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Utilizing Quality Improvement Methodology to Implement a Perioperative Intravenous Acetaminophen Protocol in Neonatal
Insights
Implementing intravenous acetaminophen in neonates undergoing surgery effectively manages pain, aligning with Enhanced Recovery After Surgery guidelines. This approach reduces opioid exposure and ensures adequate analgesia for pediatric patients.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Pharmacology
Background:
- Enhanced Recovery After Surgery (ERAS®) guidelines emphasize multimodal analgesia to minimize opioid use in pediatric patients.
- Intravenous (IV) acetaminophen presents an alternative opioid-sparing analgesic option for neonatal surgical patients when oral or rectal routes are not feasible.
- Quality improvement methodologies were employed to introduce a perioperative IV acetaminophen protocol for neonates undergoing gastrointestinal surgery.
Purpose of the Study:
- To implement and evaluate a perioperative intravenous acetaminophen protocol for neonatal surgical patients.
- To assess protocol compliance and postoperative pain management.
- To provide a model for the integration of IV acetaminophen in neonatal surgical care.
Main Methods:
- A multidisciplinary team developed and implemented a standardized perioperative IV acetaminophen dosing protocol using a Plan-Do-Study-Act (PDSA) methodology.
- A second PDSA cycle introduced an online order set to enhance administration ease and compliance.
- Protocol compliance and postoperative pain (Neonatal Pain, Agitation, and Sedation Scale - NPASS) were the primary measures.
Main Results:
- The study included 50 prospective cases with an overall protocol compliance rate of 43.9%.
- Postoperative compliance (90.2%) significantly exceeded preoperative compliance (46.0%), with higher compliance observed when the online order set was utilized.
- Median NPASS scores at 24 and 48 hours (2.4 and 2.3, respectively) indicated adequate postoperative analgesia.
Conclusions:
- Perioperative IV acetaminophen can be successfully implemented as an analgesic in neonates undergoing gastrointestinal surgery.
- Sustained compliance requires ongoing education and continuous quality improvement efforts.
- This project offers a replicable model for enhancing pain management in this vulnerable patient population.
Background:
Enhanced Recovery After Surgery (ERAS®) guidelines in the pediatric population recommend appropriate multimodal analgesia to limit opioid exposure, with the goal of preventing deleterious effects. Acetaminophen offers an alternative to opioids in neonatal surgical patients, but oral and rectal administrations cannot always be used. The authors used quality improvement methodology to implement a perioperative intravenous (IV) acetaminophen protocol for neonates undergoing gastrointestinal surgery.
Methods:
A multidisciplinary stakeholder team was created that included pediatric surgeons, neonatal intensive care physicians and nurses, nurse practitioners, pharmacists, and information technologists. Special approval was issued for IV acetaminophen in neonatal surgical patients. The first Plan-Do-Study-Act (PDSA) cycle implemented a standardized perioperative dosing protocol accompanied by training. The second PDSA cycle involved implementation of an online order set for ease of administration and compliance. The primary process measure was protocol compliance. The primary balancing measure was postoperative pain, measured by the Neonatal Pain, Agitation, and Sedation Scale (NPASS).
Results:
Fifty prospective cases were included. The overall rate of compliance was 43.9%, with 46.0% preoperative compliance and 90.2% postoperative compliance. Compliance was greater when the order set was used, though the preoperative order set was used less frequently than the postoperative order set (67.7% vs. 77.4%). Median NPASS scores at 24 and 48 hours were 2.4 (interquartile range [IQR] 1.5-3.3) and 2.3 (IQR 1.0-3.5), respectively, indicating adequate analgesia.
Conclusion:
This project provides a model for implementing perioperative IV acetaminophen as an analgesic for neonates undergoing gastrointestinal surgery. Continuing education and sustainability efforts are required to ensure ongoing compliance to the protocol.
