Reducing Pain in the NICU

Babies in the neonatal intensive care unit (NICU) experience a lot of testing in the early days of their life, and research shows the associated pain and trauma can contribute to long term neurological deficits. Matthew Bizzarro, MD and Steven Peterec, MD were at a conference on the effects of pain on the developing brain when the motivation for their recently published Pediatrics study, An Initiative to Decrease Laboratory Testing in an NICU, hit them: by reducing testing, we can reduce pain. Alongside a multidisciplinary team, they decreased laboratory testing in infants admitted to the Yale New Haven Children’s Hospital NICU by more than 26% over two years.

After attending the seminar, which presented ways to mitigate pain during neonatal testing, the doctors asked themselves: is there a better way? In addition to looking at ways to comfort babies during painful procedures, shouldn’t we ask ourselves why so many tests happen in the first place? When they began to examine how many of these tests were absolutely necessary, the rationale behind the study clearly came into focus.

Importantly, the team was very clear to clinicians and families that they were never focused on tests the provider deemed necessary for clinical care. Rather, this study focuses on reducing the routine screening tests we do, sometimes in excess, just to reassure ourselves.

“We’re learning more and more about the long-term effects of repeat testing and exposure to painful procedures on the developing neonatal brain,” said Dr. Bizzarro. “Some of the procedures that we thought were relatively benign have a significant negative impact on neurodevelopment and growth. As babies get exposed to repeated procedures, the pain and anxiety it produces can contribute to negative short and long-term outcomes.”

By designing and implementing a multifaceted quality improvement project using the Institute for Healthcare Improvement’s Model for Improvement, the team achieved a 26.8% decrease in laboratory tests performed per 1,000 patient days (~51,000 fewer tests resulting in eight liters of blood saved) over a 24-month period — with sustained improvement to present day.

“I’m most proud of the fact that we were able to safely reduce testing as much as we did and sustain it. And that across disciplines, buy-in and implementation was relatively smooth, which shows recognition on everybody’s part that this was worth pursuing,” Dr. Bizzarro said.

The study’s findings reinforce the key idea that comprehensive efforts aimed at both clinicians and families are effective in identifying and reducing unnecessary testing in children. And with new evidence to support this concept in the NICU, the team believes that the model is transferable to other inpatient areas and can be applied to other forms of patient testing — such as diagnostic imaging.

“The overall goal is for each provider to recognize the potential deleterious effects of every test they order, which in turn should cause us all to re-examine their necessity,” said Dr. Bizzarro.

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