Babies exposed to opioids prenatally often experience withdrawal symptoms once they’re born. “These symptoms are physiologic, such as a higher heart rate, neurologic, such as difficulty feeding, and gastrointestinal, such as spitting up and diarrhea,” says Penn Nursing researcher Eileen Lake. “There are also behavioral symptoms: being hard to console, a piercing cry, jerky body movements.” When enough of the symptoms surface, a newborn may get diagnosed with neonatal abstinence syndrome (NAS).
Incidence of NAS has increased five-fold in the past decade, in line with an uptick in opioid use and addiction in the United States, says Lake, who studies how nursing care across hospitals influences outcomes for at-risk infants. In a new area of research, Lake, along with Penn Nursing fellows Rachel French and Rebecca Clark, Kathleen O’Rourke of the Hospital of the University of Pennsylvania, and Scott Lorch of the Children’s Hospital of Philadelphia, wanted to better understand where newborns with NAS most often receive care.
The research team analyzed three datasets that included more than 3,100 babies diagnosed with NAS at 266 different locations. They found that these newborns were more frequently cared for in poorer quality hospitals, which have been linked to worse patient outcomes. They published their findings in Hospital Pediatrics, a journal of the American Academy of Pediatrics.
“This work really began a decade ago,” Lake says. At the time, she and colleagues were looking at how nursing care might benefit very-low-birthweight infants, those weighing less than 4 pounds at birth. Repeatedly, nurses they interviewed for that research mentioned the need to somehow denote when they had a newborn in opioid withdrawal on their unit.
“Caring for a baby in this kind of withdrawal is very time consuming,” Lake says. “We discovered that for nurses who took care of these infants their patients had additional needs that other critically ill newborns didn’t. We developed an interest in this unique group of vulnerable babies, their parents, and the kind of nursing attention that both required.”
Building on previous findings of Lake’s, the team set out to answer two overarching questions: Where are newborns with NAS being born, and what is the quality and safety of these hospitals? To conduct a retrospective cohort study, they looked at three datasets for the year 2016, the most recent comprehensive data available.
The first, RN4CAST-US, is a survey of hospital registered nurses from California, Florida, New Jersey, and Pennsylvania, states that account for about 25% of U.S. births annually. The survey focuses on hospital work conditions and safety. The researchers also looked at inpatient discharge abstracts from those four states and the American Hospital Association annual survey to measure hospital characteristics and location.
Of 659,403 infants born in the study hospitals, fewer than 1% or 3,130 were diagnosed with NAS. Nurse participants in the RN4CAST-US worked in newborn nurseries or neonatal intensive care units. By scrutinizing the data using careful analytic methods, the Penn team began noticing trends with regard to babies suffering opiate withdrawal.
“Rather than being sprinkled all over in hospitals where babies are born—and that’s most hospitals in the country—these babies are concentrated in certain places,” Lake says. “When we looked at the quality and safety data, they are poorer quality facilities that aren’t as safe.” Specifically, they tended to be teaching hospitals that cared for a lower volume of infants overall each year.
“It’s alarming and unfortunate,” she says. “It leads us to want to look more deeply into the nursing care that these newborns get.”
To that end, Lake and colleagues have submitted a National Institutes of Health grant application aimed at examining nursing factors in a large multi-state sample of hospitals. They want to understand how the resources available to nurses at these places affect how long a critically ill newborn stays, as well as how frequently newborns with neonatal abstinence syndrome get readmitted. “They tend to have a readmission rate higher than other newborns because of the complexities of caring for them and the challenges their parents face,” she says.
Though the research intent was, first and foremost, to crystallize an understanding of where babies with NAS tend to be born, Lake says the findings offer some guidance for hospitals that care for these infants. For one, they can reexamine nurses’ workloads by paying attention to the infants’ and parents’ needs. Beyond that, they can consider care bundles designed for these infants.
“These are immediate first steps,” she says, “and they can better account for the needs of these patients.”
Funding for the research came from the Leonard Davis Institute of Health Economics at the University of Pennsylvania and the National Institute of Nursing Research (training grant T32NR007104 and research grant R01NR014855).
Eileen Lake is the Jessie M. Scott Endowed Term Chair in Nursing and Health Policy, a professor of nursing, and associate director of the Center for Health Outcomes and Policy Research at the School of Nursing at the University of Pennsylvania.
Rachel French is a third-year predoctoral fellow at the Center for Health Outcomes and Policy Research at the School of Nursing and an associate fellow at the Leonard Davis Institute of Health Economics.
Scott Lorch is an attending neonatologist and associate chief of the Division of Neonatology at the Children’s Hospital of Philadelphia.
Kathleen O’Rourke is manager of the Intensive Care Nursery at the Hospital of the University of Pennsylvania.
Rebecca R. S. Clark is a postdoctoral fellow at the Center for Health Outcomes and Policy Research at the School of Nursing and an associate fellow at the Leonard Davis Institute of Health Economics.