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Best practice №27

Implement opioid use disorder discharge checklists for all hospital-based points of entry

transition-of-care

by Elliott Main, Jacqueline Rad

Last updated October 7th, 2020

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Overview

All collaborators for the Plan of Safe Care (refer to Best Practice # 29) should focus on interventions that take into consideration the safety and needs of both mother and newborn.  While there has been extensive attention to a Plan of Safe Care for the newborn, a plan for the mother is equally important.  The Plan of Safe Care should instill confidence in the mother in her ability to care for herself and her newborn; build trust and relationships with providers and other health and wellness partners; facilitate connections to resources; and ensure access to care that is inclusive of the mental, emotional, and physical aspects of opioid use disorder (OUD) postpartum and newborn health, and motherhood.  

The following Plan of Safe Care discharge recommendations are best practice guidelines known to support the safety, recovery, and wellness of the mother/baby dyad, yet they should not limit the provision of resources, support, and/or interventions that may be necessary to overcome unique situations and challenges of individual mothers and newborns. 

Every episode of care is an important opportunity to implement a Plan of Safe Care regardless of the point of entry or disposition (e.g., delivered or undelivered). Some patients have not received prenatal care, been referred to and/or participated in available support services, and may initially present to an emergency department or an alternate point of entry for care.  Pregnant women presenting to the emergency department prior to 20 weeks gestation are traditionally declined by L&D units for interdepartmental transfer and, therefore, only receive care in the emergency department. Finally, not all pregnant women who present to labor and delivery (L&D) units will progress to delivery.  

Why we are recommending this best practice

For some pregnant women, L&D units and emergency departments are the first providers of pregnancy-related care; in fact, these environments may be their only source of care during pregnancy. Providers should understand that:

  • Recognition and identification of mothers with OUD at the earliest point of care will support efforts to protect the fetus from continued opioid exposure and sequela and will support maternal recovery and wellness. 

  • Reinforcement and assessment of the Plan of Safe Care during each episode of care is an opportunity to prevent program fallouts through reinforcement of positive behaviors through praise and recognition of successes and the identification of challenges and barriers to participation, gaps of service/support, and new service/support needs.  

  • Transitions of care (e.g., hospital discharges) place the OUD screen positive mother/baby dyad at risk due to potential gaps in service, communication, and understanding of the Plan of Safe Care.  

  • Implementation of a discharge checklist supports the team and individuals responsible for this complex discharge by aiding memory, team communication, and consistency of practice.  All elements of the discharge checklist should be evidence-based, taking into consideration the unique characteristics of the mother/baby dyad and the community into which they are being discharged.   

  • Postpartum women with OUD are at very high risk for perinatal mood and anxiety disorders and should be screened using the Edinburgh Postnatal Depression Scale or the PHQ-9 plus GAD-7 prior to discharge.


The Discharge Checklist (please see example in the Resources section of this Best Practice):

  • Provides an opportunity to identify and implement opportunities for reinforcement of the OUD plan of care.  

  • Ensures consistency of best practices and equity of the services, referrals, and resources required to achieve and sustain recovery and wellness. 

  • Should support/encourage breastfeeding if not contraindicated.
    • Women should feel empowered to make an informed decision about infant feeding.
    • Women should be given complete information on the benefits of breastfeeding and the recommendations surrounding OUD and breastfeeding. 

Strategies for implementation

This is a critical portion of the toolkit and we have therefore provided especially detailed implementation steps.

  • Identify and assess all hospital-based points of entry (inpatient/outpatient) used by the pregnant OUD patient (e.g., L&D, antepartum, emergency department). 

  • Engage hospital leadership and partner with department leaders to recruit at least one provider and staff champion from each identified point of entry for support and implementation of the standardized maternal OUD screen positive discharge checklist.

  • Explain the importance of a discharge checklist with identified care providers and teams.  Get their buy-in. 
    • What is the goal? 
    • What is the benefit of implementation for the patient, provider, and community?

  • Assess culture and staff readiness for implementation of a checklist.

  • Understand the roles and responsibilities for the discharge planning project.
    • Who comprises the care teams? 
    • Where is discharge occurring? 
    • Who is creating the discharge plan?
    • Who is facilitating the discharge?
    • Who is providing/managing care for pregnant and/or delivered mothers in the inpatient and outpatient settings?
    • Where is the discharge occurring (e.g., L&D, postpartum, antepartum, emergency department, medical/surgical unit)?
    • Who are the receiving teams for discharge (e.g., community, provider resource, service representatives)? 

  • As a team, create and/or adopt an evidence-based OUD discharge checklist (please see the Resources section of this Best Practice for an example)

  • Circulate the OUD discharge checklist and provide education for all care providers responsible for discharge of the OUD mother and newborn.

  • Use the teach-back method to ensure all staff understand:
    • Tool use
    • Goals of a successful maternal OUD discharge 
    • Shared accountability of the tool and use of standard work 
    • Resources available for support

  • Monitor use of the OUD discharge checklist:
    • Regularly observe the process 
    • Audit patient charts for standard work compliance and completion/support of the elements of the Plan of Safe Care.

  • Encourage and sustain use of the OUD discharge checklist by providing feedback to staff about: 
    • Successes and opportunities of tool use
    • Case outcomes

  • Monitor outcomes:
    • Assess the discharge checklist and process early and often after implementation.
    • Ask for feedback related to successes, challenges, and barriers. Be open to feedback. 
    • Use feedback and outcomes data to guide quick tests of change that support quality improvement.

Deep dive

The checklist has quickly become the gold standard for high reliability health care organizations that want to provide exceptional, team-based care. For example, the Safe Surgery Checklist was adapted for use in U.S. hospitals in 2009 and quickly became the benchmark for improving quality and safety in the surgical suite. But are checklists enough to save lives? 

In 2017, the New England Journal of Medicine published a report1 on the BetterBirth Study, one of the largest maternal-newborn studies with over 300,000 women and their babies, that looked at maternal and newborn outcomes after implementation of the WHO Safe Childbirth Checklist. The checklist improved adherence to best practices that are associated with better outcomes; but in this large-scale study in India, there was no difference in perinatal mortality, maternal mortality, or maternal morbidity between the control and intervention groups, even though the intervention groups showed high adherence to the checklist protocols. 

Checklists in and of themselves are not enough. A discharge checklist cannot simply be about “checking the box.” The postpartum period is the most complex for mother and newborn, with multiple opportunities for relapse and the resulting sequelae. Therefore, the discharge checklist must be about providing better communication between all care providers; inpatient providers must better engage with their outpatient counterparts and community-based organizations who will be responsible for helping the patient navigate a complex pathway to recovery. It’s about changing the system, not just checking a box. 

Reference: Semrau KEA, Hirschhorn LR, Marx Delaney M, et al. Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India. The New England journal of medicine. 2017;377(24):2313-2324.

Resources

References

  • Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540- 560.
  • MCPAP for Moms Toolkit. Massachusetts Child Psychiatry Access Project. www.mcpapformoms.org.
  • ACOG committee opinion no. 757: screening for perinatal depression. Obstet Gynecol. 2018;132(5):e208-e212.
  • Semrau KEA, Hirschhorn LR, Marx Delaney M, et al. Outcomes of a coaching-based WHO safe childbirth checklist program in India. N Eng J Med. 2017;377(24):2313-2324.

Elliott Main

MD, FACOG

Dr. Main is the Medical Director of the California Maternal Quality Care Collaborative (CMQCC) and has led multiple state and national quality improvement projects. He is also the Chair of the California Pregnancy-Associated Mortality Review Committee since its inception in 2006. For 14 years, he was the Chair of the OB/GYN Department at California Pacific Medical Center in San Francisco. He is currently clinical professor of Obstetrics and Gynecology at Stanford University. Dr. Main has been actively involved or chaired multiple national committees on maternal quality measurement. In addition, he helps direct a number of national quality initiatives with ACOG, the CDC and Maternal Child Health Bureau (HRSA) including the multi-state AIM project. In 2013, Dr. Main received the ACOG Distinguished Service Award for his work in quality improvement.

Jacqueline Rad

MSN, RN

Jacqueline Rad  is the nurse manager for the Family Birth Center at Sutter Lakeside Hospital where she provides patient-centered care to mothers and newborns exposed to opioids, and teaches providers and nurses about the challenges these families face.