Improving newborn pain management: systematic pain assessment and operators' compliance with potentially better practices

Abstract

Aims and objectivesThis quality improvement (QI) initiative was designed to develop systematic pain assessments and assess operators' compliance with potentially better practices identified by means of a structured PDCA (Plan-Do-Check-Act) process, in an effort to close the evidence-practice gap for pain management in the newborn. BackgroundPain control and prevention is imperative for ethical and clinical reasons and is pursued by the American Academy of Pediatrics as a standard requirement in the paediatric and neonatal healthcare setting (American Academy of Pediatrics 2006). The Joint Commission and Accreditation Canada includes systematic pain monitoring and control during the delivery of health care among its standards of excellence. DesignA prospective three-year (2008)(2009)(2010) quality project was conducted at the Neonatal Intensive Care Unit of the Padua University Pediatric Department (Italy) using the PDCA method aiming to ensure pain monitoring as the fifth vital sign and to develop and implement potentially better practices for pain control during invasive procedures. MethodsA multidisciplinary team conducted a baseline survey of current practice, examined available evidence and specific organizational contexts, developed evidence-based changes in practice and provided educational workshops and onthe-job training on crucial appraisal and evidence-based practices (EBPs). Each step was measured using previously identified quality indicators before and after any action to document the success of each QI step. Pain monitoringDo: staff were trained to use pain scales, and space was provided in medical records for recording pain assessments based on validated newborn pain scales (PIPP and EDIN for acute and prolonged pain, respectively), and hourly indirect 'pain screening' using a VAS (the Wong-Baker Faces rating scale) was handled by nurses in all non-noxious situations.Check: the number of days when pain was monitored of the total days in hospital recorded and the number of nurses' shifts in which pain 'monitoring' was done.Pain management for invasive procedures Do: written guidelines for procedural pain were developed, based on national (Lago et al. 2009) and international guidelines and implemented at our NICU to achieve adequate pain control by identifying potential better practices (PBPs) in our setting. For all programmable procedures, it was recommended that caregivers (physicians and nurses) complete specific pharmacological and non-pharmacological pain control measures before, during and after invasive procedures and that procedures be undertaken at appropriate times whenever possible (without waking patients, for instance), taking a global approach to pain control and prevention. Check: the number of procedures performed by the NICU team according to the accepted PBPs and the efficacy of these measures, as defined by pain scores, were monitored by means of the medical records.To ascertain how well the PBPs were implemented, caregivers' compliance was also prospectively analysed considering ...

A Quality Improvement Collaborative Program for Neonatal Pain Management in Japan

“…The precision of the statistical analysis was limited because the number of participating sites was small, but we confirmed a trend of increasing implementation rates of QI 1, 2, 3, 5, 6, 8, and 10. While other pain management quality improvement activities have been demonstrated in NICUs, 8 – 11 this report highlights possibilities for collaborative improvement in pain management across various types of organization of hospital management and various regions of hospitals in Japan. The key elements of this collaborative program, including (1) the presence of pain team leaders using PDSA cycles and leadership support for their activities from nurse managers and physician managers at each site, (2) a 2-day educational session with other participating sites, (3) a supportive communication structure involving experts and exchange of experiences among participating sites, and (4) availability of best practice information, might facilitate improvements in pain practice.…”

“…The use of QIs to monitor the progress of improvement efforts has been shown to be an effective method for improving the quality of practice. Previous quality studies have reported the use of QIs for pain assessment and pain relief by both local 8 , 9 and collaborative groups. 10 , 11 …”

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

“…In our study, we could not find such an improvement after questionnaires and even following educational sessions. Lago et al have noted that training staff in pain assessment, entering pain scores in medical records, and developing a pain protocol could increase the use of pain relief measures from 28% to 76% 23 . Spence et al 24 have shown that use of breastfeeding or sucrose analgesia has improved after an initiative which included audit and feedback, benchmarking, educational workshops on critical appraisal and audit of family awareness of pain.…”

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

“…Following a preeducational and posteducational questionnaire and improving access to sucrose, they noticed increased utilisation of sucrose as non-pharmacological analgesia from 15% to 90%. Lago et al 2 have noted that training staff in pain assessment, entering pain scores in medical records and developing a pain protocol could increase the use of pain relief measures from 28% to 76%.…”