P2.H153: Achieving Equitable Toxicology Testing Utilization in the Newborn Nursery

Purpose/Objectives: The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend that all infant-birth parent dyads be screened equitably for risk of Neonatal Opioid Withdrawal Syndrome (NOWS). Toxicology testing of the infant (TOX) can support a clinical diagnosis of NOWS, but TOX utilization has been shown to vary by birth parent demographics. Our newborn nursery (NBN) reviews each birth parent chart, asks each birth parent about substance exposure, and monitors serial clinical exams to identify infants at risk of NOWS. We aimed to align the accuracy of TOX utilization across demographic groups to achieve >90% accuracy in 1 year without inhibiting detection of symptomatic NOWS.

Design/Methods: Included infants were admitted to the NBN for greater than 2 hours between January 1, 2019 and December 31, 2023 and identified using I2B2 with data extraction using Honest Broker and manual chart review. Infants deceased during the birth hospitalization were excluded. Pareto charts of indications for toxicology testing prioritized PDSA cycles (Figure 1). TOX frequency and accuracy were tracked on P charts. Process measures of TOX obtained for cannabinoid exposure, limited prenatal care, or without a documented reason were tracked on C charts. Balancing measures included rate of NOWS diagnosis tracked on U chart and NOWS diagnosis without TOX obtained followed on G chart. Montgomery rules defined special cause variation (SCV). While not part of this QI project, our institution opened a perinatal substance use disorder (SUD) clinic in January 2023.

Results: During the study period, 14626 included infants were admitted to NBN, 729 infants received TOX, and 70 received a diagnosis of symptomatic NOWS. PDSA #1 & 5 resulted in downward SCV in TOX and aligned accuracy of TOX utilization across demographic groups (Figure 2). Throughout the project, downtrend in TOX obtained for no indication was a motivational metric to share with stakeholders. NOWS diagnosis showed downward SCV around PDSA#5, which also coincides with births managed through our institution’s dedicated perinatal SUD clinic.

Conclusion/Discussion: Removal of prenatal cannabinoid exposure and limited prenatal care as indications for TOX aligned accuracy across demographic groups, with disproportionate improvement for infants born to black birth parents. However, diagnosis of symptomatic NOWS decreased toward the end of our study period. This may reflect increased integrated care through our institution’s SUD clinic, which may decrease the rate of symptomatic NOWS diagnosed at our center. A limitation of our analysis is that an infant could discharge from the nursery prior to development of NOWS symptoms. However, over testing subgroups of our nursery population, e.g., infants born to black birth parents, is an ineffective way to address this. Next steps include standardizing prenatal historical questionnaire screening, and transition to umbilical cord tissue testing.