Improving Practice for Newborn Pain

Using a Network of Neonatal Intensive Care Units (NICUs)

The Children's Hospital at Westmead

Abstract

Seven neonatal intensive care units (NICU) in NSW participated in a national project to close the evidence practice gap for newborn pain. A model using state facilitators, local champions and project teams was used to examine the evidence and use results to inform clinical guidelines and implement the best evidence into practice at the local level.

Strategies used to achieve this included audit and feedback, benchmarking, critical appraisal workshops, survey of teamwork practices and family awareness of pain. Data was collected over two time periods.

Overall, there was an increase in the number of infants either being breastfed or receiving sucrose for procedural pain and there was improvement in the use of a pain assessment tool.

Families worked in partnership with NICU staff to make improvements. Their increased awareness of pain and management strategies greatly contributed to the overall success of the project.

Aim

To close the evidence practice gap for newborn pain, using existing networks of clinicians and to find effective strategies to ensure appropriate interventions for procedural pain, pain assessment and family awareness of newborn pain.

Nature of the Problem

Whilst a degree of pain is unavoidable in newborns in the NICU, there is an increasing volume of scientific evidence to support appropriate assessment, management and guidance for reducing procedural pain and the short and long term effects of pain in neonates.

There are several consensus statements, guideline statements and policy directives at a national and international level, but despite this volume of evidence, surveys in Australia show there is a wide gap between what is known and what occurs in practice. At the start of this project, baseline data indicated that NSW hospitals did not have guidelines or practices to close the gap between evidence and practice.

Extent of the Problem

To establish the extent of the problem in NSW we asked the following questions:

Is effective care available?

• Baseline data was collected on current practices in relation to pain assessment and management and there was wide variation across units.

What is the available evidence?

• A literature search was undertaken and included the RACP guideline statement, the ACNN position statements and the NSW Health Policy Directive, all useful resources for guiding clinical practice. The Cochrane Database was searched for systematic reviews and three were applicable to the project:
  • use of sucrose for procedural pain
  • breastfeeding or breast milk for procedural pain
  • use of narcotics for ventilated infants
• All these documents formed the resource library for the project.

Are clinical practice guidelines available?

• Participating units provided their current guidelines which were then blind reviewed by a group of experienced neonatal nurses according to the AGREE criteria. Following this work, a national guideline was deemed essential in closing the practice evidence gap.

Strategic Importance

This project relates to the NSW strategic direction to create better experiences for people using health services, by ensuring the physical, emotional and safety needs of infants experiencing pain in the NICUs are met. 

By reducing the number of painful interventions and ensuring that all infants are assessed for pain, we can affect their short and long term developmental outcomes.

It is an emotional time for families with an infant in NICU and by keeping them informed and involved in their infant’s care, in particular with pain reducing strategies, we truly work in partnership with them – this is good for babies, families and staff.

Planning and Implementing Solutions

There were five main stages to the project:

1. Critical appraisal workshops.
   For clinicians to understand the evidence that supports practice, workshops were run in four hospitals, in collaboration with the Cochrane Support Group. Topics specific for newborn pain were used to enable clinicians to associate the evidence with their practice.
2. Audit and feedback.
   A baseline audit for procedural pain, pain assessment and family awareness was undertaken in the first year and repeated at the completion of the project. Audit criteria were adapted from the recommended guidelines and from the literature. Feedback was distributed to the local champions to enable benchmarking to occur.
3. Barriers to change.
   It is well documented that barriers within the organisation or local context may impede changes in practice. An environmental readiness survey was undertaken by the state coordinator with the local champions and teams to identify potential barriers to changes in practice and to develop strategies for overcoming these barriers.
4. Clinical practice guidelines.
   Practice change occurs when there is direction and desire for change. Within health, care guidelines have been utilised to facilitate best practice at the individual level of care. How guidelines are used and staff awareness of the guidelines is a component of implementing and evaluating practice. Ensuring that guidelines are based on the best available evidence can assist with this change.
5. Specific unit projects.
   Each of the seven NICUs identified a specific local issue that would improve practice. These included audits of number of painful procedures, implementation of a pain assessment tool, point of care reminders, pain awareness days (pink and yellow) and implementation of clinical guidelines.

Outcomes and Evaluation

Across the seven units there was a statistically significant increase between the two audit periods for each of the following criteria:

• There was an increase in sucrose being offered as a pain relief for procedural pain (p=0.00).
• Breastfeeding was not offered to 71% of babies at the beginning of the project which dropped to 46% at the end (it is not practical to offer breastfeeds to all infants in the NICU).
• The use of pain assessment tools on all ventilated infants increased (p=.001). Several units are still introducing the use of a tool with an educational program.
• The availability of clinical practice guidelines increased (p=.000) with many being updated during the project.
• There was an increase in families’ awareness of their infant’s pain and the strategies used (p=0.00).

These results show that there has been an overall increase in compliance with each of these care indicators. Although painful procedures are unavoidable in the NICU, the knowledge of staff with regards to better managing the experience of newborns undergoing painful procedures has greatly improved and successful strategies for managing pain, like the use of sucrose or breastfeeding, have increased. An increase in the awareness of the harmful effects of pain and the evidence to support practice have contributed to these positive changes.

Sustaining Change

By establishing a local project team in each NICU, the drive for improvement in pain management for sick newborn infants will continue.

The national guideline developed from this collaborative project includes an audit tool that will allow units to keep evaluating and improving their practice in the assessment and management of newborn pain.

An increased awareness of reducing the effects of painful procedures has been achieved through the use of information brochures and posters which are displayed for staff and families, encouraging partnership in the effective management of babies’ pain whilst in the NICU.

Future Scope

This national project was funded by the National Institute of Clinical Studies, using their networks program. The seven NSW hospitals were The Children’s Hospital at Westmead, John Hunter Children’s Hospital, Royal Hospital for Women, Royal Prince Alfred, Westmead, Liverpool and Nepean Hospitals. The clinical staff from these Hospitals will continue to meet and benchmark their practices making further improvements in this area across NSW and Australasia.

Many other projects in health could be implemented using this model, which ensures best practice by closing the evidence practice gap.

Contact 

More about the 2008 NSW Health Awards