Improving pain assessment in the NICU: a quality improvement project

A NICU Postoperative Pain Management Improvement Project to Reduce Uncontrolled Pain and Improve Staff Satisfaction

BACKGROUND

Postoperative pain management in the neonatal period is an area of high variability and a source of staff dissatisfaction. Pain management is a key component of high-quality care; however, pain assessment in infants is difficult and analgesics can negatively impact the developing brain.

PURPOSE

We aimed to improve postoperative pain control for infants in our neonatal intensive care unit (NICU), limit variability in the approach to pain management, and increase staff satisfaction.

METHODS

This project was completed between April 2019 and March 2022 with sustainment tracked through December 2023. Interventions took place in a 70-bed level IV NICU using quality improvement methodology. Interventions included efforts aimed at improving pain assessment as well as development and implementation of a pain management guideline. Outcome measures included frequency of uncontrolled postoperative pain and measures of staff satisfaction. Process measures included compliance with pain assessment cadence and guideline recommendations. Opioid exposure within 24 hours of surgery was included as a balancing measure.

RESULTS

Pain management was assessed in 811 infants: 392 prior to guideline implementation, 273 during implementation, and 146 during sustainment period. Uncontrolled postoperative pain decreased from 26% pre-implementation to 18% post implementation and into the sustainment period. Staff satisfaction improved from 67% to 83%. These improvements were associated with decreased variability in postoperative pain management and a decrease in postoperative opioid exposure.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The use of a postoperative pain management guideline can improve pain control, decrease drug regimen variability, decrease opioid exposure, and increase staff satisfaction.

Pain assessment and treatment in hospitalized infants, children, and young people

Pain in hospitalized infants, children, and young people (ICYP) is a well-known phenomenon but remains undertreated. This study aimed to examine documented pain management practices provided for ICYP and compare practices adopted in neonatal and pediatric units. This national retrospective multi-center study was conducted in 40 of the 42 Danish neonatal and pediatric units in November 2020. Data were collected from the medical records of ICYP admitted to a participating unit. We performed a total of 846 medical record audits of which pain was assessed in 51.9% of the ICYP. Pain assessment was documented for more infants (57.8%) than for children and young people (CYP) (47.4%) (p = 0.003). CYP more often received pain treatment (37.7%) than infants (6.9%, p < 0.0001) and more frequently had a pain treatment plan (50.8% versus 10.2%, p < 0.0001). Use of non-pharmacological treatment was documented for 6.3% of the ICYP. Our findings indicate that pain assessment is insufficiently documented in Danish neonatal and pediatric units. Among cases in which pain scores indicated that the patient had experienced pain, pain treatment was documented in a larger proportion of the pediatric population than in the neonatal population.

Improving Documentation of Pain Reassessment after Pain Management Interventions in the NICU

Background

Neonates exposed to painful procedures require pain assessment and reassessment using nonverbal scales. Nurses perform initial assessments routinely, but reassessment is variable. The goal was to increase pain reassessments in neonates with a previous score of 4 or higher within 60 minutes from 50% to 75% within 12 months.

Methods

After identifying key drivers, we tested several interventions using the IHI's Model for Improvement. The outcome measure was the rate of reassessments within 1 hour after scoring ≥4 on the Neonatal Pain Agitation and Sedation Scale (N-PASS). Duration of time between scoring and intervention was documented. Interventions included electronic health record (EHR) changes, direct communication with bedside nurses through text messages and emails, in-person education, and a yearly competency module. The process measure was the number of messages/emails to staff. Sedation scores were the balancing measure.

Results

Baseline compliance was 50% with significant variability. A centerline shift occurred after the first intervention. After the first four interventions in the following 3 months, a 29% total increase occurred. Overall time-lapse between reassessments decreased from 102 to 90 minutes. Overall sedation scores decreased from -2.5 during the baseline to -1.7 during the sustain period. The goal of 75% pain reassessments was achieved and sustained for two years.

Conclusions

Automated tools such as the trigger report provided data that increased noncompliance visibility. Real-time and personalized reminders and education improved awareness and set the tone for culture change. Electronic health record reminders for reassessments and standardized annual education helped in sustaining change.

Improving pain management in a neonatal intensive care unit with single-family room-A quality improvement project

Preterm birth is a risk factor for early experience of pain. Despite advances in neonatal care, evidence-based knowledge of the importance of adequate pain management and strong international guidelines for assessment and treatment of neonatal pain, only 10% of sick term and preterm infants were assessed for pain and stress on a daily basis. The aim of this quality improvement (QI) project is evaluation of implemented guidelines for pain assessment and management, and increased parental involvement in a Norwegian single-family room NICU. Method: The different steps of the project entailed translation of the English version of COMFORTneo, development and implementation of guidelines with flowcharts for pain management, and pain assessment certification of the interprofessional staff. Part two of the project is supervision of the interprofessional staff in parental involvement in stress- and painful procedures. Our study showed that one year after implementation, 88.8% of the COMFORTneo assessments were performed according to the pain management guidelines. The staff used the flowcharts to assess, treat and reassess pain and stress. There was a high interrater reliability with linearly weighted Cohen's kappa values ranging from 0.81 to 0.95, with a median of 0.90. In addition, our study showed increased parental involvement in procedures, from 50.3% before to 82.3% after the quality improvement project. The success of this quality improvement project is explained by systematic use of flowcharts and implemented guidelines for pain management, interprofessional collaboration, and cultural change agents. Theoretical lectures and practical bedside supervision to interprofessional staff increased parental involvement in stress- and painful procedures.

The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review

BACKGROUND

Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes.

OBJECTIVES

To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children.

DESIGN

Systematic literature review.

DATA SOURCES

The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020.

REVIEW METHODS

We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded.

RESULTS

In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions.

CONCLUSIONS

Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.

Implementierung eines neonatalen Schmerzassessmentinstruments auf einer neonatologischen Intensivstation - Ein Qualitätsentwicklungsprojekt

Implementation of a Neonatal Pain Assessment Instrument at a Neonatal Intensive Care Unit - A Quality Improvement Project Abstract. Background: Optimal pain management is necessary in order to not jeopardize the development of preterm neonates. Aim: Implementation and evaluation of systematic and best possible pain assessment with the Bernese Pain Scale for Neonates for all preterm and sick neonates of a neonatal intensive care unit by nursing staff. Methods: The educational concept is based on three key strategies: knowledge translation (group- and one-on-one training), reflection (case conferences) and clinical training. The frequency of the use of the Pain Score was recorded before (T0) and after implementation (T1) and six months after completion of the project (T2). Results: Before the implementation (T0) the use of the Bernese Pain Scale was regulated by an internal guideline but its application could not be verified during the baseline period (fulfillment rate of 0 %). After implementation (T1) at least one assessment per shift per neonate could be achieved in 99.1 % of the cases. Nurses conducted 210 assessments on 38 neonates in T1. In follow-up (T2) six months after implementation fulfillment rate of 100 % in 34 neonates was achieved with 188 pain assessments. Conclusions: This implementation strategy was successful in establishing the assessment instrument in clinical practice.

Reducing Opioid Exposure in a Level IV Neonatal Intensive Care Unit

INTRODUCTION

Infants in neonatal intensive care units require painful and noxious stimuli as part of their care. Judicious use of analgesic medications, including opioids, is necessary. However, these medications have long- and short-term side effects, including potential neurotoxicity. This quality improvement project's primary aim was to decrease opioid exposure by 33% in the first 14 days of life for infants less than 1,250 g at birth within 12 months.

METHODS

A multidisciplinary care team used Define, Measure, Analyze, Improve, Control methodology to identify root causes of the quality gap including: (1) inconsistent reporting of objective pain scales; (2) variable provider prescribing patterns; and (3) variable provider bedside assessment of pain. These root causes were addressed by two interventions: (1) standardized reporting of the premature infant pain profile scores and (2) implementation of an analgesia management pathway.

RESULTS

Mean opioid exposure, measured in morphine equivalents, in infants less than 1,250 g at birth during their first 14 days of life decreased from 0.64 mg/kg/d (95% confidence interval 0.41-0.87) at baseline to 0.08 mg/kg/d (95% confidence interval 0.03-0.13) during the postintervention period (P < 0.001). There was no statistical difference in rates of days to full feedings, unintentional extubations, or central line removals between epochs.

CONCLUSIONS

Following the implementation of consistent pain score reporting and an analgesia management pathway, opioid exposure in the first 14 days of life for infants less than 1,250 g was significantly reduced by 88%, exceeding the project aim.

Therapeutic hypothermia and N-PASS; results from implementation in a level 3 NICU

BACKGROUND

Neonates that have been subjected to perinatal asphyxia and fulfill criteria for therapeutic hypothermia are cooled to 33.5 °C for 72 h. There is no consensus regarding sedation and analgesic use during hypothermia, but there is evidence supporting the importance of pain relief and adequate sedation. There is a need for assessment of the neonates need for pain relief and sedation, and for adjustments of medication to ensure adequate treatment. There are many different scoring tools available. We found the N-PASS (Neonatal Pain, Agitation and Sedation Scale) scoring tool to be the most suitable for this patient group as it assesses both pain and sedation.

METHODS

We translated the scoring tool according to guidelines published by Wilder et al., and scored neonates treated with therapeutic hypothermia. Sedation and analgesia were adjusted according to scoring results. At the end of the study a questionnaire was filled out by the nurses in charge of this group of patients.

RESULTS

Both pain and sedation scores did not reach the desired levels until day 3. The nurses reported a high level of satisfaction (79.7% were extremely of very satisfied), and 96.7% of the nurses found the neonates to be better pain relieved after the initiation of the study.

CONCLUSION

The implementation of the N-PASS scoring tool in our unit has been successful, and has led to better pain relief and sedation than before the implementation.

Comparing N-PASS and NIPS: Improving Pain Measurement in the Neonate

BACKGROUND

Proper assessment of pain is essential to allow for safe and compassionate care of infants in the neonatal intensive care unit (NICU). The Neonatal Infant Pain Scale (NIPS) used in an urban level IV NICU addresses acute pain but may not adequately measure chronic neonatal pain.

PURPOSE

The purpose of this quality improvement study was to improve acute and chronic pain measurements for neonates in an NICU through implementation of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS).

METHODS/SEARCH STRATEGY

An evidence search for a comprehensive tool to assess neonatal pain in the setting of a 45-bed level IV NICU was completed. The N-PASS was found to be inclusive of measuring acute and chronic neonatal pain. Participants for a quality improvement study, including NICU nurses and providers, were educated on the N-PASS. Nurses documented in the N-PASS and the NIPS during routine pain assessments for NICU infants for comparison. Participants completed a survey assessing knowledge of the N-PASS.

FINDINGS/RESULTS

When compared, the N-PASS generated 98% of pain scores greater than the NIPS. Surveys demonstrated an increase in staff knowledge for the N-PASS.

IMPLICATIONS FOR PRACTICE

Implementation of a multidimensional pain tool that measures acute and chronic pain is essential for proper pain assessment. Providers can manage neonatal pain when accurate documentation is available.

IMPLICATIONS FOR RESEARCH

Further research evaluating guided management of acute and chronic pain scores on the N-PASS would aid hospital policies on therapies for neonatal pain.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.

A Quality Improvement Collaborative Program for Neonatal Pain Management in Japan

BACKGROUND

Neonatal pain management guidelines have been released; however, there is insufficient systematic institutional support for the adoption of evidence-based pain management in Japan.

PURPOSE

To evaluate the impact of a collaborative quality improvement program on the implementation of pain management improvements in Japanese neonatal intensive care units (NICUs).

METHODS

Seven Japanese level III NICUs participated in a neonatal pain management quality improvement program based on an Institute for Healthcare Improvement collaborative model. The NICUs developed evidence-based practice points for pain management and implemented these over a 12-month period. Changes were introduced through a series of Plan-Do-Study-Act cycles, and throughout the process, pain management quality indicators were tracked as performance measures. Jonckheere's trend test and the Cochran-Armitage test for trend were used to examine the changes in quality indicator implementations over time (baseline, 3 months, 6 months, and 12 months).

FINDINGS

Baseline pain management data from the 7 sites revealed substantial opportunities for improvement of pain management, and testing changes in the NICU setting resulted in measurable improvements in pain management. During the intervention phase, all participating sites introduced new pain assessment tools, and all sites developed electronic medical record forms to capture pain score, interventions, and infant responses to interventions.

IMPLICATIONS FOR PRACTICE

The use of collaborative quality improvement techniques played a key role in improving pain management in the NICUs.

IMPLICATIONS FOR RESEARCH

Collaborative improvement programs provide an attractive strategy for solving evidence-practice gaps in the NICU setting.

Differences in Pediatric Pain Management by Unit Types

PURPOSE

The purpose of this study was to determine differences in pediatric pain management by unit type in hospitals across the United States. The aims were to (a) compare unit-type rates of assessment, intervention, and reassessment (AIR), and (b) describe differences in assessment tools and intervention use by unit type.

DESIGN

The study used a cross-sectional design. A secondary analysis of 2013 data from the National Database of Nursing Quality Indicators (NDNQI®) pain AIR cycle indicator was conducted. The sample included 984 pediatric units in 390 hospitals.

METHODS

Data were gathered via retrospective chart review on the pain assessment tool used, presence of pain, interventions, and reassessment. Descriptive statistics and the Kruskal-Wallis one-way analysis of variance test were conducted. Post-hoc analyses included the Wilcoxon-rank sum test with Bonferroni correction.

FINDINGS

Across all units the mean unit-level percentage of patients assessed for pain was 99.6%. Of those patients assessed, surgical units had the highest average unit-level percentage of patients with pain, while Level 4 neonatal intensive care units (NICUs) had the lowest. The most commonly used assessment tool among all units was the Faces, Legs, Activity, Crying, and Consolability (FLACC) Scale. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and Neonatal Infant Pain Scale (NIPS) specifically developed for infants were more commonly used across NICU unit types. The mean unit-level percentage of patients with pain receiving an intervention was 89.4%, and reassessment was 83.6%. Overall, pharmacologic methods were the most common pain intervention, while music was the least common.

CONCLUSIONS

Assessments were performed routinely, yet interventions and reassessments were not. Pain AIR cycle completion varied by unit type. Pain was also widely present across many unit types, and pharmacologic methods were most frequently used.

CLINICAL RELEVANCE

Frontline nurses are instrumental to pain management and have the ability to improve patient care and outcomes by effectively managing pain. A comprehensive understanding of it provides valuable insight into improving our practice to produce the best outcomes for pediatric patients.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.