100 - Fewer Pokes, Stronger Starts: Minimizing Painful Procedures in the NICU

Publication Number: 3096.100

Katherine Coughlin, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, United States; Bridget A. Flynn, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States; Elsa Stout, Sharp Mary Birch, San Diego, CA, United States; Breann Adelman, Sharp, San Diego, CA, United States; Rachelle Sey, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States

Background: Caring for infants in the NICU involves painful laboratory draws (pokes) during a time of rapid brain development. Prolonged or repetitive exposure to pain in preterm infants is associated with adverse neurodevelopmental outcomes, an abnormal response to stress, and altered brain growth. These pokes are also costly and time intensive. It is critical to evaluate which pokes are unnecessary and thus incur harm and waste. In an 84-bed level III NICU, high volumes of serum bilirubin and point of care (POC) glucose testing were identified as areas for poke reduction.

Objective: The primary aims were to reduce by 10% the number of serum bilirubin checks from 48 to 43 per 100 patient days and the number of POC glucose checks from 46 to 41 per 100 patient days, by December 2024 in NICU patients. Process measures included adherence to new protocols and balancing measures were delayed diagnosis of hypoglycemia, hyperglycemia, or hyperbilirubinemia as well as the rate of basic metabolic panels (BMPs) to allow comparison between BMP and bilirubin over time.

Design/Methods: This was an interdisciplinary quality improvement initiative utilizing the Model for Improvement. The team created a driver diagram and focused on minimizing the frequency of lab draws (Figure 1). Change ideas included introducing transcutaneous bilirubin monitoring, revising the hypoglycemia protocol, and creating a hyperglycemia protocol where there was previously no guidance. The number of pokes per patient was audited over the course of the project to inform multiple PDSA cycles. Measures were tracked longitudinally using statistical process control (SPC) charts.

Results: Baseline data collection began in July of 2023. The outcome measure of serum bilirubin checks decreased from a mean of 48 to 30 checks per 100 patient days, a 21% reduction. BMPs over the same period were unchanged (41 per 100 patient days) on SPC U-charts (Figure 2). POC glucose checks decreased from a mean of 46 to 34 per 100 patient days, a 22% reduction, on SPC U-chart (Figure 3).

Conclusion(s): We exceeded our goal with a >20% reduction in both primary outcomes, significantly reducing painful procedures and nearly eliminating pokes for isolated bilirubin checks as demonstrated by a bilirubin rate that is now below that of BMPs. Ongoing work to reduce pokes and waste include standardizing management of anemia of prematurity and implementing a "Difficult IV Access" tool to reduce access attempts.

Figure 1. Driver Diagram
QI project driver diagram with primary and secondary drivers, change ideas, and change concepts.

Figure 2. SPC U charts for bilirubin and BMP rates.
The annotated control chart for bilirubin lab tests shows the rate significantly decreasing over time. It is compared to the rate of BMPs (which is stable), with bilirubins initially being checked more frequently than BMPs but now less frequently after project interventions.

Figure 3. SPC U chart for POC blood glucose rate.
Slide3.jpegThe annotated control chart for POC blood glucose tests shows the rate significantly decreasing over time.