Opioid use has reached crisis levels in part because of prescription drug abuse. According to the National Institute on Drug Abuse, 80 percent of people who use heroin first misused prescription opioids, either prescribed to them or obtained illegally. Rather than sit back idly and watch the epidemic unfold, many healthcare organizations – including Cleveland Clinic – are proactively involved in finding solutions and curbing the crisis.
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Every institute and service line at Cleveland Clinic is committed to combating opioid addiction – even those that might seem at first glance to be least affected, such as the mother/baby unit at Cleveland Clinic Fairview Hospital. (And all Cleveland Clinic hospitals with mother/baby units have taken steps to reduce opioid use in labor and delivery areas.)
“Cleveland Clinic has tackled the opioid crisis from every angle,” says Denise Speer, MSN, RN, Director of Women’s and Children’s Service at Cleveland Clinic Fairview Hospital. “We have an overarching task force that includes smaller task forces, each one focused on helping people at different points in their lives.”
For pregnant women and their babies, that’s the Opioid Addiction in Pregnancy Task Force led by Rebecca Starck, MD, an obstetrician and gynecologist who serves as President of Cleveland Clinic Avon Hospital. Nora Knipper, MSN, RN, Nurse Manager of the mother/baby unit at Fairview Hospital, is a member of that task force. She has supported the implementation of several new protocols on her unit to help decrease opioid exposure and support a population health approach.
“Being part of Cleveland Clinic, we care about the whole person – the whole community,” says Knipper.
Three new protocols
In the past two years, the mother/baby unit has instituted three protocols:
- Newborn Withdrawal Protocol – Babies who are exposed to opioids in utero are typically sent to the newborn nursery unless they are sick. Clinical nurses in the nursery are the first set of caregivers to assess those babies using the Modified Finnegan’s Neonatal Abstinence Scoring Tool, which scores babies on 21 signs and symptoms frequently observed in opiate-exposed babies. These include cry pitch, sleep, startle reflex, tremors, respiratory rate, poor feeding, regurgitation, loose stools and hypothermia. When scores reach a specific level, the babies are transferred to the neonatal intensive care unit for medication.
“The NICU manager and I worked to develop the nursery nurses’ competence skill set in scoring these babies,” says Knipper. “The goal was to prevent delays in treatment for babies that needed medication.” Because some of the scoring is subjective, nurses reviewed each of the criteria on the scoring tool and explained why they gave babies certain scores. NICU nurses also score babies using the Modified Finnegan’s tool, so Fairview Hospital sought to improve inter-rater reliability. Nurses on each unit compare scores to see if they are in agreement.
- Newborn Treatment Protocol – Cleveland Clinic participates in the Ohio Perinatal Quality Collaborative (OPQC), which strives to reduce preterm births and improve birth outcomes. The three Cleveland Clinic hospitals that deliver babies – main campus, Fairview Hospital and Hillcrest Hospital – adapted a treatment tool provided by the collaborative to ascertain what medications babies should be given and what signs to look for to either increase or decrease medication. The hospitals have been using the new protocol and treatment guidelines for more than a year.
“The treatment protocol is a little bit more aggressive. We start babies on treatment sooner, and they don’t have to reach the highest score to get medical treatment,” says Speer. “By capturing them sooner, they have improved weaning off medication to help them withdraw from the narcotic their mother took. We get them comfortable sooner and can wean them off more comfortably.”
The withdrawal and treatment protocols have also improved morale on the mother/baby unit, says Knipper. “We are keeping more babies on the unit that perhaps would’ve automatically bought a ticket to the NICU,” she says. “The nursery nurses are more confident.” Studies indicate that when babies stay with their moms, they do better, adds Speer.
- ROOT Protocol – In 2017, the anesthesia department at Fairview Hospital implemented the Reduced Opioid Option (ROOT) protocol for post-operative C-section patients. Previously, patients were given oral Percocet® or IV Toradol® as needed. Under the new protocol, during the first 24 hours post-op, patients are given staggered doses of Tylenol® (1000 mg PO) and Toradol (15 mg IV) every three hours. For breakthrough pain, patients are offered 15 mg of IV Toradol for moderate pain or 5 mg of oxycodone for severe pain as needed.
In the first year of the new protocol, use of narcotic medications during the first 24 hours following surgery for C-section patients decreased by approximately 70 percent. Eric Chiang, MD, an anesthesiologist at Fairview Hospital who spearheaded the ROOT protocol, credits nurses in the mother/baby unit for its success. “They bought into the importance of the protocol, and when they saw how well the patients did, they accelerated and sustained it for the remainder of the inpatient period. They came together as a unit and educated each other and patients,” says Dr. Chiang. “Nurses were advocates for their patients, and you can see the effect of education and nursing influence.”
In mid-March, the Ohio Patient Safety Institute recognized the new protocol with a best practice award. The data generated during the first year of the protocol supports Dr. Chiang’s recommendation to decrease the number of narcotic pills prescribed at discharge by 50 percent, down to 10 pills from an average of 20 pills.
Hope for the future
Nurses in the Women’s and Children’s Service hope that these new protocols, along with others such as one that identifies pregnant mothers and babies at risk for narcotic addiction in the outpatient setting, help curtail the opioid crisis. “We are concerned about the health of both moms and babies,” says Speer. “We have a window of opportunity to convince pregnant women that we want to help them and we want their babies to be born healthy.”
Knipper says that providing quality, nonjudgmental care for post-partum mothers, particularly those who are addicted to narcotics, is critical to moving the needle on addiction. “No one wakes up in the morning and says, ‘I want to be hooked on heroin.’ So my goal with the nursing staff is to encourage them to be supportive. Give patients all the wisdom you have on how to care for themselves and their babies,” she says. “I hope that one day, a patient in recovery will come back and say, ‘The nurse who cared for me made a difference. I’m clean X days because of that.’ We’re not going to save everybody, but we know we are going to make a positive impact in somebody’s life.”