Please work with your team to complete this birth site-level survey for the designated quarter, starting with January through March 2022.

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* 2. What is your name?

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* 3. What is your title/role?

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* 4. At the end of the quarter, what cumulative percentage of nurses caring for newborns in the nursery and/or NICU have been trained on validated assessments for NAS in the past year? (Report estimate in 10% increments rounding up)

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* 5. Based on your answer to Question 4, please select the validated assessment your team is using: (please check all that apply)

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* 6. Does your PA PQC hospital have quality improvement efforts in place to increase and maintain inter-rater reliability for NAS assessments?

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* 7. Is your hospital using standardized definitions for Substance Exposed Newborns (SENs)?

Note: The PA PQC defines SEN as in-utero exposure to any alcohol or other drug (AOD) substance.

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* 8. Is your hospital using standardized definitions for Neonatal Abstinence Syndrome (NAS)?

Note: The PA PQC defines NAS as clinical signs of withdrawal from in-utero exposure due to any of the following prescription or illicit drugs:
(a) opioids (which includes Medication for OUD (e.g., buprenorphine and methadone), natural opioids (e.g., morphine, codeine), semisynthetic opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl, or fentanyl analogs), or opioid metabolites (e.g., 6-monoacetylmorphine);
(b) benzodiazepines (e.g., diazepam, alprazolam); or
(c) barbiturates (e.g., phenobarbital)

[Please note that the sub-set of NAS related to opioids is often referred to as Neonatal Opioid Withdrawal Syndrome or NOWS. The above definition for NAS includes but is not limited to NOWS.]

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* 9. Does your hospital have a standardized process in place for assigning a standardized list of ICD-10 diagnosis codes for an infant diagnosed with NAS?

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* 10. If you responded "Yes, in place" for Question 9, please select the following ICD-10 codes that are on your hospital's standardized list for NAS:

*For Guidance on when to use these codes in the context of "confirmed" vs. "suspected" NAS, please see "Tier 2" guidance on pages 10 and 11 and Appendix 5 in the CSTE NAS Standardized Case Definition used by PA DOH here.

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* 11. Does your hospital have a standardized process in place for assigning a standardized list of ICD-10 diagnosis codes for all SENs that are not diagnosed with NAS?

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* 12. If you responded "Yes, in place" in Question 11, please select the relevant ICD-10 codes on your hospital's standardized list for all SENs that are not diagnosed with NAS:

Please note that the term “affected by” in the below list of ICD-10 codes comes from the international ICD-10 code description.  As recommended by the CSTE NAS Standardized Case Definitions, the codes in the list above may be used for infants exposed prenatally to drugs/substances that can cause withdrawal signs (known via maternal history/laboratory testing or neonatal laboratory testing) but does not show signs of withdrawal. For additional guidance, please see Appendix 5 in the CSTE NAS Standardized Case Definition.

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* 13. At the end of this reporting period, what cumulative proportion of neonatal providers and nursing staff have received an education program on respectful and equitable care within the last two years? (Report estimates in 10% increments rounded up)

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* 14. Has your hospital established breastmilk feeding guidelines and parameters based on national guidelines for parents with SUD (including OUD) and caregivers, AND does your hospital's guideline support breastfeeding among mothers who are taking prescribed medications for OUD without contraindications for breastfeeding?

(An example of a national guideline can be obtained here and an example of a visual "Traffic Light" guideline can be obtained here)

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* 15. Does your hospital have standardized pharmacologic treatment protocols for NAS?

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* 16. Does your hospital have standardized non-pharmacologic treatment protocols for NAS?

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* 17. If you responded "Yes (in place)" in Question 17, please indicate the non-pharmacological interventions that are in place and part of the protocol: (check all that apply)

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* 18. Has your newborn care team (providers, nurses, and social workers) been educated on the criteria for Plans of Safe Care, their role in establishing and initiating the Plans of Safe Care, and how to explain it to families in accordance with your hospital's, county's, and state's guidelines and policies?

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* 19. Has your newborn care team been educated on the criteria, protocols, and best practices for referring substance-exposed newborns and families to post-discharge services and supports?

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* 20. If you responded "Yes, policies and education completed for..." in Question 20, please check the relevant services and supports:

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* 21. Has your neonatal care team (providers, nurses, and social workers) created a protocol for closing the loop on the referral status with the post-discharge services and supports?

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* 22. If you responded "Yes (in place)" in Question 22, does this process also include notifying the family's outpatient primary provider?

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