Sustaining Management of Procedural Pain in Stable Babies of NICU of a Tertiary Care Center from Rural Bengaluru, India: A Quality Improvement Study

Background Neonates undergo procedures that cause pain as part of their routine management in the neonatal intensive care unit (NICU). A know-do gap exists for optimal analgesia for the procedures in the NICU. Methods A quality improvement (QI) approach was used to implement management of procedural pain in NICU from a baseline of nil analgesia to >80% over 8 weeks through a series of plan-do-study-act (PDSA) cycles. All babies with corrected gestational age >32 weeks and without ventilator support or contraindications to feeds were eligible. Analgesia compliance was the key quantitative outcome. The Pareto chart identified the most common painful procedures. Various change ideas were tested using multiple PDSA cycles, including sensitization, simulated validation of pain assessment, analgesia protocol with breast milk, pain management part of nurses’ handover, and others. A bedside nurse assessed data on analgesia compliance daily. Results Between April 2023 and July 2024, 720 neonates were part of the QI initiative and underwent nearly 3,820 procedures (five procedures per baby). The mean gestational age was 37 (±2) weeks, and the mean birth weight was 2,649 (±599) g. The Pareto chart showed that heel prick, venous sampling, and intravenous cannulation contributed to 92% of the painful procedures. Breast milk analgesia could be implemented successfully over 8 weeks and sustained for the next 13 months in eligible babies. Conclusion Breast milk was sustained as the best practice for procedural pain without additional resources. This experience will be useful in many similar scenarios, especially across the developing world.