Procedural Analgesia in the Neonatal Intensive Care Unit: A Quality Improvement Initiative

Abstract

Objective Neonates perceive pain which also has adverse long-term consequences. Newborns experience several painful procedures a day. Various methods of analgesia may be used but are underutilized. The SMART aim of this project was to increase the use of procedural analgesia from 11.5 to 75% in 6 months by using quality improvement principles.

Study Design After a baseline audit, a root cause analysis was done. Based on this, a series of interventions were done as Plan-Do-Study-Act (PDSA) cycles. These included posters on analgesia, display of the pain protocol, orders for analgesia, a written test, small power point presentations on the importance of analgesia, and reminders on the trays used for procedures. At the end of each PDSA cycle, an audit was done to determine the proportion of times analgesia was used. Process indicators were also used when possible. Analysis was done by using the Chi-square test and the paired t-test.

Results At baseline 11% of procedures were done after giving analgesia. This significantly improved to 40% at the end of the first PDSA, and 81% after third PDSA. This was sustained at 75% over the next 2 months.

Conclusion Procedural analgesia can improve and be sustained by using simple interventions.

Key Points

• Procedural pain in neonates can be decreased by the use of analgesia.

• However, most units do not utilize analgesia appropriately.

• This QI showed that simple interventions can optimize use of procedural analgesia.

Keywords

procedures - analgesia - neonate - pain

Authors' Contributions

S.R. helped design the interventions, drew the Ishikawa diagram, and helped in writing the manuscript. S.N. conceptualized the project and wrote the manuscript. J.J., I.B., and S.S. designed and implemented the interventions and did the audits.

Publication History

Received: 30 November 2020

Accepted: 03 February 2021

Article published online:
11 March 2021

• References

• 1 Hatfield LA. Neonatal pain: what's age got to do with it?. Surg Neurol Int 2014; 5 (Suppl. 13) S479-S489
• 2 Fitzgerald M, Millard C, MacIntosh N. Hyperalgesia in premature infants. Lancet 1988; 1 (8580): 292
• 3 Grunau RE, Holsti L, Peters JW. Long-term consequences of pain in human neonates. Semin Fetal Neonatal Med 2006; 11 (04) 268-275
• 4 Britto CD, Rao Pn S, Nesargi S. et al. PAIN--perception and assessment of painful procedures in the NICU. J Trop Pediatr 2014; 60 (06) 422-427
• 5 Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. Prevention and management of procedural pain in the neonate: an update. Pediatrics 2016; 137 (02) e20154271
• 6 Bellieni CV, Johnston CC. Analgesia, nil or placebo to babies, in trials that test new analgesic treatments for procedural pain. Acta Paediatr 2016; 105 (02) 129-136
• 7 Anand KJ. Clinical importance of pain and stress in preterm neonates. Biol Neonate 1998; 73 (01) 1-9
• 8 Simons SH, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med 2003; 157 (11) 1058-1064
• 9 Dunbar III AE, Sharek PJ, Mickas NA. et al. Implementation and case-study results of potentially better practices to improve pain management of neonates. Pediatrics 2006; 118 (Suppl. 02) S87-S94
• 10 Carbajal R, Rousset A, Danan C. et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA 2008; 300 (01) 60-70
• 11 Foster J, Spence K, Henderson-Smart D, Harrison D, Gray PH, Bidewell J. Procedural pain in neonates in Australian hospitals: a survey update of practices. J Paediatr Child Health 2013; 49 (01) E35-E39
• 12 Aukes DI, Roofthooft DWE, Simons SHP, Tibboel D, van Dijk M. Pain management in neonatal intensive care: evaluation of the compliance with guidelines. Clin J Pain 2015; 31 (09) 830-835
• 13 Kothari SY, Dongara AR, Nimbalkar SM, Phatak AG, Nimbalkar AS. Missed opportunities for sedation and pain management at a level III neonatal intensive care unit, India. Front Pediatr 2016; 4: 7
• 14 Abdel Razeq NM. Barriers that impede the provision of pain care to neonates by nurses in Jordan. J Obstet Gynecol Neonatal Nurs 2016; 45 (03) 371-377
• 15 Gharavi B, Schott C, Nelle M, Reiter G, Linderkamp O. Pain management and the effect of guidelines in neonatal units in Austria, Germany and Switzerland. Pediatr Int 2007; 49 (05) 652-658
• 16 Lagunas AM, Hall HR. Improving pain management in neonates exposed to intravenous insertions: a quality improvement initiative. J Neonatal Nurs 2016
• 17 Ozawa M, Yokoo K, Funaba Y. et al. A quality improvement collaborative program for neonatal pain management in Japan. Adv Neonatal Care 2017; 17 (03) 184-191