July 8, 2005

NICU ramps up efforts to control infant pain

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On hand for the opening of the Vanderbilt-Eskind Diabetes Clinic were, from left, Billy Eskind, Jane Eskind, Dick Eskind, Laurie Eskind, Julie Eskind, Steven Eskind, Annette Eskind, Jeff Eskind, Donna Eskind, David Eskind, Ellen Lehman, Matthew Eskind, Jeremy Lehman and Jon Lehman.
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NICU ramps up efforts to control infant pain

Researchers at the Monroe Carell Jr. Children's Hospital at Vanderbilt are working toward the goal of making the Neonatal Intensive Care Unit (NICU) as pain-free as possible for infants.

“We knew there was a problem with pain control, so two years ago we formed a pain team and began to look first at how well pain was being controlled after surgery,” said Brian Carter, M.D., associate professor of Pediatrics.

“We conducted a survey, following 50 NICU babies after surgical procedures and demonstrated a need for better assessment of pain, better pain intervention and improved documentation.”

The Pain team includes registered nurses, nurse educators, a case manager, a neonatal nurse practitioner, a neonatology fellow, a neonatologist, a pediatric pharmacist, pediatric anesthesiologists, a pain physician and quality improvement staff.

The group's first survey found that something as simple as the use of acetaminophen was commonly overlooked in pain management after surgery. Acetaminophen was given to fewer than 20 percent of infants after surgery.

Another problem is there was often a delay in using pain medications as orders were sorted out and infants were assessed.

“As a result, these babies were experiencing pain before pain relief was given,” Carter said. “One simple thing we did to reduce delays in administering pain relief was to standardize the review of forms that follow the babies from the operating room to the post-op area and then back to the NICU.”

In February, Neonatology Fellow Benton Cofer, M.D., presented a second survey of 50 post-operative NICU babies at the Southern Society for Pediatric Research in New Orleans. This survey looked at some changes in pain assessment and intervention proposed by the pain team.

Cofer's results showed the babies under the pain team's recommended interventions did appear to experience better pain control.

“Largely due to the work of Jenny Bryant, R.N., Neonatal Nurse Practitioner Nancy Kraft, and Stephen Hays, M.D., the pain team came up with a Post Operative Pain Management Plan, called POPP,” said Carter.

“It allowed for an anticipated length of need for pain control following certain surgical procedures and recommended continuous intravenous pain medication, fentanyl, with assessments at regular intervals. Tylenol was made a scheduled medication after surgery and a new standardized pain assessment tool was introduced to the unit as well.”

The new pain assessment tool is called N-PASS, for Neonatal Pain, Agitation and Sedation Scale.

N-PASS assigns a number to behaviors that signal pain, such as level of crying, amount and type of movement of the baby, facial expressions and tone of the body's muscles along with involuntary signs like blood pressure, heart rate, rate of breathing and oxygen saturation.

“The next step is to educate the whole NICU and find ways to standardize the management of pain for all babies,” Carter said.

“But we had additional questions, like whether the increased use of pain medications might keep babies on the ventilators longer because of increased sedation.”

To find answers to that and other questions, Carter has applied for and received a research grant from the MAYDAY Fund. The $15,000 grant will be used to study implementation of the pain team's protocol, including a new element of the hospital's computerized data entry system, WizOrder.

The study will begin in August, and will involve 50 post-operative NICU babies.