Creating a Regional Anasthesia CPG to Manage Postoperative Pain in Eligible NICU Patients: A Quality Improvement Project

Over 4000 neonates require surgery annually in the United States. The use of opioids for postoperative pain control and sedation during a lengthy stay in the NICU can result in increased cumulative doses, leading to adverse effects in the neonatal patient. Opioid administration may have adverse clinical side effects, including respiratory suppression, delayed bowel motility, and possible neurodevelopmental issues during childhood. Few studies in the surgical neonatal population exist regarding the reduction of opioid use through different analgesic strategies, such as regional anesthesia. Utilizing regional anesthesia has the potential to reduce opioid use, yet there is a knowledge gap regarding the efficacy and use of regional anesthesia in the NICU population. Local Problem: While the use of regional anesthesia is commonplace for pain control in other patient populations, there is no clinical practice guideline for regional anesthesia to treat postoperative pain in neonates. Without a standardized guideline for regional anesthesia, this pain treatment modality is underutilized. This project aims to develop a clinical practice guideline to provide regional anesthesia to eligible patients in the NICU. Methods: This project utilized a literature review, stakeholder meetings, clinician surveys, and a chart review to understand attitudes and education regarding regional anesthesia and to guide the creation of a CPG. Data was presented to a multidisciplinary team and used to define the population and parameters of the process change. The designed educational processes in conjunction with the unit education team to ensure the project's sustainability. Unit resources were assessed to create an integrative implementation plan. Interventions: The project lead surveyed providers regarding the use of regional anesthesia in the NICU. Using the information from the survey, the QI team created and implemented an education plan for bedside nursing about regional anesthesia and its utility in the neonatal population. Stakeholders, including the NICU medical director, surgery, and anesthesia, created and approved the clinical practice guideline. The project lead designed and implemented a sustainability plan to ensure the success of the CPG. Results: The chart review showed that patients received between 0.6-30.77 OME/kg of opioids with a mean of 7.49 OME/kg (SD 8.56) in the first 72 hours postoperatively. NICU providers indicated their openness to utilizing regional anesthesia as a pain relief modality in the NICU, with the majority indicating a CPG would increase their likelihood of implementing the use of regional anesthesia (n=59, 82%). The qualitative analysis identified two overarching categories: barriers to implementing the CPG and facilitators for implementation which varied based on role in the NICU. Based on our data collection, the QI team created a CPG with defined inclusion and exclusion criteria, streamlined necessary communication, and outlined roles for every provider involved. Educational needs were identified and addressed through educational offerings and documents. The project lead created and implemented a sustainability plan, including PDSA cycles, an electronic medical record trigger, and ongoing education to ensure the uptake of the practice change. Conclusion: Adopting this guideline as the standard of care would likely improve patient outcomes. Data collection must continue through sustained PDSA cycles to determine the benefits of this practice change and assess the intervention's feasibility, usability, and satisfaction.