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

Background: Neonates managed in neonatal intensive care units undergo several invasive procedures. However, neonatal procedural pain is not well recognized and managed in most neonatal units.

Aims: To decrease the severity of procedural pain in preterm neonates (<37 weeks gestational age at birth), as measured by Premature Infant Pain Profile , by 50% by April 2020.

Methods: A quality improvement initiative was conducted in a level 3 neonatal intensive care unit in South India. The pain was assessed independently by 2 interns not involved in clinical care using Premature Infant Pain Profile. After a baseline data recording and questionnaire assessing knowledge of healthcare personnel regarding neonatal pain, the interventions were planned. These were conducted as plan-do-study-act cycles-(i) Educational sessions, (ii) Introduction of bedside visual aids, (iii) Simulation sessions demonstrating the use of nonpharmacological measures and introduction of procedure surveillance chart in daily rounds, and (iv) Video feedback-based sessions. In the maintenance phase, the observations were continued.

Results: The healthcare personnel under recognized pain related to heel pricks and endotracheal intubation. They also had poor awareness of signs and symptoms of neonatal pain. A total of 202 procedures were observed during the study period. The mean pain score decreased significantly from 12.8 ± 4.5 in baseline period to 6.2 ± 1.8 in the maintenance phase. The use of analgesic measures increased from 13% in the baseline period to 73% in the maintenance phase. The use of automated lancet for heel prick increased from 0% to 94% in maintenance phase. More and more procedures were done with appropriate environment and baby state. The mean number of procedures per day decreased from 6.5 ± 1.8 in baseline period to 2.7 ± 0.9 in the maintenance phase.

Conclusions: Targeted interventions can improve neonatal procedural pain management by improving use of analgesic measures, decreasing the number of procedures, and educating and training healthcare personnel.