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A Quality Improvement Initiative to Increase Scoring Consistency and Accuracy of the Finnegan Tool

Challenges in Obtaining Reliable Assessments of Drug Withdrawal in Neonatal Abstinence Syndrome

Timpson, Wendy MD, MEd; Killoran, Cheryl MS, RNC-NIC; Maranda, Louise PhD; Picarillo, Alan MD; Bloch-Salisbury, Elisabeth PhD

Section Editor(s): Dowling, Donna PhD, RN; ; Thibeau, Shelley PhD, RNC-NIC;

doi: 10.1097/ANC.0000000000000441
Original Research

Background: Current practice for diagnosing neonatal abstinence syndrome and guiding pharmacological management of neonatal drug withdrawal is dependent on nursing assessments and repeated evaluation of clinical signs.

Purpose: This single-center quality improvement initiative was designed to improve accuracy and consistency of Finnegan scores among neonatal nurses.

Methods: One-hundred seventy neonatal nurses participated in a single-session withdrawal-assessment program that incorporated education, scoring guidelines, and a restructured Finnegan scale. Nurses scored a standardized video-recorded infant presenting with opioid withdrawal before and after training.

Results: Nearly twice as many nurses scored at target (Finnegan score of 8) posttraining (34.7%; mean error = 0.559, SD = 1.4) compared with pretraining (18.8%; mean error = 1.31, SD = 1.95; Wilcoxon, P < .001). Finnegan scores were significantly higher than the target score pretraining (mean = 9.31, SD = 1.95) compared with posttraining (mean = 8.56, SD = 1.40, Wilcoxon P < .001); follow-up assessments reverted to pretraining levels (mean = 9.16, SD = 1.8). Score dispersion was greater pretraining (variance 3.80) compared with posttraining (variance 1.96; Kendall's Coefficient, P < .001) largely due to score disparity among central nervous system symptomology.

Implications for Practice: Education, clinical guidelines, and a restructured scoring tool increased consistency and accuracy of infant withdrawal-assessments among neonatal nurses. However, more than 60% of nurses did not assess withdrawal to the target score immediately following the training period and improvements did not persist over time.

Implications for Research: This study highlights the need for more objective tools to quantify withdrawal severity given that assessments are the primary driver of pharmacological management in neonatal drug withdrawal.

Video Abstract available at

Division of Neonatology and Division of Newborn Nursery, University of Massachusetts Memorial Healthcare Center, Worcester (Drs Timpson and Picarillo and Ms Killoran); and Department of Quantitative Health Sciences (Dr Maranda) and Department of Pediatrics, University of Massachusetts Medical School, Worcester (Dr Bloch-Salisbury). Dr Timpson is now with Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, and Dr Picarillo is now with Division of Neonatology, Barbara Bush Children's Hospital, Maine Medical Center, Portland, ME.

Correspondence: Elisabeth Bloch-Salisbury, PhD, Department of Pediatrics, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655 (

This study was conducted at University of Massachusetts Memorial Medical Center–Memorial Campus.

There are no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

© 2018 by The National Association of Neonatal Nurses