Article Text

  1. B. E. Cofer,
  2. J. B. Bryant,
  3. N. L. Kraft,
  4. A. C. Ewing,
  5. D. S. Hodge,
  6. S. Hays,
  7. B. Engelhardt,
  8. B. S. Carter,
  9. J. K. Deshpande
  1. Nashville, TN.


Background Pain management in the neonatal intensive care unit (NICU) remains inadequate despite advocacy for improvement.

Purpose To study the impact of an interdisciplinary team approach to improving postoperative and other pain management in a large tertiary NICU.

Methods The study followed the Plan, Do, Study, Act model for improvement. We identified a need to improve postoperative pain management in the NICU. We predicted that implementing a plan to educate staff and standardize management would result in better assessment and treatment of neonatal pain. A real-time chart audit was conducted to collect data on a convenience sample of 50 postoperative cases in the NICU. The team met weekly to review cases and consider ideas for meeting the pain management needs of NICU patients. Following the initial audits of care, the Pain Team devised postoperative pain management guideline that utilized preemptive pain management as a continuum from intraoperative anesthesia/analgesia. Specific recommendations included continuous intravenous fentanyl infusion, “prn” boluses of fentanyl for breakthrough pain, scheduled acetaminophen, and regular pain assessment and reassessment using the N-PASS scale.

Results Prior to the pain team formation, acetaminophen was used in < 20% of postoperative cases. Fentanyl was the opoid of choice and typically ordered “prn” at inappropriate intervals. Anxiolytics were often prescribed before full analgesia was accomplished. Learning has occurred at all levels. The plan has been broadly accepted by staff. Resistance to change remains the biggest hurdle, with occassional reluctance by physicians and nurses to follow a strict protocol for postoperative pain management.

Conclusions Based on early observations, a collaborative interdisciplinary team approach to neonatal pain results in better postoperative pain management. Sustained improvement likely depends on consistent use of the Plan, Do, Study, Act model. This experience is part of an ongoing quality improvement process within the Children's Hospital. The model described will be used and further studied in other patient care units.

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