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The practice change
The newborn nursery and neonatal unit in this project care for infants with neonatal opioid withdrawal syndrome using the Finnegan scoring tool, which often leads to medication and long hospital stays. The project replaces it with the Eat, Sleep, Console (ESC) approach, which focuses on whether the infant can eat, sleep and be consoled, and puts nonpharmacological care led by parents first. The units and their figures are illustrative.
Evidence for ESC
In a cluster-randomized trial at 26 US hospitals, 1,305 infants born at 36 weeks' gestation or later with neonatal opioid withdrawal syndrome were enrolled as hospitals moved, at randomly assigned times, from usual care with the Finnegan tool to ESC. Among infants who met the trial's definition of medical readiness for discharge, the time from birth to readiness was 8.2 days with ESC and 14.9 days with usual care (adjusted mean difference 6.7 days). Adverse outcomes were similar in the two groups (Young et al., 2023).
Why implementation outcomes
Knowing an intervention works in a trial doesn't show whether it is being delivered well locally. Proctor et al. (2011) proposed eight implementation outcomes that are conceptually distinct from clinical outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability. Measuring them helps explain why clinical results do or don't improve.
Implementation outcomes at 3 months
| Outcome | Measure | Result |
|---|---|---|
| Acceptability | Staff survey on satisfaction with ESC | 81% of nurses agreed ESC was an improvement |
| Adoption | Percentage of nurses who completed training and used ESC | 94% trained; 88% documented at least one ESC assessment |
| Appropriateness | Staff and parent views of fit with family-centered care | Parents valued being involved; some nurses worried about infants whose parents couldn't stay |
| Feasibility | Time to complete an ESC assessment | Median 6 minutes per assessment |
| Fidelity | Audit of 30 charts against the ESC protocol | 77% fully followed, including the team "huddle" when an infant didn't meet criteria |
| Implementation cost | Training hours and cuddler volunteer coordination | 2 hours of training per nurse; 0.2 full-time equivalent for volunteer coordination |
| Penetration | Percentage of eligible infants managed with ESC | 90% |
| Sustainability | Planned review at 12 months | Champions named on each shift; ESC added to orientation |
The figures are illustrative.
Interpreting the results
Adoption and penetration were high, but fidelity lagged. The most common gap was skipping the huddle that the protocol requires before starting medication, often on night shift. That matters, because a clinical outcome such as length of stay could worsen if medication decisions drift back toward score-based habits. The appropriateness finding about infants without a parent present led to a new cuddler volunteer schedule and guidance for nurses in providing consoling care themselves.
Next Plan-Do-Study-Act cycle
- Add a huddle prompt to the electronic record when an infant does not meet ESC criteria.
- Provide night-shift refresher sessions led by champions.
- Re-audit fidelity in 6 weeks, aiming for at least 90%.
Clinical outcomes to report alongside
Length of stay, the percentage of infants receiving opioid medication, readmissions within 30 days and breastfeeding at discharge, all compared with the baseline year.
References
Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65–76. https://doi.org/10.1007/s10488-010-0319-7
Young, L. W., Ounpraseuth, S. T., Merhar, S. L., Hu, Z., Simon, A. E., Bremer, A. A., Lee, J. Y., Das, A., Crawford, M. M., Greenberg, R. G., Smith, P. B., Poindexter, B. B., Higgins, R. D., Walsh, M. C., Rice, W., Paul, D. A., Maxwell, J. R., Telang, S., Fung, C. M., . . . Devlin, L. A. (2023). Eat, Sleep, Console approach or usual care for neonatal opioid withdrawal. New England Journal of Medicine, 388(25), 2326–2337. https://doi.org/10.1056/NEJMoa2214470
