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Years Active: 2012-2015


Abstinence Syndrome


This collaborative inter-institutional QI project seeks to improve the health of infants admitted to the NICU for management of Neonatal Abstinence Syndrome in Tennessee. Clearly many of the social and upstream contributors to NAS length of stay are beyond the span of control of the hospital nurseries. However, substantial opportunities for optimizing in-patient management, and thereby minimizing impact to the infant, the family, and society are possible. Thus, we seek to optimize our management by attaining high reliability (>90%) processes for NAS scoring, NAS treatment initiation and weaning, and post-NAS discharge preparation by December 2013.

During discussions at the 2010 Fall Regional Learning Session in Knoxville, participants noted an increase in admissions for management of Neonatal Abstinence Syndrome (NAS) and suggested a statewide improvement project was needed to identify and spread evidence-based approaches to management. The TIPQC membership subsequently voted to develop and pilot test an NAS management project, and a development team was formed in 2011 to review the literature and assemble a QI toolkit.

State level stakeholders became more directly involved in the development process as the scope of maternal opiate use became increasingly apparent and cases of NAS increased markedly in the eastern half of the state. A State Round Table Conference was hosted by East Tennessee Children’s Hospital on November 12, 2012 to facilitate input to the TIPQC toolkit. Participants including Commissioners and senior leaders from the Tennessee Department of Health, the Tennessee Department of Children’s Services, TennCare Managed Care Organizations, the Tennessee Hospital Association and other advocacy groups provided expertise and discussed opportunities for both local and state level collaboration to address the challenges presented by rapidly increasing numbers of NAS cases. The TIPQC Neonatal Absinence Syndrome (NAS) Project Kick off was held on February 25, 2013 with 90 attendees from 15 TN hospitals as well as representatives from state government, advocacy groups, payers, and other state perinatal collaboratives.

In addition to implementing evidence-based approaches to the management of NAS, the TIPQC NAS project included tests of a number of new collaborative partnerships to facilitate large-scale improvement. Prior to implementing mandatory reporting of NAS cases, the Tennessee Department of Health and the TIPQC development team coordinated operational definitions for NAS identification in an effort to minimize the NAS data burden at the local level. Additionally, to incentivize local-level project start up, United HealthCare offered participation grants to teams that met criteria for submission of data and project involvement.

Despite active and coordinated state level stakeholder support, local change teams encountered a number of challenges. Teams experienced widely varying delays in project start up arising from difficulty securing local Institutional Review Board review prior to participation in this quality improvement project. Additionally, inter-institutional variation in interpretation of the HIPAA-HITECH final rule necessitated a project wide pause in data entry while data use agreements and business associates agreements were reviewed, and subsequently re-negotiated as required where possible.

By the end of 2014, participating teams had made substantial progress toward high-reliability NAS screening, diagnosis, scoring, and implementation of both non-pharmacological and pharmacological management of infants with NAS. Inter-institutional variation in length of stay diminished, and both project wide aggregate length-of-therapy and length-of-stay decreased (Preliminary provisional QI data at right).

In late 2014, TIPQC joined the multi-state NAS project led by the Ohio Perinatal Quality Collaborative (OPQC) funded by an unrestricted investigator initiated grant from Cardinal Health Foundation. At the 2015 TIPQC Annual Meeting NAS Breakout Session participating hospital teams voted to transition to OPQC operational definitions and data structures to facilitate continued work on NAS in Tennessee and collaboration with other state NAS QI efforts.

Monthly aggregate length of stay by month of admission for NAS management, preliminary provisional data in Xm chart format subject to revision.
Monthly aggregate percentage of infants receiving non-pharmacologic management of NAS, preliminary provisional data in p-chart format subject to revision.

Project Resources

QI Project Guidance

TIPQC NAS Project Toolkit

Active Participating

Hospital Teams

  • Baptist Memorial Health Care
  • Baptist Memorial Hospital – Tipton
  • Children’s Hospital at Erlanger
  • East Tennessee Children’s Hospital
  • Erlanger Health System – East Campus
  • Gateway Medical Center
  • Holston Valley Medical Center
  • Monroe Carell Jr. Children’s Hospital at Vanderbilt
  • Niswonger Children’s Hospital
  • TriStar Centennial Medical Center
  • The University of Tennessee Medical Center

State Project Leaders

Barbara Engelhardt, MD from Monroe Carell Jr. Children’s Hospital, Sheri Smith, RN, Terry King, PharmD, and Carla Saunders, APN, from East Tennessee Children’s Hospital, Mark Anderson, MD from the University of Tennessee Medical Center, and Karen D’Apolito from Vanderbilt University brought a truly multi-disciplinary approach to this timely project.



TIPQC is actively recruiting devoted health care professionals, community leaders and patient and family partners to further our mission of improving health outcomes for mothers and babies in Tennessee.