Wong on Web Paper
Standardized Pain Management Protocol Improves Outcomes in the NICU

Abstract by Marlene Walden, PhD, RNC, NNP

Since the establishment of Neonatal Intensive Care Units (NICUs) to care for sick and preterm neonates in the early 1970's, the technology to save lives has often proceeded at a faster rate than the understanding of how to relief pain and suffering associated with that technology. In 1989, Donna Wong proposed a philosophy of care known as "atraumatic care". Atraumatic care advocates for the provision of therapeutic care by health care professionals which eliminates or minimizes the physical and psychological distress often experienced by children and their families (Wong, 1989). One of the key principles identified in this philosophy of care is preventing and/or minimizing pain and discomfort associated with therapeutic care. Yet, despite a decade of information demonstrating that neonates have the functional and anatomic capacity to perceive and respond to pain, assessment of pain in preverbal patients and the provision of consistent and adequate pain relief continues to challenge caregivers in the NICU. This abstract will review two related manuscripts published by Susan Furdon and colleagues in which they use the principles of atraumatic care and current research to develop an interdisciplinary standardized pain management protocol for postoperative patients in the NICU at Albany Medical Center's Children's Hospital (AMC) in Albany, New York.

In 1992, AMC was asked to participate in a national survey of analgesic practices. As part of this process, a review of current pain management practices within the NICU was undertaken. While nursing and medical staffs perceived that patients in the NICU were receiving optimal pain management, the results of the survey suggested multiple problems including deficiencies in assessment, inconsistent administration, and under-prescription of analgesics for postoperative patients. Subsequently, a multidisciplinary group was charged with the development of a standardized research-based approach to postoperative and procedural pain in the NICU. The Acute Pain Management in Infants, Children and Adolescents: Operative and Medical Procedures, Quick Reference Guide for Clinicians (Agency for Health Care Policy and Research [AHCPR], 1992) provided the foundation for the pain management protocol. This pain protocol was fundamental in standardizing the NICU's approach to the assessment, management and documentation of postoperative and procedural pain in infants in the NICU. Among the key AHCPR principles addressed in the protocol were:

1. Employ a high index of suspicion in identification of infants in pain. Remember that lack of pain response does not necessarily indicate no pain. Caregivers must be careful to consider the infant's gestational age, behavioral state, and/or energy reserves available to respond to the painful stimulus.
2. Use a multi-dimensional assessment approach to identify the patient who is in pain. Whenever possible, physiologic measures should be combined with a behavioral assessment to assess the infant in pain. At AMC, caregivers combined physiologic parameters (BP, HR, RR, O₂ saturations) with the use of the Neonatal Infant Pain Scale (NIPS), a primarily behavioral approach, to identify the infant in pain, evaluate the effectiveness of pharmacologic and nonpharmacologic interventions, and communicate with other caregivers their concerns about the ineffectiveness of pain management.
3. Assess and reassess pain at regular intervals based on the type of procedure or operative repair. The AMC protocol specified that pain management was to be discussed daily as an integral part of multidisciplinary patient care rounds. Written guidelines were also provided to standardize and improve documentation related to pain assessments, medication administration and documented effectiveness, necessary modifications in pain relief strategies, and presence of any side effects.
4. Prevention of pain provides more effective pain relief than treatment of established pain. The AMC pain protocol emphasized a loading dose followed by a continuous infusion of opioids (choice of either morphine or fentanyl) for postoperative care. Tables based on dosage and weight were available to assist caregivers in mixing standardized infusion concentrations, thereby minimizing potential medication errors.
5. Tailor choice of analgesic based on duration and/or severity of pain assessed or anticipated. At AMC, acetaminophen was ordered for around the clock administration for minor operative procedures or as adjunctive therapy with opioids. The protocol also recommended the use of local anesthetics such as lidocaine or topical anesthetics such as eutectic mixture of local anesthetics (EMLA) cream for procedural pain, including percutaneous central line insertions, lumbar punctures and circumcision. Nonpharmacologic measures were also advocated for minor procedures including decreased environmental sound and light levels, use of pacifiers for nonnutritive sucking, and containment strategies including swaddling and facilitated tucking.
6. Incorporate active family involvement into pain assessment and management strategies. The AMC protocol emphasized parent education to help parents recognize when their infant was in pain and strategies for how they could best assist caregivers in comforting their infant.

Following adoption of the pain protocol by attending physicians, nursing staff, and the clinical pharmacist of the unit, an evaluation of staff compliance and protocol effectiveness was conducted. Using retrospective chart reviews, patient care outcomes were compared before (1993) and after (1995-1996) implementation of the pain management protocol. Thirty-one neonates with gestational ages between 25 and 41 weeks (14 before and 15 after implementation) who had underwent abdominal surgery and who returned to the NICU intubated postoperatively were included in the study. Infants with gastroschisis, incomplete charts, who died postoperatively, or who required additional surgical intervention not related to the abdominal surgery were excluded from the review. No significant differences were noted between the two groups in terms of gestational ages, types of surgery, or severity of medical illness.

Evaluation of standardized pain management strategies demonstrated an improvement in both medical team and nursing documentation related to the effectiveness of pain management. While there was no standardized assessment instrument in use prior to the implementation of the pain protocol, there was a 70% compliance with the use of the NIPS after implementation of the protocol. Prior to the pain protocol, infants received either intermittent or as needed boluses of an opioid. As part of the pain protocol, all infants routinely received continuous opioid infusions for 24 to 48 hours postoperatively. Furthermore, data demonstrated that after implementation of the pain protocol more infants received an analgesic over the first 3 postoperative days. In addition, the continuous infusions of morphine following implementation of the pain protocol resulted in fewer reported side effects and a lower overall morphine (mg/kg/day) dosage to achieve adequate pain relief. Other benefits of the pain protocol included decreased length of time to extubation, better fluid management as indicated by quicker return to baseline weight by postoperative day 2, and reduced length of stay in the post-implementation group. Finally, the number of morphine vials used per day was decreased after implementation of the pain protocol resulting in reduced hospital costs and decreased nursing time to prepare and administer analgesics.

Although the small sample size and retrospective nature of this research tends to limit generalizability of the results beyond this hospital setting, this research is an excellent example of how integrating current research into an interdisciplinary approach to care can result in a more consistent approach to care as well as contribute to improvements in patient care outcomes. Because of nursing's constant presence at the bedside, nurses are often in an ideal position to recognize pain in the infants they care for and to advocate for more effective pain relief interventions. However, without a philosophical commitment and standardized approach to pain management by all caregivers in the NICU, pain management may remain inconsistent and vary based on individual caregivers' knowledge base and attitudinal beliefs. As is so wonderfully illustrated at AMC, health care professionals can effectively employ staff education and data collection techniques to overcome cognitive, attitudinal, and institutional barriers that hamper the delivery of quality patient care.

For additional information about Albany Medical Center's Pediatric Pain Protocol, contact Sue Furdon, RNC, MS, NNP, at voice mail (518) 262-3054 or email her at sfurdon@ccgateway.amc.edu.

References

Agency for Health Care Policy and Research: Acute pain management in infants, children, and adolescents: operative and medical procedures, quick reference guide for clinicians. Rockville, MD, U. S. Department of Health and Human Services, 1992.

Furdon, S., Eastman, M., Benjamin, K., and Horgan, M.: Outcome measures after standardized pain management strategies in postoperative patients in the neonatal intensive care unit, Journal of Perinatal Neonatal Nursing 12(1): 58-69, 1998.

Furdon, S., Pfeil, V., and Snow, K: Operationalizing Donna Wong's principle of atraumatic care: pain management protocol in the NICU, Pediatric Nursing 24(4): 336-342, 1998.

Wong, D.: Principles of atraumatic care. In Feeg, V. (Ed.): Proceedings and Report of Pediatric Nursing Forum on the Future: Looking Toward the 21st Century, Anthony J. Jannetti, Inc., NJ, 1989.

Additional Information

See Chapter 9 in Essentials of Pediatric Nursing, 5th edition.

See Chapter 10 in Nursing Care of Infants and Children, 6th edition.

March 15, 2002

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