A quality improvement project on implementing a standardized pain assessment and opioid stewardship guidance at a level IV NICU

BackgroundBalancing between adequate analgesia and preventing the harmful side effects of opioids in the NICU is an important clinical conundrum. Lack of awareness among caregivers and guidance on pain management are the key limiting factors. By initiating this quality improvement (QI) project, we aimed to reduce the usage of opioids in a quaternary NICU care by 5% within 1 year.MethodsA multidisciplinary team developed standardized guidance focusing on regular pain assessment, appropriate initiation, and weaning of opioids for infants undergoing surgical procedures and those requiring mechanical ventilation. The Plan, Do, Study, Act (PDSA) methodology was used for improvement, beginning with a survey and Pareto analysis to identify key drivers. Data were collected for the baseline period and after implementing the QI interventions.ResultsWe demonstrated a significant decrease in the cumulative opioid use measured as morphine equivalent (mg/kg) from a mean of 2.7 to below 0.85 mg/kg, demonstrating a reduction of >50%. There was no worsening in pain or opioid withdrawal scores within three and 5 days after weaning of opioids, a surrogate measure for appropriate weaning.ConclusionImplementation of standardized guidelines for initiating and weaning of opioids can reduce the overall opioid use and thus minimize opioid withdrawal in critically ill neonates.