223 - Improvement in staff satisfaction and reduction on post-operative narcotic exposure using quality improvement methodology to implement a post-operative pain management algorithm

Poster Number: 223
Publication Number: 223.127

Kimberly J. Roeloffs, Children's Hospital of Wisconsin, Pewaukee, WI, United States; Genesee Hornung, Children's Hospital of Wisconsin, Greenfield, WI, United States; Ann Grippe, Children's Wisconsin, Milwaukee, WI, United States; Sally J. Keller, Children's Wisconsin, Wauwatosa, WI, United States; Paula J. Lembke, Medical College of Wisconsin, Wauwatosa, WI, United States; Anna Kissell, Children's Hospital of Wisconsin, Milwaukee, WI, United States; Alicia Sprecher, Medical College of Wisconsin, Wauwatosa, WI, United States

Background: Our group targeted improvement in the management of post-operative pain after a survey of nurses and providers specifically highlighted the areas of post-operative pain management and the lack of standardization surrounding pain management as a source of dissatisfaction. This work took place in a Level IV, 70-bed neonatal intensive care unit, with 20-30 surgical cases per month where pain management is primarily at the discretion of the neonatal ICU team. 

Objective: Our objective was to increase nursing and provider satisfaction of post-operative pain control in neonatal patients, by 10% over a 12-month period subsequent to the implementation of a post-operative pain (POP) algorithm.

Design/Methods: This project was completed in conjunction with the Children’s Hospital Neonatal Consortium’s Erase Post-Operative Pain in Neonates collaborative project. An interdisciplinary collaboration of nurses, pharmacists, and physicians within neonatology, anesthesia and surgery drove the framework for our post-operative pain algorithm (Figure 1).  Multiple iterations of algorithm development, pilot testing, and nursing and provider education took place. The outcome measure was nurse and provider satisfaction of pain management in post-operative neonates. The process measure was POP algorithm compliance. Balancing measures included the maximum post-op N-PASS score and the narcotic exposure in the 24 hours post-op.

Results: Nursing and provider satisfaction on a 7-point likert scale increased from 4.76 to 5.18 (P=0.0013) and percent answering 5, 6, or 7 increased from 67% to 83% between 2019 and 2021 (2019 n = 96, 2021 n = 65). Compliance in utilization of the POP algorithm increased over the study period. Following implementation of the POP algorithms there was not an increase in maximal N-PASS scores (Figure 2). The exposure to narcotics, measured as milligram per kilogram of morphine equivalents in 24 hours, decreased over the study period from an average of 1.9mg/kg to 1.0mg/kg in 24 hours (Figure 3).
 Conclusion(s): Through a collaborative quality improvement project with the implementation of post-operative pain management algorithms, improvement in staff satisfaction of pain management in the neonate can be achieved, while significantly decreasing the cumulative opioid exposure in the acute post-operative period.
Figure 1:Post-operative pain algorithms. Algorithms for mild and moderate/severe pain procedures.
Figure 2:X-bar and S chart of maximum N-PASS score within 24 hours post-operatively. Dashed lines represent upper and lower control limits set at 3 sigmas. POP algorithm implementation is annotated. We did not observe an increase in maximum pain score following algorithm implementation