Reducing Opiate and Benzodiazepine Exposure in Preterm Infants on High-Frequency Jet Ventilation

Extremely low birth weight newborns are at increased risk of pain and agitation, prompting treatment with opiates and benzodiazepines, which are associated with adverse neurodevelopmental and pulmonary outcomes. We aimed to decrease the cumulative dose of opiates and benzodiazepines given to infants at 28 weeks' gestation or younger or weighing at most 1000 g at birth on high-frequency jet ventilation by 50% over 12 months and sustain that improvement for 6 months in our level IV neonatal intensive care unit.

A multidisciplinary team undertook a quality improvement initiative using the Model for Improvement. A driver diagram identified primary drivers of lack of awareness of the potential harms of medications, lack of standardization of pain assessments, and lack of clear medication indications for initiation. Plan-Do-Study-Act cycles tested 6 interventions. Statistical process control charts were used to analyze data over time for special cause variation.

We observed special cause variation with decreased cumulative doses of opiates and benzodiazepines per patient by 75.9% and 61.5%, respectively. Process measures for guideline adherence and pain documentation also improved. Balancing measures of pain scores and unplanned extubations did not worsen. Changes were implemented over 12 months and sustained for more than 6 months.

Our efforts to standardize medication administration, pain assessments, and frequent pain/agitation audits significantly decreased exposure to opiates and benzodiazepines via a multidisciplinary quality improvement approach.