Postoperative Pain Management in the Neonatal ICU: Benefits from an Interdisciplinary Quality Improv

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Post-operative Pain Management in the Neonatal
ICU Benefits from an Interdisciplinary Quality
Improvement Approach

• Brian S. Carter, MD, FAAP
• Professor of Pediatrics
• Division of Neonatology
• Vanderbilt University Medical Center
• Nashville, Tennessee

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Background Problem

• Post-operative pain management in the NICU is
  difficult and inconsistent.
• Unmanaged pain has negative effects on
• hospital LOS
• short-term physiology well-being, and
• it may negatively impact patient neurobehavioral
  state and long-term outcome.
• Project designed to study the impact of an
  interdisciplinary team approach to improving
  post-op pain management in a large NICU.

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Analysis of Cause

• Chart audit of 50 post-op NICU patients

• Needs for improved pain assessment and management
  revealed. Causes included
• Nature of surgery
• Time to 1st dosing of post-op analgesia
• Type of analgesia used
• Pain scale scores responses to medication

• Change would require
• Staff education
• Standard assessment
• Standardized physician order entry
• Reference table of expected duration of pain
  based upon the nature of the procedure.

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Ishikawa fish-bone cause/effect diagram
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Errors in Pain Management
J Pain Symptom Mgmt July 2004 2847-58
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Pain happens in a social context, must be
communicated, and then acted upon.
Kenneth Craig, et al. Challenges of judging pain
in vulnerable infants. Clin Perinatol 29
(2002)445-457.
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Strategy for change

• Change was implemented through 3 repetitive PDSA
  cycles
• Educational interventions
• Development of a computerized analgesia physician
  order-entry set
• Standardized table of expected duration of pain
  following 17 common surgical procedures
• Each cycle of analysis looked at 50 post-op NICU
  patients.
• An interdisciplinary NICU pain management team
  (physicians, nurses, educators, pharmacist) met
  regularly over a 3 year period guiding change.
• Results were disseminated through
• Unit-based education
• New staff orientation
• Physician house officer and staff education
  conferences
• Incorporation of the protocol into an NICU Manual
• An increased presence of team members on the unit
  for consultation.

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Measured improvement

• Change was measured during repeated PDSA
  cycles to examine
• Improvement in medication use
• Reduced time until 1st analgesic dosing
• Improved documentation of pain assessment using
  the Neonatal-Pain, Agitation, and Sedation Score
  (N-PASS).

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VCH Post-op Pain Management
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What about sedation in ventilated newborns?

• Do not make it routine
• Opioids are probably safer than benzos
• Always assess causes for agitation dont assume
  that its due to pain

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Effects of changes

• Pain control improved by measures of the N-PASS
• Staff had less angst about delayed or
  inappropriate pain management
• Physicians reported ease of ordering medications
• Use of non-opioid analgesics improved
• Inappropriate use of anxiolytics declined
• Efforts continue to address ongoing pain
  management beyond surgical conditions
• NICU procedural pain is addressed more
  consistently
• General use of opioid sedation for ventilated
  patients is reduced
• The pain management team continues to meet and is
  currently evaluating
• total opioid dose exposure
• use of methadone
• alternative protocols for laparoscopic procedures
• impact of pain management upon patients time on
  assisted ventilation
• Resistance to change was largely limited to
  surgeons early in the process, ongoing education
  continues to address new staff.

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Lessons Learnt

• The value of the interdisciplinary team,
  unit-based staff involvement, and a continuous
  process that looks carefully at data cannot be
  overstated.
• Such efforts require a time commitment and also
  likely financial support.
• In our experience, the work was accelerated when
  one investigator received extramural grant
  support.

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Message for others

• Pain can be better managed in the NICU
• The quality performance improvement methods
  described are applicable to other units of
  patient care.