Avoiding NICU Transfers for Newborns With Neonatal Opioid Withdrawal Syndrome (NOWS): A Quality Improvement Initiative to Manage NOWS on the Mother-baby Unit.

Objectives: To reduce transfers to the neonatal intensive care unit (NICU) for neonates with opioid withdrawal while also reducing length of stay and pharmacologic intervention, and maintaining standards of safety.
Patients and Methods: This was a single-center quality-improvement (QI) initiative in a free-standing maternity hospital comparing outcomes for neonatal opioid withdrawal syndrome (NOWS) before and after a series of QI bundles in infants >36 weeks' gestation age (GA). We compared outcomes to our preintervention period (January, 2013 to December, 2013; n = 42) with outcomes postintervention cycle 1 (October, 2016 to September, 2017; n = 126), and postintervention cycle 2 (November, 2017 to October, 2018; n = 160). Cycle 1 included organizing a multidisciplinary task force who focused on emphasis on nonpharmacologic and dyad-centered care, and also standardized pharmacologic management. Cycle 2 reflects the transition to a functional assessment tool and as-needed morphine administration on the postpartum floor.
Results: Transfer to the NICU for management of NOWS dropped from 71.4% before the quality improvement project down to 5.6% (P < 0.001), with the remainder managed on the mother-baby unit. Length of stay decreased from 17.8 days to 7.2 days, and opioid replacement dropped from 60% down to 16% (P < 0.001 for both). There were no adverse events from morphine administration for any of the infants in this series.
Conclusions: Our study demonstrates how care can be safely provided to most infants with neonatal opioid withdrawal on a postpartum unit without needing transfer to another unit or a higher level of care facility.