A quality improvement initiative to improve management of procedural pain in preterm neonates

Abstract

Background Neonates managed in neonatal intensive care units undergo several invasive procedures. However, neonatal procedural pain is not well recognized and managed in most neonatal units. Aims To decrease the severity of procedural pain in preterm neonates (<37 weeks gestational age at birth), as measured by Premature Infant Pain Profile , by 50% by April 2020. Methods A quality improvement initiative was conducted in a level 3 neonatal intensive care unit in South India. The pain was assessed independently by 2 interns not involved in clinical care using Premature Infant Pain Profile. After a baseline data recording and questionnaire assessing knowledge of healthcare personnel regarding neonatal pain, the interventions were planned. These were conducted as plan‐do‐study‐act cycles—(i) Educational sessions, (ii) Introduction of bedside visual aids, (iii) Simulation sessions demonstrating the use of nonpharmacological measures and introduction of procedure surveillance chart in daily rounds, and (iv) Video feedback‐based sessions. In the maintenance phase, the observations were continued. Results The healthcare personnel under recognized pain related to heel pricks and endotracheal intubation. They also had poor awareness of signs and symptoms of neonatal pain. A total of 202 procedures were observed during the study period. The mean pain score decreased significantly from 12.8 ± 4.5 in baseline period to 6.2 ± 1.8 in the maintenance phase. The use of analgesic measures increased from 13% in the baseline period to 73% in the maintenance phase. The use of automated lancet for heel prick increased from 0% to 94% in maintenance phase. More and more procedures were done with appropriate environment and baby state. The mean number of procedures per day decreased from 6.5 ± 1.8 in baseline period to 2.7 ± 0.9 in the maintenance phase. Conclusions Targeted interventions can improve neonatal procedural pain management by improving use of analgesic measures, decreasing the number of procedures, and educating and training healthcare personnel.

Improving Consistency in the Use of Sucrose With Comfort Measures During Minor Painful Procedures

“…Improvements in staff knowledge, behaviors, and sucrose use were consistent with findings from the literature. Improving the use of analgesic measures improved procedural pain through targeted pain management interventions 13. Increased knowledge of neonatal pain management practices and proper sucrose use resulted in better pain management during PIV insertion procedures 14…”

“…Improving the use of analgesic measures improved procedural pain through targeted pain management interventions. 13 Increased knowledge of neonatal pain management practices and proper sucrose use Improving Consistency in the Use of Sucrose With Comfort Measures During Minor Painful Procedures resulted in better pain management during PIV insertion procedures. 14 The increase in documented sucrose use with comfort measures during PIV placements was modest.…”

Application of the Adverse Childhood Experiences Framework to the NICU

“…54 Even more important, when painful procedures, including endotracheal intubation or chest tube placement, are performed, advocating for pain management medications is essential and cannot be replaced with only nonpharmacological interventions. 55 Oral feeding is another action that should be a positive experience for both the infant and parents. While placing the infant directly at the chest for oral feedings is best, infants in the NICU often receive some feedings by bottle.…”

“…When skin-to-skin holding is not an option, facilitated tucking has also been shown to reduce stress and pain 54. Even more important, when painful procedures, including endotracheal intubation or chest tube placement, are performed, advocating for pain management medications is essential and cannot be replaced with only nonpharmacological interventions 55…”

Implementing use of sucrose analgesia (non-pharmacological management of neonatal pain) in a standalone private facility level 3 neonatal care unit using point of care quality improvement methodology

“…Anne et al 4 in their quality improvement initiative to improve management of procedural pain in preterm neonates concluded that targeted interventions can improve neonatal procedural pain management by improving use of analgesic measures, decreasing the number of procedures and educating and training healthcare personnel. Nana et al 5 have reported that educational interventions like training have modest effect 9.7% (5.5%–21.3%) on improving processes of care in 2018.…”