State and Local Efforts to Address Perinatal Substance Use
When substance use becomes personal What efforts have been put in place at What are the state level we doing in How a hospital network has addressed Indiana? this issue How a community develops a response.
Deborah Evert, RN Performance Improvement/Clinical Informatics Family Beginnings/Acuity Adaptable Eskenazi Health
Indiana Efforts to Address Perinatal Substance Use Perinatal Substance Use Conference August 27, 2019
The 2014 Indiana General Assembly charged ISDH with: • The development of the appropriate standard clinical definition of Neonatal Abstinence Syndrome (NAS) • The development of a uniform process of identifying NAS Indiana • Determine the estimated time and resources needed to Legislation to educate hospital personnel in implementing an Address Drug appropriate and uniform process for identifying NAS Exposed • The identification of standard reporting and trending NAS Newborns diagnoses and related data including the identification of whether payment methodologies for identifying NAS and the reporting of NAS data are currently available or needed • Permissive language for the ISDH to conduct hospital pilots to determine the prevalence of perinatal drug exposure 5
Co-Chairs: • Dr. Maria Del Rio Hoover PSU Task • Dr. John Ellis Force Sixty Member Task Force representing: Established - 2014 • Professional Organizations • Medicaid Managed Care Entities • State Agencies • Private Providers • Consumers
Neonatal Abstinence Syndrome and In-Utero Drug Exposure Algorithm Algorithm INFANT SCREENING AND TESTING : all newborns will have umbilical UNIVERSAL MATERNAL TESTING : verbal screening and toxicology cord samples saved for two weeks testing for maternal use of illicit drugs, opiates or alcohol at the first prenatal visit DISCHARGE and again at presentation for delivery. If no signs , continue Follow Discharge observation and Readiness Protocol Refer for Behavioral provide routine Health Consult and/ Upon delivery, send newborn care Verbal screening Observe infant for Permission granted or additional umbilical cord for and or toxicologic signs for toxicology test: screening if testing tests are positive Send original urine appropriate If signs,or at risk sample for toxicology fo opiate or benzo withdrawal, initiate testing Finnegan scoring Infant has a confirmed Verbal screening Upon delivery, Routine NAS Diagnosis Follow Discharge and toxicologic provide routine Newborn Verbal screening is with or without Readiness Protocol tests are negative Newborn Care Discharge conducted and pharmacologic permission requested treatment for toxicology test Permission refused If signs , send cord for for toxicology test and testing and initiate verbal screening Finnegan scoring positive Permission refused Upon delivery, for toxicology test and observe infant for verbal screening signs for 48 hours negative If no signs , continue Follow observation and Discharge provide routine Readiness newborn care Prrotocol
5P Screening Tool
Recommended Perinatal Action Mother’s status Level of Risk for infant Suggested Action Negative verbal and toxicology Newborn with no identifiable risk No testing recommended at birth screens • Perform urine and cord tissue Positive verbal screen and/or Newborn at risk for NAS positive toxicology screen toxicology screening at birth • Perform Modified Finnegan scoring • Evaluate maternal support resources No known verbal or toxicology Newborns with unknown risk Observe infant for signs • If signs: Send cord for testing and screen during pregnancy Perform Modified Finnegan scoring
Symptomatic (tremor/jitteriness, difficult to console, poor feeding, or abnormal sleep); and NAS Diagnosis Have one of the following: Criteria • A positive toxicology test, or • A maternal history with a positive verbal screen or toxicology test.
• In 2016, statutory language was added that prohibited the release to law enforcement agencies: • “the results of: (1) a verbal screening or questioning concerning drug or alcohol use; (2) a urine test; or (3) a blood test; provided to a pregnant woman without the pregnant woman’s consent.” Addi dditional al • In 2019, statutory language was added to require health providers to: Indiana • use a validated and evidence based verbal screening tool to assess a substance use disorder in pregnancy for all pregnant Legi egislatio ion women who are seen by the health care provider; and • If the health care provider identifies a pregnant woman who has a substance use disorder and is not currently receiving treatment, provide treatment or refer for treatment. • Adds DCS to the list of agencies to which a health care provider may not release the results of certain tests given to a pregnant woman. •
Perinatal Substance Use Hospitals 14 27 Steuben 26 La Grange Elkhart 13 La Porte 1. * Columbus Regional Hospital 7 St.Joseph 28 Noble 2. Community Howard Regional De Kalb Marshall Health Kosciusko Lake 3. Community East- Indianapolis 11 Starke 4. Community North Whitley Allen Jasper 5. Community Hospital of Anderson Fulton 23 24 Newton Pulaski 6. Community South 7. Community Munster Wabash Huntington 8. Deaconess Women’s Hospital Wells Adams Miami 9. Eskenazi Health White Cass 10. Franciscan Health–Indianapolis Benton 22 Carroll 11. Franciscan Health– Crown Point Jay 34 12. Franciscan Health– Lafayette East Howar Grant Blackford 12 Warren 2 13. Franciscan Health– Hammond Clinton 14. Franciscan Health– Michigan City Tippecanoe Madison Delaware Tipton Randolph 15. Franciscan Health– Mooresville 18 Montgomery 16. Good Samaritan Hospital Fountain Hamilton 5 17. Hendricks Regional Hospital Boone 31 Henry 18. * IU Health Ball Memorial Hospital 20 30 Wayne 32 4 19. * IU Health Methodist Hospital Hendricks Hancock Parke Putnam 9 19 20. * IU Health North Hospital 3 17 Rush Marion 21. Margaret Mary Hospital Union Fayette 10 15 6 Shelby 22. Marion General Hospital Vigo Clay 23. Parkview Hospital– Fort Wayne Morgan Johnson 24. Parkview Hospital Randallia Franklin Owen 25. Schneck Medical Center Decatur 21 26. St. Catherine East Chicago Bartholomew Monroe Brown 27. St. Joseph RegionalMedical 1 Ripley Dearborn Sullivan Center– Mishawaka Greene 28. St. Mary Hobart Jennings 25 29. St. Vincent– Evansville Ohio Jackson Lawrence 30. St. Vincent Carmel Hospital 33 Knox Switzerland Jefferson 31. St. Vincent Fishers Hospital Daviess Martin 32. St. Vincent Women’s Hospital 16 Washington Scott 33. St. Vincent Dunn Orange 34. St. Vincent Kokomo Clark Pike Dubois Gibson Crawford Floyd Harrison Warrick Vanderburgh 8 Perry Posey Spencer 29 Source: Indiana State Department of Health, Division of Maternal and Child Health *These hospitals do not use USDTL for cord tissue testing. Their data is included in the screening reports but [Updated July, 2019] not in the positivity reports.
Non-Pharmacologic Care Pharmacologic Care Perinatal Transfer Substance Use Practice Discharge Planning for Women Bundle Discharge Planning for Infant https://www.in.gov/laboroflove/208.htm
Goals To promote a standard policy for all health care providers for best practices Substance in breastfeeding when moms are using prescribed and illicit substances for the health and safety of Indiana’s infants. Use and To establish guidelines for providers regarding methods for counseling Breastfeeding families on how to breastfeed successfully when safe, and for promoting attachment for all babies even when breastfeeding is determined unsafe with using substances. Guidance To evaluate the social and emotional factors as they relate to breastfeeding Document and perinatal substance use populations to determine appropriate patient- centered care plans To ensure families across Indiana have information and necessary resources to achieve success in both breastfeeding and medication assisted therapy follow-up care during pregnancy and after hospital discharge.
• Areas of focus included: • Prenatal Care • Breastfeeding and Perinatal Guidance Substance Use Chart Document • Psychosocial aspects in decisions Format regarding breastfeeding with NAS • Discharge Planning
PSU Data
Positivity Report January 2017 - June 2019 35.0 31.3 30.0 Percent of Positive Cords 25.0 20.0 16.9 14.1 15.0 11.1 10.5 10.0 7.7 3.4 3.1 3.1 5.0 2.7 2.6 2.3 2.2 1.8 1.6 1.4 0.0 Indiana (11,351 cords tested) USDTL (138,989 cords tested)
USDTL Users Monthly • Number of Births each month Reports by • Number of NAS Diagnosis the 15 th of Other Labs the following • Number of Births each month • Number of Cords Tested month • Number of Positive Cords • Number of NAS Diagnosis
Screening Data (January 2017 – June 2019) Number of Births: 79,343 40.0% 36.6% 35.0% 30.0% 25.0% 18.8% 20.0% 15.0% 10.0% 6.6% 5.0% 0.0% Cords Tested Positive Cords NAS Diagnosis
Screening Rates (January 2017 – June 2019) Rate of positive cords per 1,000 live births: 68.7 Rate of positive cords per 1,000 cords tested: 365.7 Rate of NAS diagnosis per 1,000 live births: 12.3 Rate of NAS diagnosis per 1,000 cords tested: 65.6 These data reflect all pilot hospitals regardless of laboratory used.
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