Linda Ikuta, RN, MS, CCNS, PHN ❍ Section Editor
Foundations in Newborn Care
Improving Pain Assessment in the NICU A Quality Improvement Project Daphne A. Reavey, PhD, RN, NNP-BC; Barbara M. Haney, MSN, RNC-NIC, CPNP-AC; Linda Atchison, BSN, RNC-NIC; Betsi Anderson, BSN, RN, CPHQ; Tracy Sandritter, PharmD; Eugenia K. Pallotto, MD, MSCE ABSTRACT Pain assessment documentation was inadequate because of the use of a subjective pain assessment strategy in a tertiary level IV neonatal intensive care unit (NICU). The aim of this study was to improve consistency of pain assessment documentation through implementation of a multidimensional neonatal pain and sedation assessment tool. The study was set in a 60-bed level IV NICU within an urban children’s hospital. Participants included NICU staff, including registered nurses, neonatal nurse practitioners, clinical nurse specialists, pharmacists, neonatal fellows, and neonatologists. The Plan Do Study Act method of quality improvement was used for this project. Baseline assessment included review of patient medical records 6 months before the intervention. Documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment were reviewed. Literature review and listserv query were conducted to identify neonatal pain tools. Survey of staff was conducted to evaluate knowledge of neonatal pain and also to determine current healthcare providers’ practice as related to identification and treatment of neonatal pain. A multidimensional neonatal pain tool, the Neonatal Pain, Agitation, and Sedation Scale (N-PASS), was chosen by the staff for implementation. Six months and 2 years following education on the use of the N-PASS and implementation in the NICU, a chart review of all hospitalized patients was conducted to evaluate documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment in the medical progress note. Documentation of pain scores improved from 60% to 100% at 6 months and remained at 99% 2 years following implementation of the N-PASS. Pain score documentation with ongoing nursing assessment improved from 55% to greater than 90% at 6 months and 2 years following the intervention. Pain assessment documentation following intervention of an elevated pain score was 0% before implementation of the N-PASS and improved slightly to 30% 6 months and 47% 2 years following implementation. Identification and implementation of a multidimensional neonatal pain assessment tool, the N-PASS, improved documentation of pain in our unit. Although improvement in all quality improvement monitors was noted, additional work is needed in several key areas, specifically documentation of reassessment of pain following an intervention for an elevated pain score. Key Words: N-PASS, neonatal pain, pain scores, quality improvement
Author Affiliations: Department of Neonatology, Children’s Mercy Hospitals and Clinics, and University of Missouri–Kansas City School of Nursing (Dr Reavey); Children’s Mercy Hospitals and Clinics (Mss Haney and Atchison); Department of Neonatology (Ms Anderson) and Department of Clinical Pharmacology and Medical Toxicology (Dr Sandritter), Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; and University of Missouri– Kansas City School of Medicine (Dr Pallotto).
The authors declare no conflict of interest. Correspondence: Daphne A. Reavey, PhD, RN, NNP-BC, Children’s Mercy Hospitals and Clinics, Department of Neonatology, University of Missouri– Kansas City School of Nursing, 2401 Gillham Rd, Kansas City, MO 64108 ([email protected]). Copyright © 2014 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000034 Advances in Neonatal Care • Vol. 14, No. 3 • pp. 144-153
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BACKGROUND KNOWLEDGE Anand and Hickey’s1 sentinel article describing the potential mechanisms by which neonates could perceive pain dispelled the long-held medical myth that neonates were unable to experience pain. Since the 1980s, numerous studies have documented the physiological, behavioral, and biochemical responses of the neonate to painful procedures.2 In addition to the many short-term consequences of acute pain in neonates, there is growing concern of potential longterm adverse outcomes that may be associated with repetitive pain during the neonatal period. Differences in pain perception were found in response to routine immunizations in infants who had been previously circumcised as compared with infants who had not been circumcised or who had undergone a circumcision with analgesia. 3 Alterations in pain sensitivity have also been documented in toddlers4 and adolescents5 who were born prematurely and exposed to painful procedures in the NICU. In addition to differences in later pain perception, repetitive pain in preterm neonates may also contribute to long-term adverse neurodevelopmental and behavioral outcomes.6-9 Despite the increasing evidence that neonatal pain may be detrimental, assessment and treatment of neonatal pain often remain inadequate.10-14 It is not uncommon for neonates to undergo medical and nursing procedures without an objective measurement of their pain.15,16 In response to the growing body of literature supporting the treatment of neonatal pain, professional health organizations have published recommendations for the assessment and management of pain in the neonate including a joint policy statement from the American Academy of Pediatrics (AAP), and the Canadian Paediatric Society (CPS),17 and the National Association of Neonatal Nurses (NANN).18 The AAP and the CPS joint policy statement recommends routine neonatal pain assessment using a multidimensional tool and the use of nonpharmacologic and pharmacologic therapies for the treatment of pain during the neonatal period.17 In addition, The Joint Commission (TJC) has had a standard regarding the routine assessment of pain in all hospitalized patients, including neonates, since 2001.19 Although it is well documented that pain assessment and pain management in neonates have been inadequate10,12-14 there is little information available to guide the clinician in implementing current TJC pain standards. In 1995, Friedrichs et al20 described a quality improvement (QI) project to improve pain assessment and management in the NICU. Improvement in pain assessment documentation, the development of pain management guidelines, and weekly pain rounds were goals accomplished with the project. The project began with the development of a multidisciplinary task force and QI education
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using the Plan Do Study Act (PDSA) model. The initial phase or cycle included didactic staff education on the assessment, pathophysiology, and pharmacological treatment of neonatal pain. Retrospective review of neonatal surgical patients was undertaken and a questionnaire was developed and implemented to assess the perceptions of staff that determined pain management in their unit. These results lead to recognition of the need for a bedside assessment tool that was subsequently developed. Their bedside neonatal pain assessment tool consisted of facial actions, infant state, activity, and physiological parameters. Documentation of pharmacologic interventions was also included in the tool. Documentation of pain assessment increased from 41% to 81% over the 2-year project. Staff nurse evaluation of intervention effectiveness also improved from 58% to 81%. Improvement, although not as robust, was also noted in physician evaluation of intervention effectiveness, increasing from 11% to 25%. Weekly pain rounds were used to individualize pharmacologic pain treatment for neonates. The authors concluded that these rounds decreased the use of inappropriate medications and improved consistency of pain management.20 A subgroup of the Neonatal Intensive Care Quality Collaborative 2002, with oversight by the Vermont Oxford Network (VON), involving 12 NICUs interested in improving neonatal pain management, published their methods to improve clinical practice in 2006. There were several items identified by the group that were considered essential to their collaborative effort. These items included clear and measurable goals, the use of a content expert for the literature review, the expertise of individual subgroups, and individual center databases that provided objective measures before and after implementation of potentially better practices (PBPs) in each unit.21 The teams from the participating NICUs collaborated to develop 10 PBPs to improve management of pain. The PBPs were based on published literature available at that time related to neonatal pain assessment and management. Each team implemented a variety of the PBPs; one center implemented all 10. The preassessment phase of that VON NICU collaborative QI project found that fewer than 20% of the 277 neonates were assessed for pain during a medical or nursing procedure in the NICU. Only 19% of the painful procedures were accompanied by analgesic treatment.21 Postintervention assessments done 2 years later revealed significant improvements in a variety of areas, including the average number of pain assessments during the first 48 hours of care in both ventilated (P < .0001) and nonventilated neonates (P < .0001). There were also a significantly higher number of neonates who received pharmacologic treatments (P < .0001),
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sucrose (P < .0001), or both before invasive procedures. In one NICU, postoperative pain management also was significantly improved. Before the project, only 13% of neonates had scheduled narcotics ordered. This improved to 53% postintervention. Behavioral interventions, to treat pain, doubled during the time period with 18% of neonates in the preimplementation phase and 37% of neonates in the postimplementation assessment receiving behavioral interventions (P < .0001) prior to painful procedures.22 Through a systematic, collaborative effort, this group implemented evidence-based recommendations and improved the clinical practice pertaining to neonatal pain in the participating NICUs, in part because of improved pain assessment.
LOCAL PROBLEM In the late 1990s, a pain task force was formed to address pain assessment in our NICU. The small task force involved nursing and physician participation. Standardized pain tools were evaluated and on the basis of an internal, unpublished, study done by one member of the task force, the Infant Pain Scale (IPS) was chosen. The IPS is a modified form of the clinical postoperative pain scoring system developed by Barrier et al23 and closely resembles the Modified Infant Pain Scale (MIPS) although only behavioral and not physiologic responses were included.24 The IPS was not trialed by staff nurses prior to implementation in the NICU. The IPS, a unidimensional pain scale using behavioral criteria, was consistently challenging for nursing staff. They believed that they were unable to use the pain tool in our population of patients, especially when scoring a ventilated or paralyzed neonate or a patient with congenital anomalies. Concurrent with IPS implementation, computerized nursing documentation was modified. This modification allowed the nurse to subjectively assess the infant. Allowing this initial subjective assessment discouraged the use of the IPS in all neonates. If the nurse, in her professional opinion, did not feel that the neonate was experiencing pain, the expectation was set up that no further pain assessment was indicated. Although NANN guidelines and TJC mandates were acknowledged, the inclusion of a subjective initial assessment supported a system of noncompliance with these guidelines. The IPS, along with subjective “pain screening,” remained in place for several years prior to the formation of a formal multidisciplinary NICU Pain Committee. The NICU Pain Committee members included a neonatologist, clinical nurse specialist, neonatal nurse practitioner (NNP), staff nurse, clinical pharmacy specialist, QI coordinator, and a representative of the hospital-wide pain task force. Consultants such as anesthesiologists were included when their
input was needed. The NICU Pain Committee set goals to improve pain assessment and consistency of pain management in neonatal patients. This article describes the improvement process used to identify and implement an objective pain assessment tool for our NICU.
INTENDED IMPROVEMENT Using a TJC compliance tool, an organizational review of pain assessment and management was completed to identify focus areas for improvement.19 This institutional tool is designed to evaluate the organizational processes in place to improve pain assessment and management. Categories include patient rights and organizational ethics, assessment of patient’s pain, care of patients related to pain, education, continuum of care, improving organizational performance, leadership, management of human resources, and medical staff. This assessment identified several opportunities for improvement including the need to standardize pain assessment, documentation, and review of pain status. A QI project was initiated with the primary aim of improving compliance with an objective assessment and documentation of pain for all neonates. The NICU pain committee believed that a key driver to meet this aim was the identification and implementation of a standardized multidimensional pain assessment tool, as recommended by NANN (2012),18 that could be used consistently for our NICU population.
METHODS The setting for the QI project was a 60-bed level IV NICU that is housed in a free-standing urban children’s hospital. The NICU has a diverse, complex patient population with a mix of surgical and medical patients. Pediatric subspecialty services are available, as are specialty services, including Extracorporeal Membrane Oxygenation and cardiovascular surgery. The NICU cares for high-acuity patients and has a nursing staff of 150 to 200 nurses. The patient population includes term and preterm neonates with both medical and surgical illnesses and variable lengths of hospitalization from a few days to months. The NICU includes 15 to 20 neonatologists and 45 to 50 NNPs, as well as neonatal fellowship and pediatric resident training programs. Identifying a comprehensive pain assessment tool for this varied population of patients and large group of providers that was simple and useful for clinical decisionmaking was critical to successful implementation in our NICU. This QI project was reviewed by the hospital’s institutional review board. The NICU Pain www.advancesinneonatalcare.org
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Committee chose to use the PDSA QI model for implementation of this project. The PDSA QI model is used for rapid cycle improvement. PDSA cycles are ideally small-scale tests used to implement desired change within organizations.25 This QI method is used to systemically plan a desired change, study the change in measured outcomes, and then act on the information gained to begin another cycle. The NICU Pain Committee chose the PDSA QI model for implementation of our project because it has been used successfully in many VON QI projects26 and as a member of VON, the use of PDSA cycles had become part of our NICU culture. The following steps were followed in our QI project: assessment of the problem, literature review, query of experts, staff input for pain tool selection, and education of healthcare personnel (Table 1). Assessment of the problem was achieved by measurement of current pain documentation within our unit and completion of the TJC compliance tool. A literature review and listserv query was done specifically to identify multidimensional neonatal pain tools successfully used in similar NICUs. After a comparison of identified pain tools, the NICU Pain committee narrowed the options to 5 tools that included the CRIES (Crying, Requires O2, Increased vital signs, Expression, Sleeplessness),27 Premature Infant Pain Profile,28 the Neonatal Infant Pain Scale,29 the MIPS,24 and the Neonatal Pain, Agitation and Sedation Scale (N-PASS).30 Staff nurses reviewed the 5 scales and ranked their opinion of each tool using a Likert scale between 1 (not useful) and 5 (very useful). The results of this survey identified the MIPS and N-PASS tools as most likely to meet the needs of the diverse patient population and have the potential for successful integration in nursing work flow. Trained volunteer staff nurses then used each pain tool for a 2-week period and ranked them on feasibility and clinical utility. Advantages of the N-PASS (Figure 1), as expressed by staff nurses and the NICU Pain Committee, were that it included physiological parameters, was simple to use, acknowledged agitation as part of pain assessment, and included points for prematurity. At the time of project initiation, the N-PASS had been published only in abstract form.30 There were other neonatal pain tools with established reliability and validity, yet the N-PASS had been well-accepted by neonatal nurses31 and was being used in VON NICUs across the country.32 Although reliability and validity had not yet been published, the belief was that the N-PASS had the most potential for successful implementation in our culture based on the initial nursing assessment because of ease of use, ability to integrate in workflow, inclusion of physiological and behavioral cues (multidimensional), and applicability to a varied patient population in a tertiary NICU population. Since the inception of this QI
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project, beginning reliability and validity has been published for the N-PASS.33,34 The N-PASS has been shown to be valid and reliable for assessing acute heelstick pain in neonates between birth and 30 days of age and 23 and 40 weeks gestation.34 In the measurement of prolonged pain, the N-PASS has also been shown to be reliable and valid in neonates greater than or equal to 23 weeks gestation and 0 to 100 days of age, requiring ventilation and/or recovering from surgery.33 Following identification of the N-PASS as the neonatal pain tool for implementation in our NICU, education of all staff members, including registered nurses, NNPs, neonatal fellows and neonatologists, was completed. In additional to didactic instruction, during nursing education, videos of patients were reviewed and scored as a group and results were discussed. The N-PASS was built into the electronic medical record. Reminder posters as well as directions in the use of the tool were posted throughout the unit and at each individual bedside. A super user group of nurses who had participated in the tool selection was available as a resource to other nurses in the unit. Specific QI monitoring was then completed at 6 months and again at 2 years following implementation of the N-PASS. The aim for all measures was greater than 95% compliance. Measures included documentation of initial nursing pain assessment on admission, routine pain assessment with full patient assessments, reassessment of pain after an elevated score and intervention, discussion of pain assessment and pain scores during multidisciplinary rounds, and documentation in provider daily progress notes.
RESULTS Baseline monitoring of provider discussion of pain and pain scores before education and implementation of the new pain tool identified that pain scores discussion on multidisciplinary rounds never occurred, although pain was briefly mentioned on 7% of the patients (Table 2). Documentation of pain assessment in the daily progress note was only 2% preimplementation. Six months after implementation, pain assessment was discussed during rounds 52% of the time and only slightly improved to 57% 2 years later. Further investigation revealed that although pain was not always discussed on rounds, it was being discussed in the medical record. Eightysix percent of neonates requiring pharmacologic intervention for pain or having high pain scores had documentation of pain management in the provider daily progress note. Nursing documentation of pain assessment upon admission was only 60% at baseline before N-PASS implementation and increased to 100% at 6 months
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TABLE 1. Phases of Quality Improvement Project Methods Assessment of the problem
Key Points Overall belief by healthcare providers that pain was inadequately assessed and managed Completion of a JCAHO compliance tool Analysis revealed several opportunities for improvement: Standardization of pain assessment Consistent pain documentation
Review of literature and identification of expert resources
Identification of published neonatal pain assessment tools Identification of pain tools used in other VON NICUs through e-mail and listserv query Comparison of neonatal pain tools with recommendation of 5 tools for further consideration: CRIES, PIPP, NIPS, MIPS and the N-PASS Evaluation of the 5 pain tools by staff nurses using a Likert scale Trained volunteer staff nurses to use pain tools Trial of each pain tool by volunteer staff nurses for 2 weeks Judged N-PASS tool as best fit for implementation in our NICU
Assessment of unit culture
Mental model survey of pain practices and pain assessment completed by neonatologist, neonatal fellows, NNPs, and staff nurses Identified individual practice preferences from each team member regarding: Frequency of pain assessments Clinical parameters used to assess pain Use of a standardized pain tool Knowledge of JCAHO pain assessment requirements
Education of NICU staff
Initial general neonatal pain education to all NICU nursing staff at unit update meetings Follow-up nursing education regarding N-PASS tool at unit update meetings Education consisted of: Lecture and video presentations Practice using the N-PASS pain tool via video demonstration of neonates in varying painful situations Education of physicians and NNPs on neonatal pain, JCAHO requirements, and the N-PASS tool Reminder e-mails, posters, and bedside signs
Implementation of new pain tool
Built N-PASS into electronic medical record Established expectation of N-PASS completion with every assessment Included as part of routine assessment documentation Included pain intervention options to assist with documentation Posted laminated color copies of N-PASS with scoring directions at every patient bedside and bulletin boards throughout the NICU Added pain and sedation scores to data collection sheets used by NNPs/residents Included pain field in physician/NNP electronic templates to ensure routine pain documentation in the progress note (continues)
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TABLE 1. Phases of Quality Improvement Project, Continued Methods
Key Points
Monitoring of quality improvement data
QI monitoring included: Admission nursing pain score documentation Routine nursing pain score documentation with every routine assessment Reassessment of nursing pain score documentation following elevated pain score Assessment of pain discussion during multidisciplinary rounds Daily pain assessment documented in physician/NNP progress notes QI monitoring completed: Prior to implementation of the N-PASS tool 6 months and 2 years following implementation of the N-PASS Ongoing monitoring of key components QI results communicated to all staff in e-mails, posters, and electronic bulletin board
Abbreviations: CRIES, crying, requires O2, increased vital signs, expression, sleeplessness; JCAHO, Joint Commission on Healthcare Organization; MIPS, Modified Infant Pain Scale; N-PASS, Neonatal Pain, Agitation, and Sedation Scale; NICU, neonatal intensive care unit; NIPS, Neonatal Infant Pain Scale; NNP, neonatal nurse practitioner; PIPP, Premature Infant Pain Profile; QI, quality improvement; VON, Vermont Oxford Network.
FIGURE 1.
N-PASS Pain Tool. Used with permission from P. Hummel, MA, RNC, NNP, PNP. Advances in Neonatal Care • Vol. 14, No. 3 Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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TABLE 2. Physician Pain Documentation/Discussiona Preimplementation (N ⫽ 55)
6 Months Postimplementation (N ⫽ 56)
2 Years Postimplementation (N ⫽ 58)
Daily progress note: all patients (%)
1 (2)
__
19 (33)
Daily progress note: patients receiving opiates or acetaminophen (%)
__
__
50 (86)
4 (7)
29 (52)
33 (57)
Monitor
Rounds (%)
Dashes indicate that data were not collected. Daily progress notes were reviewed to identify documentation of pain assessment and pain scores. Multidisciplinary rounds were monitored for discussion of pain assessment and pain scores. a
postimplementation (Table 3). Two years later, this improvement had been sustained. Ninety-nine percent of neonates continued to have pain assessment (N-PASS score) documented on admission. In addition, every quarter consistently demonstrated greater than 90% compliance (Figure 2). Before implementation of the N-PASS, the expectation for documentation of routine, ongoing pain assessment was only once a shift and whenever pain was identified. Compliance with this recommendation was 55% (Table 3). Six months after N-PASS implementation, compliance had increased and was sustained 2 years later. All quarterly reviews following implementation of the N-PASS have demonstrated that routine assessment of pain was documented by nursing staff more than 90% of the time (Figure 3). Documentation of pain reassessment following an elevated pain score (≥4) has been a consistent challenge. Historically, no monitoring of pain reassessment was done in our NICU. Six months after implementation, pain reassessment documentation was noted to be only 30% (Table 3). Despite additional education, e-mails, and reminders on all the bedside computers, reassessment documentation remained at 47% 2 years later.
DISCUSSION Change is a challenging process in a large NICU. With many healthcare providers involved in the care of critically ill neonates, successful implementation of thorough pain assessment and pain management strategies can be challenging. There must be “buyin” and support from the entire team to achieve compliance and successful implementation. Champions to a new process are critical to the success of any new project, but to fully change the culture of the NICU and impact practice, involvement and support at all levels is needed. In the implementation of any new process, it is important to acknowledge and incorporate beliefs that are already held as important to the group. In our NICU, vital sign measurement changes were identified by healthcare providers and validated with surveys as the parameter that they felt best assessed neonatal pain. The use of a tool that did not include these measurements would have been difficult to implement, potentially resulting in failure. Education on the importance of using a multidimensional pain tool and reviewing the literature on neonatal pain facilitated buy-in from all staff. It was also clear by our
TABLE 3. Nursing Pain Documentationa Preimplementation (N = 58)
6 Months Postimplementation (N = 56)
2 Years Postimplementation (N = 58)
Admission (%)
35 (60)
56 (100)
57 (99)
Routine (%)
32 (55)
54 (97)
55 (95)
—
17 (30)
27 (47)
Monitor
Reassessment (%)
Dashes indicate that data were not collected. Expectation of frequency of routine pain assessments changed at the time of implementation from a minimum of once per shift to every hands-on assessment, at least every 6 hours. a
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FIGURE 2.
Admission nursing pain assessment documentation. Review of nursing documentation of all patients in a 60-bed neonatal instensive care unit to identify the percentage of patients with Neonatal Pain, Agitation, and Sedation Scale (NPASS) pain score documentation on admission.
trials of the various pain tools that satisfaction with the tool was greatly influenced by the ability of the staff nurse to integrate the tool within the daily workflow. Establishing pain assessment intervals that coincided with routine nursing assessments
assisted in the successful implementation of a new pain tool in our NICU. Although there were improvements noted in the discussion of pain in daily medical rounds, these improvements were less than those seen in nursing
FIGURE 3.
Routine nursing pain assessment documentation. Review of nursing documentation of all patients in a 60-bed neonatal intensive care unit to identify the percentage of patients with Neonatal Pain, Agitation, and Sedation Scale (NPASS) pain score documentation with every assessment, at least every 6 hours. Advances in Neonatal Care • Vol. 14, No. 3 Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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FIGURE 4.
Inclusion of pain scores in electronic progress note. Cerner PowerNote smart template. Allows inclusion of nursing Neonatal Pain, Agitation, and Sedation Scale pain score documentation into daily progress note with the click of a mouse.
documentation. It may not be realistic to expect that pain scores be discussed 100% of the time, especially in neonates with low pain scores or those not requiring interventions for pain. The complexity and length of daily medical rounds in a busy, large NICU necessitates prioritization of current clinical issues. Absence of the need for pain interventions or normal to low pain scores indicate that pain is not a problem and therefore may not warrant a detailed discussion in daily medical rounds. Pain assessment and documentation are essential for all neonates. Neonates with elevated pain scores or those requiring pain interventions should be discussed in daily medical rounds to develop an appropriate pain management plan. This remains the ongoing expectation in our unit; nursing providers are encouraged to mention pain if not discussed by the NNP or physician. As our electronic tools have developed over time, this has required ongoing review of our compliance and verifying the tools to support the clinical goals. Pain scores are even more readily available to providers in summary rounds reports with the vital signs and can automatically populate into the progress note (Figure 4). Documentation of pain reassessment following an intervention remains a challenge. Resolution of pain and lack of active worry for the neonate may lead to “forgetfulness” in nursing documentation of pain intervention responses. Identifying methods to remember to document pain reassessment remains a challenge. As bedside electronic medical records become more sophisticated, alerts and decision support for reassessment documentation based on high pain scores as well as following pain interventions
could trigger improved compliance. Continued new creative methods to reinforce success in meeting the assessment, reassessment, and treatment expectations remain a goal of our team. Including families has been an important part of our recent improvements. Seeing their baby experience pain and having inadequate information on neonatal pain are an added stress to parents.35 Education of parents and anticipatory guidance in the recognition of neonatal pain behaviors and strategies of pain management has been shown to decrease parental stress.36 Our multidisciplinary pain team believes that improved identification and treatment of pain lead to more satisfied families, through decreased parental stress. Although sometimes difficult, successful change can identify new related opportunities to improve care. In our NICU, satisfaction with our standardized pain assessment tool opened many opportunities to improve our treatment of pain as it related to specific procedures and conditions. Our team has progressed to successful implementation of improved standards for postoperative pain management, treatment of pain for bedside procedures such as intubations, lumbar punctures, and circumcisions, as well as standardizing sedation processes for laser surgeries and magnetic resonance imaging studies. Our NICU Pain Committee remains enthusiastic in identifying novel therapies for treating pain and painrelated conditions in neonates. We also continue to provide education and support for all NICU providers as well as working as a liaison within the hospital system advocating for pain relief and management for all neonates. www.advancesinneonatalcare.org
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References 1. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-1329. 2. Franck LS, Miaskowski C. Measurement of neonatal responses to painful stimuli: a research review. J Pain Symptom Manage. 1997;14:343-378. 3. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349(9052):599-603. 4. Grunau RV, Whitfield MF, Petrie JH. Pain sensitivity and temperament in extremely low-birth-weight premature toddlers and preterm and full-term controls. Pain. 1994;58:341-346. 5. Buskila D, Neumann L, Zmora E, Feldman M, Bolotin A, Press J. Pain sensitivity in prematurely born adolescents. Arch Pediatr Adolesc Med. 2003;157:1079-1082. 6. Bhutta AT, Anand KJ. Vulnerability of the developing brain. Neuronal mechanisms. Clin Perinatol. 2002;29:357-372. 7. Grunau RE, Tu MT. Long-term consequences of pain in human neonates. In: Anand KJS, Stevens BJ, McGrath PJ, eds. Pain in Neonates and Infants. Philadelphia, PA: Elsevier; 2007;3:45-57. 8. Johnston CC, Stevens BJ. Experience in a neonatal intensive care unit affects pain response. Pediatrics. 1996;98:925-930. 9. Whitfield MF, Grunau RE. Behavior, pain perception, and the extremely low-birth weight survivor. Clin Perinatol. 2000;27: 363-379. 10. Debillon T, Bureau V, Savagner C, Zupan-Simunek V, Carbajal R. Pain management in French neonatal intensive care units. Acta Paediatr. 2002;91:822-826. 11. Dodds E. Neonatal procedural pain: a survey of nursing staff. Paediatr Nurs. 2003;15(5):18-21. 12. Harrison D, Loughnan P, Johnston L. Pain assessment and procedural pain management practices in neonatal units in Australia. J Paediatr Child Health. 2006;42:6-9. 13. Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP. Pain and pain management in newborn infants: a survey of physicians and nurses. Pediatrics. 1997;100:626-632. 14. Simons SHP, Van Dijk M, Anand KS, Roofthooft D, Van Lingen RA, Tibboel D. Do we still hurt newborn babies? Arch Pediatr Adolesc Med. 2003;157:1058-1064. 15. Duhn LJ, Medves JM. A systematic integrative review of infant pain assessment tools. Adv Neonatal Care. 2004;4:126-140. 16. Stevens BJ, Pillai Riddell RR, Oberlander TE, Gibbins S. Assessment of pain in neonates and infants. In: Anand KJS, Stevens BJ, McGrath PJ, eds. Pain in Neonates and Infants. Edinburgh, Scotland: Elsevier; 2007;(3):67-91. 17. American Academy of Pediatrics, Committee on Fetus and Newborn and Section on Surgery, Section on Anesthesiology and Pain Medicine, Canadian Paediatric Society, and Fetus and Newborn Committee. Prevention and management of pain in the neonatal: an update. Pediatrics. 2006;118:2231-2241. 18. National Association of Neonatal Nurses. Newborn Pain Assessment and Management Guideline for Practice. Glenview, IL: National Association of Neonatal Nurses; 2012:3.
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19. Bartel J, Beasley J, Berry PH. Approaches to Pain Management. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2003:35-48. 20. Friedrichs JB, Young S, Gallagher D, Keller C, Kimura RE. Where does it hurt? An interdisciplinary approach to improving the quality of pain assessment and management in the neonatal intensive care unit. Nurs Clin N Am. 1995;30(1):143-159. 21. Sharek PJ, Powers R, Koehn A, Anand KJ. Evaluation and development of potentially better practices to improve pain management of neonates. Pediatrics. 2006;118(Suppl 2):S78S86. 22. Dunbar 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 2): S87-S94. 23. Barrier G, Attia J, Mayer MN, Amiel-Tison C, Shnider SM. Measurement of post-operative pain and narcotic administration in infants using a new clinical scoring system. Intensive Care Med. 1989;15(Suppl 1):S37-S39. 24. Buchholz M, Karl HW, Pomietto M, Lynn A. Pain scores in infants: a modified infant pain scale versus visual analogue. J Pain Symp Manage. 1998;15(2):117-124. 25. Plsek PE. Quality improvement methods in clinical medicine. Pediatrics. 1999;103:203-214. 26. Horbar JD, Soll RF, Edwards WH. The Vermont Oxford Network: a community of practice. Clin Perinatol. 2010;37:29-47. 27. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53-61. 28. Stevens B, Johnston C, Petryshen P, Taddio A. Premature Infant Pain Profile: development and initial validation. Clin J Pain. 1996;12(1):13-22. 29. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59-66. 30. Hummel PA, Puchalaski MJ, Creech SD, Weiss MG. N-PASS: neonatal pain, agitation, and sedation scale. Pediatr Res. 2003;53:2580A. 31. Stokowski LA. Validation of the N-PASS. Adv Neonatal Care. 2008;8:75-77. 32. Anderson B. Re: Pain Scale Tools. Message posted to [email protected]; 2004. 33. Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: Neonatal Pain, Agitation and Sedation Scale with prolonged pain. J Perinatol. 2008;28(1):55-60. 34. Hummel P, Lawlor-Klean P, Weiss MG. Validity and reliability of the N-PASS assessment tool with acute pain. J Perinatol. 2010;30:474-478. 35. Franck LS, Cox S, Allen A, Winter I. Parental concern and distress about infant pain. Arch Dis Child Fetal Neonatal Ed. 2004;89: F71-F75. 36. Gale G, Franck LS, Kools S, Lynch M. Parents’ perceptions of their infant’s pain experience in the NICU. Int J Nurs Stud. 2004;41:51-58.
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Improving Pain Assessment in the NICU A Quality Improvement Project Daphne A. Reavey, PhD, RN, NNP-BC; Barbara M. Haney, MSN, RNC-NIC, CPNP-AC; Linda Atchison, BSN, RNC-NIC; Betsi Anderson, BSN, RN, CPHQ; Tracy Sandritter, PharmD; Eugenia K. Pallotto, MD, MSCE ABSTRACT Pain assessment documentation was inadequate because of the use of a subjective pain assessment strategy in a tertiary level IV neonatal intensive care unit (NICU). The aim of this study was to improve consistency of pain assessment documentation through implementation of a multidimensional neonatal pain and sedation assessment tool. The study was set in a 60-bed level IV NICU within an urban children’s hospital. Participants included NICU staff, including registered nurses, neonatal nurse practitioners, clinical nurse specialists, pharmacists, neonatal fellows, and neonatologists. The Plan Do Study Act method of quality improvement was used for this project. Baseline assessment included review of patient medical records 6 months before the intervention. Documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment were reviewed. Literature review and listserv query were conducted to identify neonatal pain tools. Survey of staff was conducted to evaluate knowledge of neonatal pain and also to determine current healthcare providers’ practice as related to identification and treatment of neonatal pain. A multidimensional neonatal pain tool, the Neonatal Pain, Agitation, and Sedation Scale (N-PASS), was chosen by the staff for implementation. Six months and 2 years following education on the use of the N-PASS and implementation in the NICU, a chart review of all hospitalized patients was conducted to evaluate documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment in the medical progress note. Documentation of pain scores improved from 60% to 100% at 6 months and remained at 99% 2 years following implementation of the N-PASS. Pain score documentation with ongoing nursing assessment improved from 55% to greater than 90% at 6 months and 2 years following the intervention. Pain assessment documentation following intervention of an elevated pain score was 0% before implementation of the N-PASS and improved slightly to 30% 6 months and 47% 2 years following implementation. Identification and implementation of a multidimensional neonatal pain assessment tool, the N-PASS, improved documentation of pain in our unit. Although improvement in all quality improvement monitors was noted, additional work is needed in several key areas, specifically documentation of reassessment of pain following an intervention for an elevated pain score. Key Words: N-PASS, neonatal pain, pain scores, quality improvement
Author Affiliations: Department of Neonatology, Children’s Mercy Hospitals and Clinics, and University of Missouri–Kansas City School of Nursing (Dr Reavey); Children’s Mercy Hospitals and Clinics (Mss Haney and Atchison); Department of Neonatology (Ms Anderson) and Department of Clinical Pharmacology and Medical Toxicology (Dr Sandritter), Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; and University of Missouri– Kansas City School of Medicine (Dr Pallotto).
The authors declare no conflict of interest. Correspondence: Daphne A. Reavey, PhD, RN, NNP-BC, Children’s Mercy Hospitals and Clinics, Department of Neonatology, University of Missouri– Kansas City School of Nursing, 2401 Gillham Rd, Kansas City, MO 64108 ([email protected]). Copyright © 2014 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000034 Advances in Neonatal Care • Vol. 14, No. 3 • pp. 144-153
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BACKGROUND KNOWLEDGE Anand and Hickey’s1 sentinel article describing the potential mechanisms by which neonates could perceive pain dispelled the long-held medical myth that neonates were unable to experience pain. Since the 1980s, numerous studies have documented the physiological, behavioral, and biochemical responses of the neonate to painful procedures.2 In addition to the many short-term consequences of acute pain in neonates, there is growing concern of potential longterm adverse outcomes that may be associated with repetitive pain during the neonatal period. Differences in pain perception were found in response to routine immunizations in infants who had been previously circumcised as compared with infants who had not been circumcised or who had undergone a circumcision with analgesia. 3 Alterations in pain sensitivity have also been documented in toddlers4 and adolescents5 who were born prematurely and exposed to painful procedures in the NICU. In addition to differences in later pain perception, repetitive pain in preterm neonates may also contribute to long-term adverse neurodevelopmental and behavioral outcomes.6-9 Despite the increasing evidence that neonatal pain may be detrimental, assessment and treatment of neonatal pain often remain inadequate.10-14 It is not uncommon for neonates to undergo medical and nursing procedures without an objective measurement of their pain.15,16 In response to the growing body of literature supporting the treatment of neonatal pain, professional health organizations have published recommendations for the assessment and management of pain in the neonate including a joint policy statement from the American Academy of Pediatrics (AAP), and the Canadian Paediatric Society (CPS),17 and the National Association of Neonatal Nurses (NANN).18 The AAP and the CPS joint policy statement recommends routine neonatal pain assessment using a multidimensional tool and the use of nonpharmacologic and pharmacologic therapies for the treatment of pain during the neonatal period.17 In addition, The Joint Commission (TJC) has had a standard regarding the routine assessment of pain in all hospitalized patients, including neonates, since 2001.19 Although it is well documented that pain assessment and pain management in neonates have been inadequate10,12-14 there is little information available to guide the clinician in implementing current TJC pain standards. In 1995, Friedrichs et al20 described a quality improvement (QI) project to improve pain assessment and management in the NICU. Improvement in pain assessment documentation, the development of pain management guidelines, and weekly pain rounds were goals accomplished with the project. The project began with the development of a multidisciplinary task force and QI education
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using the Plan Do Study Act (PDSA) model. The initial phase or cycle included didactic staff education on the assessment, pathophysiology, and pharmacological treatment of neonatal pain. Retrospective review of neonatal surgical patients was undertaken and a questionnaire was developed and implemented to assess the perceptions of staff that determined pain management in their unit. These results lead to recognition of the need for a bedside assessment tool that was subsequently developed. Their bedside neonatal pain assessment tool consisted of facial actions, infant state, activity, and physiological parameters. Documentation of pharmacologic interventions was also included in the tool. Documentation of pain assessment increased from 41% to 81% over the 2-year project. Staff nurse evaluation of intervention effectiveness also improved from 58% to 81%. Improvement, although not as robust, was also noted in physician evaluation of intervention effectiveness, increasing from 11% to 25%. Weekly pain rounds were used to individualize pharmacologic pain treatment for neonates. The authors concluded that these rounds decreased the use of inappropriate medications and improved consistency of pain management.20 A subgroup of the Neonatal Intensive Care Quality Collaborative 2002, with oversight by the Vermont Oxford Network (VON), involving 12 NICUs interested in improving neonatal pain management, published their methods to improve clinical practice in 2006. There were several items identified by the group that were considered essential to their collaborative effort. These items included clear and measurable goals, the use of a content expert for the literature review, the expertise of individual subgroups, and individual center databases that provided objective measures before and after implementation of potentially better practices (PBPs) in each unit.21 The teams from the participating NICUs collaborated to develop 10 PBPs to improve management of pain. The PBPs were based on published literature available at that time related to neonatal pain assessment and management. Each team implemented a variety of the PBPs; one center implemented all 10. The preassessment phase of that VON NICU collaborative QI project found that fewer than 20% of the 277 neonates were assessed for pain during a medical or nursing procedure in the NICU. Only 19% of the painful procedures were accompanied by analgesic treatment.21 Postintervention assessments done 2 years later revealed significant improvements in a variety of areas, including the average number of pain assessments during the first 48 hours of care in both ventilated (P < .0001) and nonventilated neonates (P < .0001). There were also a significantly higher number of neonates who received pharmacologic treatments (P < .0001),
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sucrose (P < .0001), or both before invasive procedures. In one NICU, postoperative pain management also was significantly improved. Before the project, only 13% of neonates had scheduled narcotics ordered. This improved to 53% postintervention. Behavioral interventions, to treat pain, doubled during the time period with 18% of neonates in the preimplementation phase and 37% of neonates in the postimplementation assessment receiving behavioral interventions (P < .0001) prior to painful procedures.22 Through a systematic, collaborative effort, this group implemented evidence-based recommendations and improved the clinical practice pertaining to neonatal pain in the participating NICUs, in part because of improved pain assessment.
LOCAL PROBLEM In the late 1990s, a pain task force was formed to address pain assessment in our NICU. The small task force involved nursing and physician participation. Standardized pain tools were evaluated and on the basis of an internal, unpublished, study done by one member of the task force, the Infant Pain Scale (IPS) was chosen. The IPS is a modified form of the clinical postoperative pain scoring system developed by Barrier et al23 and closely resembles the Modified Infant Pain Scale (MIPS) although only behavioral and not physiologic responses were included.24 The IPS was not trialed by staff nurses prior to implementation in the NICU. The IPS, a unidimensional pain scale using behavioral criteria, was consistently challenging for nursing staff. They believed that they were unable to use the pain tool in our population of patients, especially when scoring a ventilated or paralyzed neonate or a patient with congenital anomalies. Concurrent with IPS implementation, computerized nursing documentation was modified. This modification allowed the nurse to subjectively assess the infant. Allowing this initial subjective assessment discouraged the use of the IPS in all neonates. If the nurse, in her professional opinion, did not feel that the neonate was experiencing pain, the expectation was set up that no further pain assessment was indicated. Although NANN guidelines and TJC mandates were acknowledged, the inclusion of a subjective initial assessment supported a system of noncompliance with these guidelines. The IPS, along with subjective “pain screening,” remained in place for several years prior to the formation of a formal multidisciplinary NICU Pain Committee. The NICU Pain Committee members included a neonatologist, clinical nurse specialist, neonatal nurse practitioner (NNP), staff nurse, clinical pharmacy specialist, QI coordinator, and a representative of the hospital-wide pain task force. Consultants such as anesthesiologists were included when their
input was needed. The NICU Pain Committee set goals to improve pain assessment and consistency of pain management in neonatal patients. This article describes the improvement process used to identify and implement an objective pain assessment tool for our NICU.
INTENDED IMPROVEMENT Using a TJC compliance tool, an organizational review of pain assessment and management was completed to identify focus areas for improvement.19 This institutional tool is designed to evaluate the organizational processes in place to improve pain assessment and management. Categories include patient rights and organizational ethics, assessment of patient’s pain, care of patients related to pain, education, continuum of care, improving organizational performance, leadership, management of human resources, and medical staff. This assessment identified several opportunities for improvement including the need to standardize pain assessment, documentation, and review of pain status. A QI project was initiated with the primary aim of improving compliance with an objective assessment and documentation of pain for all neonates. The NICU pain committee believed that a key driver to meet this aim was the identification and implementation of a standardized multidimensional pain assessment tool, as recommended by NANN (2012),18 that could be used consistently for our NICU population.
METHODS The setting for the QI project was a 60-bed level IV NICU that is housed in a free-standing urban children’s hospital. The NICU has a diverse, complex patient population with a mix of surgical and medical patients. Pediatric subspecialty services are available, as are specialty services, including Extracorporeal Membrane Oxygenation and cardiovascular surgery. The NICU cares for high-acuity patients and has a nursing staff of 150 to 200 nurses. The patient population includes term and preterm neonates with both medical and surgical illnesses and variable lengths of hospitalization from a few days to months. The NICU includes 15 to 20 neonatologists and 45 to 50 NNPs, as well as neonatal fellowship and pediatric resident training programs. Identifying a comprehensive pain assessment tool for this varied population of patients and large group of providers that was simple and useful for clinical decisionmaking was critical to successful implementation in our NICU. This QI project was reviewed by the hospital’s institutional review board. The NICU Pain www.advancesinneonatalcare.org
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Committee chose to use the PDSA QI model for implementation of this project. The PDSA QI model is used for rapid cycle improvement. PDSA cycles are ideally small-scale tests used to implement desired change within organizations.25 This QI method is used to systemically plan a desired change, study the change in measured outcomes, and then act on the information gained to begin another cycle. The NICU Pain Committee chose the PDSA QI model for implementation of our project because it has been used successfully in many VON QI projects26 and as a member of VON, the use of PDSA cycles had become part of our NICU culture. The following steps were followed in our QI project: assessment of the problem, literature review, query of experts, staff input for pain tool selection, and education of healthcare personnel (Table 1). Assessment of the problem was achieved by measurement of current pain documentation within our unit and completion of the TJC compliance tool. A literature review and listserv query was done specifically to identify multidimensional neonatal pain tools successfully used in similar NICUs. After a comparison of identified pain tools, the NICU Pain committee narrowed the options to 5 tools that included the CRIES (Crying, Requires O2, Increased vital signs, Expression, Sleeplessness),27 Premature Infant Pain Profile,28 the Neonatal Infant Pain Scale,29 the MIPS,24 and the Neonatal Pain, Agitation and Sedation Scale (N-PASS).30 Staff nurses reviewed the 5 scales and ranked their opinion of each tool using a Likert scale between 1 (not useful) and 5 (very useful). The results of this survey identified the MIPS and N-PASS tools as most likely to meet the needs of the diverse patient population and have the potential for successful integration in nursing work flow. Trained volunteer staff nurses then used each pain tool for a 2-week period and ranked them on feasibility and clinical utility. Advantages of the N-PASS (Figure 1), as expressed by staff nurses and the NICU Pain Committee, were that it included physiological parameters, was simple to use, acknowledged agitation as part of pain assessment, and included points for prematurity. At the time of project initiation, the N-PASS had been published only in abstract form.30 There were other neonatal pain tools with established reliability and validity, yet the N-PASS had been well-accepted by neonatal nurses31 and was being used in VON NICUs across the country.32 Although reliability and validity had not yet been published, the belief was that the N-PASS had the most potential for successful implementation in our culture based on the initial nursing assessment because of ease of use, ability to integrate in workflow, inclusion of physiological and behavioral cues (multidimensional), and applicability to a varied patient population in a tertiary NICU population. Since the inception of this QI
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project, beginning reliability and validity has been published for the N-PASS.33,34 The N-PASS has been shown to be valid and reliable for assessing acute heelstick pain in neonates between birth and 30 days of age and 23 and 40 weeks gestation.34 In the measurement of prolonged pain, the N-PASS has also been shown to be reliable and valid in neonates greater than or equal to 23 weeks gestation and 0 to 100 days of age, requiring ventilation and/or recovering from surgery.33 Following identification of the N-PASS as the neonatal pain tool for implementation in our NICU, education of all staff members, including registered nurses, NNPs, neonatal fellows and neonatologists, was completed. In additional to didactic instruction, during nursing education, videos of patients were reviewed and scored as a group and results were discussed. The N-PASS was built into the electronic medical record. Reminder posters as well as directions in the use of the tool were posted throughout the unit and at each individual bedside. A super user group of nurses who had participated in the tool selection was available as a resource to other nurses in the unit. Specific QI monitoring was then completed at 6 months and again at 2 years following implementation of the N-PASS. The aim for all measures was greater than 95% compliance. Measures included documentation of initial nursing pain assessment on admission, routine pain assessment with full patient assessments, reassessment of pain after an elevated score and intervention, discussion of pain assessment and pain scores during multidisciplinary rounds, and documentation in provider daily progress notes.
RESULTS Baseline monitoring of provider discussion of pain and pain scores before education and implementation of the new pain tool identified that pain scores discussion on multidisciplinary rounds never occurred, although pain was briefly mentioned on 7% of the patients (Table 2). Documentation of pain assessment in the daily progress note was only 2% preimplementation. Six months after implementation, pain assessment was discussed during rounds 52% of the time and only slightly improved to 57% 2 years later. Further investigation revealed that although pain was not always discussed on rounds, it was being discussed in the medical record. Eightysix percent of neonates requiring pharmacologic intervention for pain or having high pain scores had documentation of pain management in the provider daily progress note. Nursing documentation of pain assessment upon admission was only 60% at baseline before N-PASS implementation and increased to 100% at 6 months
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TABLE 1. Phases of Quality Improvement Project Methods Assessment of the problem
Key Points Overall belief by healthcare providers that pain was inadequately assessed and managed Completion of a JCAHO compliance tool Analysis revealed several opportunities for improvement: Standardization of pain assessment Consistent pain documentation
Review of literature and identification of expert resources
Identification of published neonatal pain assessment tools Identification of pain tools used in other VON NICUs through e-mail and listserv query Comparison of neonatal pain tools with recommendation of 5 tools for further consideration: CRIES, PIPP, NIPS, MIPS and the N-PASS Evaluation of the 5 pain tools by staff nurses using a Likert scale Trained volunteer staff nurses to use pain tools Trial of each pain tool by volunteer staff nurses for 2 weeks Judged N-PASS tool as best fit for implementation in our NICU
Assessment of unit culture
Mental model survey of pain practices and pain assessment completed by neonatologist, neonatal fellows, NNPs, and staff nurses Identified individual practice preferences from each team member regarding: Frequency of pain assessments Clinical parameters used to assess pain Use of a standardized pain tool Knowledge of JCAHO pain assessment requirements
Education of NICU staff
Initial general neonatal pain education to all NICU nursing staff at unit update meetings Follow-up nursing education regarding N-PASS tool at unit update meetings Education consisted of: Lecture and video presentations Practice using the N-PASS pain tool via video demonstration of neonates in varying painful situations Education of physicians and NNPs on neonatal pain, JCAHO requirements, and the N-PASS tool Reminder e-mails, posters, and bedside signs
Implementation of new pain tool
Built N-PASS into electronic medical record Established expectation of N-PASS completion with every assessment Included as part of routine assessment documentation Included pain intervention options to assist with documentation Posted laminated color copies of N-PASS with scoring directions at every patient bedside and bulletin boards throughout the NICU Added pain and sedation scores to data collection sheets used by NNPs/residents Included pain field in physician/NNP electronic templates to ensure routine pain documentation in the progress note (continues)
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TABLE 1. Phases of Quality Improvement Project, Continued Methods
Key Points
Monitoring of quality improvement data
QI monitoring included: Admission nursing pain score documentation Routine nursing pain score documentation with every routine assessment Reassessment of nursing pain score documentation following elevated pain score Assessment of pain discussion during multidisciplinary rounds Daily pain assessment documented in physician/NNP progress notes QI monitoring completed: Prior to implementation of the N-PASS tool 6 months and 2 years following implementation of the N-PASS Ongoing monitoring of key components QI results communicated to all staff in e-mails, posters, and electronic bulletin board
Abbreviations: CRIES, crying, requires O2, increased vital signs, expression, sleeplessness; JCAHO, Joint Commission on Healthcare Organization; MIPS, Modified Infant Pain Scale; N-PASS, Neonatal Pain, Agitation, and Sedation Scale; NICU, neonatal intensive care unit; NIPS, Neonatal Infant Pain Scale; NNP, neonatal nurse practitioner; PIPP, Premature Infant Pain Profile; QI, quality improvement; VON, Vermont Oxford Network.
FIGURE 1.
N-PASS Pain Tool. Used with permission from P. Hummel, MA, RNC, NNP, PNP. Advances in Neonatal Care • Vol. 14, No. 3 Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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TABLE 2. Physician Pain Documentation/Discussiona Preimplementation (N ⫽ 55)
6 Months Postimplementation (N ⫽ 56)
2 Years Postimplementation (N ⫽ 58)
Daily progress note: all patients (%)
1 (2)
__
19 (33)
Daily progress note: patients receiving opiates or acetaminophen (%)
__
__
50 (86)
4 (7)
29 (52)
33 (57)
Monitor
Rounds (%)
Dashes indicate that data were not collected. Daily progress notes were reviewed to identify documentation of pain assessment and pain scores. Multidisciplinary rounds were monitored for discussion of pain assessment and pain scores. a
postimplementation (Table 3). Two years later, this improvement had been sustained. Ninety-nine percent of neonates continued to have pain assessment (N-PASS score) documented on admission. In addition, every quarter consistently demonstrated greater than 90% compliance (Figure 2). Before implementation of the N-PASS, the expectation for documentation of routine, ongoing pain assessment was only once a shift and whenever pain was identified. Compliance with this recommendation was 55% (Table 3). Six months after N-PASS implementation, compliance had increased and was sustained 2 years later. All quarterly reviews following implementation of the N-PASS have demonstrated that routine assessment of pain was documented by nursing staff more than 90% of the time (Figure 3). Documentation of pain reassessment following an elevated pain score (≥4) has been a consistent challenge. Historically, no monitoring of pain reassessment was done in our NICU. Six months after implementation, pain reassessment documentation was noted to be only 30% (Table 3). Despite additional education, e-mails, and reminders on all the bedside computers, reassessment documentation remained at 47% 2 years later.
DISCUSSION Change is a challenging process in a large NICU. With many healthcare providers involved in the care of critically ill neonates, successful implementation of thorough pain assessment and pain management strategies can be challenging. There must be “buyin” and support from the entire team to achieve compliance and successful implementation. Champions to a new process are critical to the success of any new project, but to fully change the culture of the NICU and impact practice, involvement and support at all levels is needed. In the implementation of any new process, it is important to acknowledge and incorporate beliefs that are already held as important to the group. In our NICU, vital sign measurement changes were identified by healthcare providers and validated with surveys as the parameter that they felt best assessed neonatal pain. The use of a tool that did not include these measurements would have been difficult to implement, potentially resulting in failure. Education on the importance of using a multidimensional pain tool and reviewing the literature on neonatal pain facilitated buy-in from all staff. It was also clear by our
TABLE 3. Nursing Pain Documentationa Preimplementation (N = 58)
6 Months Postimplementation (N = 56)
2 Years Postimplementation (N = 58)
Admission (%)
35 (60)
56 (100)
57 (99)
Routine (%)
32 (55)
54 (97)
55 (95)
—
17 (30)
27 (47)
Monitor
Reassessment (%)
Dashes indicate that data were not collected. Expectation of frequency of routine pain assessments changed at the time of implementation from a minimum of once per shift to every hands-on assessment, at least every 6 hours. a
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FIGURE 2.
Admission nursing pain assessment documentation. Review of nursing documentation of all patients in a 60-bed neonatal instensive care unit to identify the percentage of patients with Neonatal Pain, Agitation, and Sedation Scale (NPASS) pain score documentation on admission.
trials of the various pain tools that satisfaction with the tool was greatly influenced by the ability of the staff nurse to integrate the tool within the daily workflow. Establishing pain assessment intervals that coincided with routine nursing assessments
assisted in the successful implementation of a new pain tool in our NICU. Although there were improvements noted in the discussion of pain in daily medical rounds, these improvements were less than those seen in nursing
FIGURE 3.
Routine nursing pain assessment documentation. Review of nursing documentation of all patients in a 60-bed neonatal intensive care unit to identify the percentage of patients with Neonatal Pain, Agitation, and Sedation Scale (NPASS) pain score documentation with every assessment, at least every 6 hours. Advances in Neonatal Care • Vol. 14, No. 3 Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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FIGURE 4.
Inclusion of pain scores in electronic progress note. Cerner PowerNote smart template. Allows inclusion of nursing Neonatal Pain, Agitation, and Sedation Scale pain score documentation into daily progress note with the click of a mouse.
documentation. It may not be realistic to expect that pain scores be discussed 100% of the time, especially in neonates with low pain scores or those not requiring interventions for pain. The complexity and length of daily medical rounds in a busy, large NICU necessitates prioritization of current clinical issues. Absence of the need for pain interventions or normal to low pain scores indicate that pain is not a problem and therefore may not warrant a detailed discussion in daily medical rounds. Pain assessment and documentation are essential for all neonates. Neonates with elevated pain scores or those requiring pain interventions should be discussed in daily medical rounds to develop an appropriate pain management plan. This remains the ongoing expectation in our unit; nursing providers are encouraged to mention pain if not discussed by the NNP or physician. As our electronic tools have developed over time, this has required ongoing review of our compliance and verifying the tools to support the clinical goals. Pain scores are even more readily available to providers in summary rounds reports with the vital signs and can automatically populate into the progress note (Figure 4). Documentation of pain reassessment following an intervention remains a challenge. Resolution of pain and lack of active worry for the neonate may lead to “forgetfulness” in nursing documentation of pain intervention responses. Identifying methods to remember to document pain reassessment remains a challenge. As bedside electronic medical records become more sophisticated, alerts and decision support for reassessment documentation based on high pain scores as well as following pain interventions
could trigger improved compliance. Continued new creative methods to reinforce success in meeting the assessment, reassessment, and treatment expectations remain a goal of our team. Including families has been an important part of our recent improvements. Seeing their baby experience pain and having inadequate information on neonatal pain are an added stress to parents.35 Education of parents and anticipatory guidance in the recognition of neonatal pain behaviors and strategies of pain management has been shown to decrease parental stress.36 Our multidisciplinary pain team believes that improved identification and treatment of pain lead to more satisfied families, through decreased parental stress. Although sometimes difficult, successful change can identify new related opportunities to improve care. In our NICU, satisfaction with our standardized pain assessment tool opened many opportunities to improve our treatment of pain as it related to specific procedures and conditions. Our team has progressed to successful implementation of improved standards for postoperative pain management, treatment of pain for bedside procedures such as intubations, lumbar punctures, and circumcisions, as well as standardizing sedation processes for laser surgeries and magnetic resonance imaging studies. Our NICU Pain Committee remains enthusiastic in identifying novel therapies for treating pain and painrelated conditions in neonates. We also continue to provide education and support for all NICU providers as well as working as a liaison within the hospital system advocating for pain relief and management for all neonates. www.advancesinneonatalcare.org
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Improving Pain Assessment in the NICU
References 1. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-1329. 2. Franck LS, Miaskowski C. Measurement of neonatal responses to painful stimuli: a research review. J Pain Symptom Manage. 1997;14:343-378. 3. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349(9052):599-603. 4. Grunau RV, Whitfield MF, Petrie JH. Pain sensitivity and temperament in extremely low-birth-weight premature toddlers and preterm and full-term controls. Pain. 1994;58:341-346. 5. Buskila D, Neumann L, Zmora E, Feldman M, Bolotin A, Press J. Pain sensitivity in prematurely born adolescents. Arch Pediatr Adolesc Med. 2003;157:1079-1082. 6. Bhutta AT, Anand KJ. Vulnerability of the developing brain. Neuronal mechanisms. Clin Perinatol. 2002;29:357-372. 7. Grunau RE, Tu MT. Long-term consequences of pain in human neonates. In: Anand KJS, Stevens BJ, McGrath PJ, eds. Pain in Neonates and Infants. Philadelphia, PA: Elsevier; 2007;3:45-57. 8. Johnston CC, Stevens BJ. Experience in a neonatal intensive care unit affects pain response. Pediatrics. 1996;98:925-930. 9. Whitfield MF, Grunau RE. Behavior, pain perception, and the extremely low-birth weight survivor. Clin Perinatol. 2000;27: 363-379. 10. Debillon T, Bureau V, Savagner C, Zupan-Simunek V, Carbajal R. Pain management in French neonatal intensive care units. Acta Paediatr. 2002;91:822-826. 11. Dodds E. Neonatal procedural pain: a survey of nursing staff. Paediatr Nurs. 2003;15(5):18-21. 12. Harrison D, Loughnan P, Johnston L. Pain assessment and procedural pain management practices in neonatal units in Australia. J Paediatr Child Health. 2006;42:6-9. 13. Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP. Pain and pain management in newborn infants: a survey of physicians and nurses. Pediatrics. 1997;100:626-632. 14. Simons SHP, Van Dijk M, Anand KS, Roofthooft D, Van Lingen RA, Tibboel D. Do we still hurt newborn babies? Arch Pediatr Adolesc Med. 2003;157:1058-1064. 15. Duhn LJ, Medves JM. A systematic integrative review of infant pain assessment tools. Adv Neonatal Care. 2004;4:126-140. 16. Stevens BJ, Pillai Riddell RR, Oberlander TE, Gibbins S. Assessment of pain in neonates and infants. In: Anand KJS, Stevens BJ, McGrath PJ, eds. Pain in Neonates and Infants. Edinburgh, Scotland: Elsevier; 2007;(3):67-91. 17. American Academy of Pediatrics, Committee on Fetus and Newborn and Section on Surgery, Section on Anesthesiology and Pain Medicine, Canadian Paediatric Society, and Fetus and Newborn Committee. Prevention and management of pain in the neonatal: an update. Pediatrics. 2006;118:2231-2241. 18. National Association of Neonatal Nurses. Newborn Pain Assessment and Management Guideline for Practice. Glenview, IL: National Association of Neonatal Nurses; 2012:3.
153
19. Bartel J, Beasley J, Berry PH. Approaches to Pain Management. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2003:35-48. 20. Friedrichs JB, Young S, Gallagher D, Keller C, Kimura RE. Where does it hurt? An interdisciplinary approach to improving the quality of pain assessment and management in the neonatal intensive care unit. Nurs Clin N Am. 1995;30(1):143-159. 21. Sharek PJ, Powers R, Koehn A, Anand KJ. Evaluation and development of potentially better practices to improve pain management of neonates. Pediatrics. 2006;118(Suppl 2):S78S86. 22. Dunbar 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 2): S87-S94. 23. Barrier G, Attia J, Mayer MN, Amiel-Tison C, Shnider SM. Measurement of post-operative pain and narcotic administration in infants using a new clinical scoring system. Intensive Care Med. 1989;15(Suppl 1):S37-S39. 24. Buchholz M, Karl HW, Pomietto M, Lynn A. Pain scores in infants: a modified infant pain scale versus visual analogue. J Pain Symp Manage. 1998;15(2):117-124. 25. Plsek PE. Quality improvement methods in clinical medicine. Pediatrics. 1999;103:203-214. 26. Horbar JD, Soll RF, Edwards WH. The Vermont Oxford Network: a community of practice. Clin Perinatol. 2010;37:29-47. 27. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53-61. 28. Stevens B, Johnston C, Petryshen P, Taddio A. Premature Infant Pain Profile: development and initial validation. Clin J Pain. 1996;12(1):13-22. 29. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59-66. 30. Hummel PA, Puchalaski MJ, Creech SD, Weiss MG. N-PASS: neonatal pain, agitation, and sedation scale. Pediatr Res. 2003;53:2580A. 31. Stokowski LA. Validation of the N-PASS. Adv Neonatal Care. 2008;8:75-77. 32. Anderson B. Re: Pain Scale Tools. Message posted to [email protected]; 2004. 33. Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: Neonatal Pain, Agitation and Sedation Scale with prolonged pain. J Perinatol. 2008;28(1):55-60. 34. Hummel P, Lawlor-Klean P, Weiss MG. Validity and reliability of the N-PASS assessment tool with acute pain. J Perinatol. 2010;30:474-478. 35. Franck LS, Cox S, Allen A, Winter I. Parental concern and distress about infant pain. Arch Dis Child Fetal Neonatal Ed. 2004;89: F71-F75. 36. Gale G, Franck LS, Kools S, Lynch M. Parents’ perceptions of their infant’s pain experience in the NICU. Int J Nurs Stud. 2004;41:51-58.
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