drug screening patients

[moz]

Ok, I'll get right to the point.

Most of the nurses at the hospital I work at have always worked here, we deliver about 600/yr. I don't know who to ask or where to start. I really feel the need for some help for our drug abusing moms, and babies. We don't see much of it, but we are seeing more and more. We have no policy, no standards to guide us. If a woman comes in with no prenatal care, we ask the doc if we can get a UDS. That's pretty much it. I've recently had one who quit using 6 mo before her 1st ob appt....and no random or any drug screen during her pregnancy at all. When we do get a pos we call the child abuse hotline and I personally have gotten the response anywhere from they can't do anything unless the baby shows a pos screen, to being up in the dept within hrs (I'm assuming those probably were already in the system). We had our first full blown withdrawal baby over the weekend, and the nurses sat on it all evening/ night and into the day shift....stating, well his resps are over 100 because he's withdrawling...he's sweating and screaming etc because of that....when they finally did call, the doc ruled out infection with bc, cbc, cxr, ekg (which was next to impossible to get), THEN consulted someone at a bigger hospital and gave the little guy phenobarbitol.

I'm frustrated.

I would like to know what other facilities do, what resources are out there to help these moms during pregnancy and after, besides dhs taking the baby or whatever.

Does anyone do drug screens on all their moms? We have only one nurse that has worked elsewhere who says where she worked on the east coast, everyone got screened.

Your help would be appreciated.

[JenniferSews]

So, I'm confused. What exactly about being pregnant means you have a right, or a mandate, to do drug screens? Does your hospital do them on every pt you admit? Or every employee who cares for those patients?

[BritEdRn]

I think the bigger question is why did it take the nurses so long to take care of the infant. Yes drug screens should be done on all L&D patients just like the STD swabs are done.

[moz]

I didn't start this thread to debate mandatory drug testing.

Yes, where I'm employed a drug screen is required for employment, and random drug screens on employees are done. If I were a patient, I would certainly want my nurse to pass a drug screen.

BritEdRn I agree. We have no screening for withdrawal in babies, and little to no experience with it....only have the neonatal/infant pain scale.

I want to know what resources are out there for these patients, if anyone knows of any successful program to help these mothers, and by helping them help their babies.

[JenniferSews]

I guess your title and mention of drug screening moms threw me off and made me think you were looking for a way to test all your moms for drugs. Have you talked to your case management about resources?

[sethmctenn]

I don't work in OB but have talked about this subject with a friend who does (a while back so it's not fresh in my memory). I believe that all mom's are tested in our hospital. If mom is +, baby is tested. Our local social services is very backlogged and takes no action on THC. They do take action on cocaine and amphetamines and any case where the baby has withdrawal. Sorry that I don't have more info for you.

It sounds like some policy development and staff education could be supportive for improving the services you provide for these babies. Thanks for bringing up a difficult issue and working to make improvements!

[Elvish, BSN, DNP, RN, NP]

At my place we do a UDS on any mom who has no prenatal care, limited prenatal care (

For babies, we do a UDS if mom had no or limited prenatal care, if mom's UDS comes back +, or if mom admits to using (even if her UDS on admit is negative). I have seen babies come back + when mom is negative.

Any baby whose mom took narcotics (and sometimes even SSRIs) regularly during pregnancy gets abstinence scores with feedings, and we start q4h morphine (0.05 mg/kg) for 3 consecutive scores above 8. If scores are still consistently bad and/or baby has marked tremors, we start daily phenobarb too. According to the scores the peds titrate the dose up or down and wean accordingly. One thing to keep in mind is that babies can seize and possibly die from untreated withdrawal, so next time around whoever is taking care of the baby needs to not sit on those symptoms. (Not casting blame on you...just making a general statement.)

When a baby comes in that we suspect may start withdrawing our NPs are really really good about educating their parents about what we're doing and why. They let them know up front that the baby may not be going home with them upon Mom's discharge. However, most babies do get discharged home with parents once they are weaned off the morphine. We encourage Mom to breastfeed/pump if she wants to, as it's not contraindicated and most babies' scores are much better if they're getting her breastmilk. In any case, they can come and visit anytime they want after Mom's discharged from the hospital.

It can be a tricky situation. If your place isn't equipped to care for withdrawing babies - it can be a challenge - you may need to push for a transfer to a bigger hospital. Not saying that you or your facility are incapable, just that it's not a fair thing to ask of a small facility that may not have the staff/resources to deal with this.

Interesting article: http://emedicine.medscape.com/article/978763-overview

[Mimi2RN, ASN, RN]

We do similar testing on the moms, and on the babies, too. And I've seen mom negative and baby positive and vice versa. We also frequently do mec screens, as even a negative urine test on baby can show up positive in mec. This may mean that mom will have to deal with CPS, and may or may not take the baby home right away.

We don't use morphine for withdrawals, but methodone and phenobarb.

[babyktchr, BSN, RN]

If you google neonatal abstinence scoring, you will come up with a plethora of information on screening tools, the basis behind the scoring and how to score a newborn going thru withdrawal. You can also call your local tertiary care center and see what they have as far as protocol and policy. You really need to have something in place if you have suspected drug use in a mom. Depending on the drug of choice, the baby may not have symptoms for a few days....and withdrawal can lead to seizures. We are seeing more and more methadone babies and they stay with us until they are totally weaned. Depending on the dose the mom takes, we have had babies stay with us for up to 8 weeks. NAS (neonatal abstinence scoring) is used for dosing and treatment.

[bagladyrn, RN]

Personally I favor universal drug screening in OB. By screening everyone you remove the possibility of prejudice or profiling of patients. Many cases are likely missed when the patient doesn't fit the "mold" of a drug abuser.

At any rate, I see the purpose of the screen not to "accuse" the mother, or even to address her need to stop using at that time, but more to be prepared to deal with withdrawal in the infant. I have explained this to mothers and have gotten honest responses from some who were previously denying any use.

[SmilingBluEyes]

To address the original post and questions (and not debate drug screening): Our OBs screen everyone when beginning care, no matter who they are or what their situation. They are told this both verbally and in writing when they start their OB care, so no one is "singled out" or surprised. Those coming back + get counseled about drug use and how it affects their fetus and also referred for treatment as appropriate. We also have similar protocols to what Elvish described, when they enter our care in the hospital. It's true, people you would NEVER suspect of using do, you can't tell by looking at them or judging their histories. Having a clear protocol in place and using it consistently will protect you best in cases of doubt on who to screen. Anyone coming back positive or with a history of drug use, automatically we have to test their babies.

I also agree the much larger issue is getting appropriate and prompt treatment for withdrawing babies. This is not for small or inexperienced nurseries but for larger facilities with experience in this area. Withdrawal in and of itself can be dangerous and even deadly if baby is in care of inexperienced staff. MUCH larger and important is the issue of knowing which babies are affected and how to treat them. Referral to a facility where this is done is best.

I would be working on a protocol on whom to screen and what is to be done for babies withdrawing from substances ASAP. You would not want a baby to experience undue complications due to not knowing of them or inexperience in dealing with them. I work in such a smaller community hospital that transfers such babies out to higher Level facilities that have neonatal abstinence programs and staff who know how to treat them. The posts before mine are excellent and offer insight into what you should do when you suspect drug use or babies withdrawing from such substances.

[moz]

Thanks everyone for your input. I will talk to my nurse manager tomorrow (have already emailed her with my concerns but have not heard back) and as soon as possible visit with the medical head of nursery.