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Stopping the Hurt: A NICU Quality Improvement Project to Reduce Postoperative Pain

July 6, 2023

In this recently released Pediatrics article, Dr. Roopali Bapat and colleagues, from neonatal intensive care units (NICUs) within the Children’s Hospitals Neonatal Consortium (CHNC) that care for infants with complex surgical needs, engaged in an ambitious collaborative quality improvement project, Erase Postoperative Pain (10.1542/peds.2022-059860). Twenty-six of 34 CHNC NICUs decided to participate: teams committed to reducing infant postoperative pain through collaboration, education, tests of change, and reporting improvement metrics all working under a central project management group.

Salient features of this collaborative QI project included development of an evidence-based clinical practice recommendations document, use of validated pain assessment tools, strategies to support pain score documentation and discussion on rounds, family involvement in pain management, creation of a multi-disciplinary stakeholder team, and development of a pain treatment algorithm with both pharmacologic and non-pharmacologic treatments. The initiative included both helpful flexibility and structure. On one hand, centers were not asked to embrace the clinical practice recommendations as an all-inclusive intervention bundle, but rather to use those elements of the guidance document that best fit locally, including choosing their own pain assessment tool. On the other hand, the central project management team provided support and structure to teams, including monthly one hour learning webinars, biweekly thirty minute “huddle” calls to share lessons learned, and faculty advisors who aided in monitoring monthly center data and self-assessments. This unique approach combined central guidance with hospital team “permission” to “personalize” the interventions; this seemed particularly effective in pushing the project forward.  

The primary outcome measure was to decrease the percentage of patients with unrelieved postoperative pain in the first 24 hours, and in fact, this percentage decreased by 35% from 19.5% to 12.6%. The secondary outcome was, notably, a parent and family driven measure to improve family satisfaction with pain management in the first 24-hour postoperative period, and already high family satisfaction (93%) stayed high (96%). I think you will enjoy reading about the many nuanced and innovative changes and processes described. The collaborative project management group emphasized to members that each baby matters using a huddle presentation called “Baby Steps to Big Improvements” so teams could “…visualize how one less patient with consecutive pain scores achieves a big impact on the project…”  What a positive approach! Enjoy this great article and let us know what your NICU is doing to ease postoperative pain.

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