A Roadmap to Improved Quality Outcomes in Neonates Exposed to Illegally Manufactured Fentanyl

The incidence of neonatal opioid withdrawal syndrome (NOWS) has dramatically increased, and illegally manufactured fentanyl may be a significant contributor. The optimal treatment approach for an infant experiencing severe withdrawal from fentanyl is unknown. Our aim was to decrease the mean length of stay (LOS) by 20% over 19 months for infants with NOWS by implementing a transitional phase before establishing our modified Eat, Sleep, Console (ESC) model of care.

A multidisciplinary team used quality improvement methodology to improve treatment of NOWS in 2 phases, each adapted to fentanyl's complex pharmacology. Beginning May 2023, a hybrid Finnegan/ESC protocol was implemented to address hospital barriers for a year before initiating full ESC management. Data were collected on infants >35 weeks of gestational age admitted to a level III neonatal intensive care unit. Primary metrics included LOS and total days/doses of morphine. Rates of apnea and naloxone were used as balancing measures. The LOS was plotted on a statistical process control chart and the data were summarized with descriptive statistics.

Outcomes were analyzed for 217 infants. The aim was exceeded with a mean LOS reduction of 29% (hybrid) and 49% (ESC). On average, decreased morphine days (22.5, 11.2, 6.9, P < .001) and doses (162, 63, 14, P < .001) also were observed. No significant apnea occurred, nor was naloxone used.

This quality improvement project provides a successful fentanyl-adapted ESC model that may be adopted to decrease postnatal morphine usage and LOS.