Utilizing Quality Improvement Methodology to Implement a Perioperative Intravenous Acetaminophen Protocol in Neonatal...

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.

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).

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.

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.