Fellow St Christopher Hospital for Children's Saint Christopher's Hospital for Children Philadelphia, Pennsylvania, United States
Background: Opioids are prescribed to critically ill neonates to provide analgesia and/or sedation. Prolonged opioid exposure in neonates is associated with poor neurodevelopmental outcomes(1). Reasons for opioid prescription include analgesia for procedural or post-operative pain, or sedation during chronic ventilation for hypoxemic respiratory failure and/or pulmonary hypertensive crisis. Local review of sedation and analgesia practices of admissions to our out-born NICU between 01/2019 –12/2019 identified 34 neonates prescribed opioids for sedation or analgesia. Fifty-six percent were given >7 days of opioids.
Objective: Our goal was to decrease the average days of opioid used for analgesia and/or sedation in critically ill neonates in our outborn level IV NICU by 10% within one year of project initiation.
Design/Methods: A multidisciplinary quality improvement team used the model for improvement, beginning with a Pareto analysis (Figure 1), and identified a lack of consistent approach to weaning opioids as a primary driver for prolonged exposure. The team devised guidelines to improve consistency in management by facilitating decision-making with a standardized withdrawal scoring tool (WAT-1) and a weaning guideline. Data monitoring, audit, and re-education were done from 01/8/2020 – 11/1/2020. The outcome measure was mean days of opioid exposure per patient. Process measure was documentation of WAT -1 scores in the medical record. Balancing measure was mean days of benzodiazepine exposure per patient.
Results: Statistical process control analysis demonstrated mean days of opioid exposure decreased by 40% from 27.6 to 16.8 days (Figure 2). The quarterly frequency of nursing WAT-1 score documentation on pertinent neonates increased from 0% to 89%. Mean days of benzodiazepine exposure per patient did not change (Figure 3). Conclusion(s): A standardized approach for evaluation of patient withdrawal combined with a basis for decision-making tied to concrete patient assessments can decrease the use of opioids for analgesia and/or sedation for critically ill neonates in a level IV NICU.
1. Zwicker JG, Miller SP, Grunau RE, et al. Smaller Cerebellar Growth and Poorer Neurodevelopmental Outcomes in Very Preterm Infants Exposed to Neonatal Morphine. J Pediatr 2016;172:81-7 e2.
Authors/Institutions: Dipen P. Vyas, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States; Vilmaris Quinones Cardona, St Christopher's Hospital for Children/Drexel University College of Medicine, Philadelphia, Pennsylvania, United States; Catherine Markel, Saint Christopher's Hospital for Children, Marlton, New Jersey, United States; Amanda M. Carroll, St Christopher's Hospital for Children, Blue Bell, Pennsylvania, United States; Megan Young, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States; Rachel Fleishman, St Christopher's Hospital for Children, Merion, Pennsylvania, United States