Copyright 2014 Wright and Retskin NAS

Inter-Observer Reliability of
the Modified Finnegan Score
in a Population of Neonatal
and Pediatric Nurses
Cathy Retskin, MSN, RNC
DNP Candidate Walden University
Mary Ellen Wright, MSN, APRN, CPNP
PhD Candidate Florida Atlantic University
copyrlghL 2014 8eLskln and WrlghL
Copyright 2014 Wright and Retskin NAS
History of Mission Hospital Neonatal Abstinence Syndrome/
Neonatal Withdrawal Initiatives
0
20
40
60
80
100
120
2010 2011 2012 2013*
Number of 8ab|es 1reated per ear at
M|ss|on nosp|ta|
Copyright 2014 Wright and Retskin NAS
Timeline of Mission Health NAS Initiative
Years of Effort
Aim: To provide consistent, comprehensive, caring approaches
to infants and families affected by NAS
Copyright 2014 Wright and Retskin NAS
nC uPPS
nAS lnluauve
Commun|ty
Co||aboranve
Inpanent NAS
1eams
CCnC
lnlCC
Commun|ty
Subcomm|uee
harmacologlc
ManagemenL
1eam
non-
harmacologlc
ManagemenL
1eam
nAS SLeerlng
Commluee
revennon
Subcomm|uee
lamlly
lannlng
1hrough
MAPLC
Coord|nanon of Care
Worklng on pauenL
experlence aer dlscharge.
Collaboration on National, State, Regional and Local Levels
Copyright 2014 Wright and Retskin NAS
Opportunities to Standardize Care Processes
Murphy-Oikonen, Motelpare, Bertoldo, Southon & Persichino, 2010.
Retrospective cohort comparison pre and post implementation of
clinical practice guideline.
Conclusion: Decrease in Finnegan Scores
Decrease in Length of Stay

Identification
Evaluation
Treatment
Discharge






Copyright 2014 Wright and Retskin NAS
Mission Process Mapping
Just One Example
Details not visible: Point just to show broad view of mapping


MoLher negaLlve
SubsLance use Px
!"#$% "'( )*+,-*%.
no renaLal Care,
lacenLa AbrupLlon, Px
uomesLlc vlolence, Px of
SubsLance use wlLhln 2 yrs

MaLernal
1oxlcology
Screenlng negaLlve
oslLlve
/$01*% 2"#. 3',0
/$01*% 2"#. 3',0
ulscharged
edlaLrlclan
noLlfled ???
urlne/Meconlum
Screen on 8aby
8esulLs can Lake
up Lo 7 days.
nAS Crder SeL
lnlLlaLed?
m-llnnegan
Scores
m-llnnegan > 8 for 3
measuremenLs 3 hours aparL
or m-llnnegan > 12 for Lwo
measuremenLs 3 hours aparL
Crders?

8aby SLable on
MoLher 8aby unlL

harmacologlc 8x
8aby condlLlon needlng
lnLenslve monlLorlng
4563
MoLher ulscharged
8aby remaln lnpaLlenL

7*(,"0%,89
nurses lnlLlaLe m-llnnegan scorlng &
noLlfy Mu of need Lo lnlLlaLe nAS order seL

m-llnnegan scores C 3- 4 hrs
Low m-llnnegan Scores
non-pharmacologlcal
lnLervenLlons such as
swaddllng, paclfler, low llghL,
low nolse, Mamaroo, rhyLhmlc
paLLlng, skln Lo skln

LlevaLed m-llnnegan
Mu noLlfled
nAS Crder
SeL already
lnlLlaLed
nAS Crder
SeL noL
lnlLlaLed
8aby
8eadmlLLed
for nAS
m-llnnegan scores C 4 hrs
edlaLrlclans, lnLenslvlsLs, PosplLallsLs
lnlLlaLe nAS Crder SeL
edlaLrlclans, lnLenslvlsLs, PosplLallsLs
ulscharge
lollow up AppolnLmenLs
Pome PealLh
lnpaLlenL
weanlng
ulscharge on
medlcaLlons
non-harmacologlcal
8x
MoLher oslLlve
SubsLance use Px
harmacologlcal
8x
ulscharge
lollow up AppolnLmenLs
Pome PealLh
lnpaLlenL
weanlng
ulscharge on
medlcaLlons
non-harmacologlcal
8x
harmacologlcal
8x
non-harmacologlc 8x

lmprovemenL efforLs sLarLed
luLure lmprovemenLs
Copyright 2014 Wright and Retskin NAS
All Areas had Opportunities for Improvement
Formed Sub-Committees to address the opportunities in the areas of
identification, evaluation, treatment and discharge.

Steering committee coordinates the overall initiative with reports from
the sub-committees.

Example of initiative derived from looking at evaluation:

Inter-Observer Reliability (IOR) of the Modified Finnegan of Nurses
from Mother/Baby, Pediatrics, PICU, NICU and nurses in the region.


Copyright 2014 Wright and Retskin NAS
Evaluation
Inter-Observer Reliability of Modified Finnegan Score
Origin of study: Comments being made at provider meetings
Depends on what shift of nurses and who is doing the
Finnegan. . .

Impression that there was variability without evidence.

The purpose of the study was to determine if there is inter-
observer reliability (IOR) of the Finnegan Neonatal Abstinence
Scoring Tool (FNAST) among nurses caring for infants with
neonatal abstinence syndrome (NAS) in the NICU, Mother/Baby
and PEDS/PICU units and regional nurses.



Copyright 2014 Wright and Retskin NAS
Description of Nurses in Study
Education Level, Years Experience, Certification
Total n=122
Copyright 2014 Wright and Retskin NAS
Methods
An interactive DVD developed
by Karen DApolito, PhD, APRN,
NNP-BC and Loretta Finnegan, MD
on the IOR of the FNAST was
used with permission.

Copyright 2014 Wright and Retskin NAS
Methods
IRB approval, Mission Research Institute and Nursing Research
Council Approval obtained.
Potential participants for this reliability study would come from
nursing staff in the NICU, Mother/Baby, and PEDS/PICU units and
nurses in the region.
Participation in the study was conducted through annual education,
staff meetings, Care Partners and regional member hospitals.
Consent to participate was obtained.
Vignette was shown, and the nurses were asked to score using the
Modified Finnegan Scoring System for Neonatal Abstinence
Syndrome
Comparison was made to the expert score and Inter-Class
Correlation for IOR was calculated using SPSS.
Copyright 2014 Wright and Retskin NAS
Results
lnLer-class Correlauon CoemclenL (lCC) was evaluaLed uslng Lwo-way mlxed
eecLs model where people eecLs are random and measures eecLs are xed.
values of 0.60 Lo 0.80 are oen used as mlnlmal sLandards.

Copyright 2014 Wright and Retskin NAS
IOR in Sections of the FNAST
The least inter-observer reliability was in the area of the Central
Nervous System with ICC at 0.603.
Question: Is that consistent in different tests of IOR? We may want as
a collaborative to compare those findings.
INAS1 Secnon Intrac|ass
Corre|anon
Coemc|ent
CenLral nervous
SysLem
0.603
MeLabollc,
vasomoLor, and
resplraLor
0.831
CasLrolnLenunal 0.944
Copyright 2014 Wright and Retskin NAS
Discussion
Study offered opportunity for education.

Modified Finnegan Scoring was added to orientation, continuing
education for existing nurses.

Medical Resident education on Modified Finnegan scoring.

Sharing with providers the results and standardization.
Copyright 2014 Wright and Retskin NAS
Standardizing the Environment of Finnegan Scoring
Work currently underway
Score in standard environment
! Quiet
! Minimize noxious lights
! After feeding
! In mothers arms?

Copyright 2014 Wright and Retskin NAS
Education to Move to Standardization of Creating the
Environment for Modified Finnegan
Adding the standardization of creating the environment for scoring
through:

Nursing Education
Orientation
Resident Education
Physician Service Line Provider Meetings
Quality Rounds
Huddles
Newsletters

Copyright 2014 Wright and Retskin NAS
Informing Standardization through Work of Sub-Committees
Idennhcanon
Subcomm|uee

ICD-9 codes
Screen|ng
1ox|co|ogy


1reatment -

harmaco|og|c sub-
Comm|uee

Non-harmaco|og|c
Sub - Comm|uee
Lva|uanon

Creanng Lnv|ronment
for M- I|nnegan.

Comp|eted ICk of M-
I|nnegan
D|scharge
Subcomm|uee

D|scharge cr|ter|a

Standard|ze educanon

Commun|ty Io||ow-up


ollcy and rocedures
Copyright 2014 Wright and Retskin NAS
The nice thing about teamwork is that you always
have others on your side
Margaret Carty
Copyright 2014 Wright and Retskin NAS
References
D'Apolito K; MCN: The American Journal of Maternal Child Nursing, 1999 May-Jun; 24 (3): 138-44.
DApolito, K. & Finnegan, L. (2010). Assessing signs & symptoms of neonatal abstinence syndrome
using the Finnegan Scoring tool: An inter-observer reliability program [DVD]. Nashville, TN:
NeoAdvances, LLC.
Finnegan, L., Connaughton, J., Kron, R. & Emich, J. (1975). Neonatal abstinence syndrome:
Assessment and management. Addictive Diseases: An International Journal. 2(1), 677-687.
Franck, L.S., Harris, S.K., Soetenga, D.J., Amling, J.K., Curley M.A. The withdrawal assessment tool
1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal
symptoms in pediatric patients. (2008). Pediatric Critical Care Medicine. 9(6), 573-580.
Murphy-Oikonen, J., Montelpare, W.J., Bertoldo, L., Southon, S.,
Persichino, N. (2012). The impact of clinical practice guideline on
infants with neonatal abstinence syndrome. British Journal of Midwifery, 20(7),
493- 501
Retskin, C.M. & Wright, M.E. (2013). Inter-Observer Reliability of the Modoified Finnegan Neonatal
Abstinence Scoring Tool in an Acute Care Setting. Poster presentation at the 2013 Vermont
Oxford Network Annual Meeting. Manuscript submission
Zimmermann-Baer U, Ntzli U, Rentsch K, Bucher HU. (2010). Finnegan
neonatal abstinence scoring system: normal values for first 3 days and weeks 5-6 in
non-addicted infants. Addiction. 2010 Mar;105(3):524-8.