk factor” for NOWS. Removal of this indication reduced TOX rates and improved screening accuracy across demographic groups, with disproportionate improvement for infants born to black birth parents. Opportunities to improve equity in NOWS screening remain.