515 - Implementation of a Neonatal Pain Clinical Practice Guideline in a Level IV NICU: A Quality Improvement (QI) Initiative

Publication Number: 515.5165

Ying Ge (Inga) Wang, NYP-Weill Cornell, New York City, NY, United States; James M. kim, Weill Cornell Medicine, new york, NY, United States; Priyanka Tiwari, Weill Cornell Medicine, New York, NY, United States; Yurhee Lee, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Ilaria Mignatti, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Allison N. Weaver, Weill Cornell Medicine, New York, NY, United States; Samantha Frankenberg, Weill Cornell Medicine, Bloomfield, NJ, United States; Sara E.. Rostas, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States

Background: Neonates in the neonatal intensive care unit (NICU) are frequently exposed to painful stimuli, risking adverse neurodevelopmental outcomes if not adequately treated. The American Academy of Pediatrics (AAP) recommends unit-specific guidelines for assessing and managing neonatal pain. Baseline data from our unit revealed inconsistent pain assessment and management, highlighting the need for a standardized pain guideline.

Objective: We implemented a quality improvement initiative in a level IV NICU to standardize pain assessment and optimize pain management in post-operative neonates. Our SMART AIMS were to 1) improve adherence of pain assessment using Neonatal Pain, Agitation, and Sedation Scale (N-PASS) in post-operative neonates by 50% and 2) reduce the N-PASS scores in the 48 post-operative hours by 10% by the end of June 2024.

Design/Methods: We conducted a 13-month observational, time-series study (May 2023 to June 2024), starting with a baseline data from May to August 2023. A key driver diagram was created (Figure 1) and interventions included creation of a pain management guideline, updates to N-PASS flowsheet in EMR, standardization of nursing and pharmacy education. Outcome measures included post-operative N-PASS scores, and process measures included utilization of N-PASS scale and appropriate post-op acetaminophen orders. Balancing measures included cumulative morphine equivalent dosing (MED) and timing for enteral feeds. Statistical process control charts (p and X-bar/S charts) were used to display and analyze our data. Associates for Process Improvement (API) rules for special cause variation were applied.

Results: Adherence to N-PASS scoring in the first 12 post-operative hours improved from 4% to 58% (Figure 2). Overall N-PASS scores for the first 12 hours post-operatively remained at 1.4, but a trend towards a decrease in scores was observed. In addition, for those surgeries anticipated to cause severe pain, there was a center line (CL) change in N-PASS scores from 2.5 to 1.3 (Figure 3). Post-operatively, acetaminophen orders remained at 80% with no CL change. There was no change in cumulative MED and time to enteral feeds.

Conclusion(s): Implementation of a neonatal pain clinical practice guideline for post-operative patients and EMR changes resulted in significant improvements in adherence of pain assessment using N-PASS scale and a decrease in mean N-PASS scores for surgeries anticipated to cause severe pain. Future efforts will focus on further improving adherence to N-PASS scoring, reducing N-PASS scores in post-operative neonates, and implementing pain guidelines for intubated patients.

Key Driver Diagram
Figure 1. Key driver diagram showing primary aims, drivers and change ideas.

P-Chart: N-PASS Adherence 1st 12hr Post-operative Period
Figure 2. Adherence to N-PASS scoring in the first 12 post-operative hours improved from 4% to 58%.

X-bar Chart: Mean N-PASS Score in 1st 12hr in Severely Painful Surgeries
Figure 3. Mean N-PASS scores in the first 12 post-operative hours decreased from 2.5 to 1.3 in surgeries anticipated to cause severe pain.

Key Driver Diagram
Figure 1. Key driver diagram showing primary aims, drivers and change ideas.

P-Chart: N-PASS Adherence 1st 12hr Post-operative Period
Figure 2. Adherence to N-PASS scoring in the first 12 post-operative hours improved from 4% to 58%.

X-bar Chart: Mean N-PASS Score in 1st 12hr in Severely Painful Surgeries
Figure 3. Mean N-PASS scores in the first 12 post-operative hours decreased from 2.5 to 1.3 in surgeries anticipated to cause severe pain.