Breaking Through the WALL to Pain Assessment Quality ... - FANNP

FANNP 23RD NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW 

A9 

Breaking Through the WALL to Pain 

Assessment Quality Improvement 

Elizabeth A. Gyland, DNP, NNP, PNP 

Manager, NP/PA Services 

Wolfson Children’s Hospital, Jacksonville, FL 

The speaker has signed a disclosure form and indicated she has no significant financial interest or relationship with companies or the 

manufacturer(s) of any commercial product/service that will be discussed as part of this presentation. 

Session Summary 

This presentation discusses the quality improvement project of an NICU interdisciplinary evidenced-based 

practice committee of a Level III NICU in northeast Florida using Six Sigma methodology. 

Session Objectives 

Upon completion of this presentation, the learner: 

• will understand the five key stages of Six Sigma methodology; 

• will understand the benefits of process flowcharting and performing SWOT analyses in defining a 

research problem; 

• will understand ways to implement change. 

References 

American Academy of Pediatrics (2006). Prevention and management of pain in the neonate: An update. Pediatrics, 

118(5): 2231-2241. 

Anand, K.J.S. (2001). Consensus statement for the prevention and management of pain in the newborn. Archives of Pediatric and 

Adolescent Medicine, 155: 173-180. 

Anand, K.J.S. & Hickey P.R. (1987). Pain and its effects in the human neonate and fetus. The New England Journal of Medicine, 

317(21): 1321-1329. 

Anand, K.J.S. & IEBNP (2001). Consensus statement for the prevention and management of pain in the newborn. Archives of 

Pediatric and Adolescent Medicine, 155: 173-180. 

Anand, K.J.S., Stevens, B.J. & McGrath, P.J. (Eds.). (2000). Pain in neonates, 2nd revised and enlarged edition. Amsterdam: Elsevier. 

Anand, K.J.S., Aranda, J.V., Berde, C.B., Buckman, E.V., et al. (2006). Summary proceedings form the neonatal pain-control group. 

Pediatrics, 117(3): S9-S22. 

Aguggia, M. (2003). Neurophysiology of pain. Neurology Science, 24: S57-S60. 

Cervo, F.A., Bruckenthal, P., Chen, J.J., Bright-Long, L.E., et. al. (2009). Pain assessment in nursing home residents with dementia: 

psychometric properties and clinical utility of the CAN pain assessment tool (CPAT). Journal of American Medical Directors 

Association, 10: 505-510. 

Cignacco, E., Mueller, R., Hamers, J.P.H. & Gessler, P. (2004). Pain assessment in the neonate using the bernese pain scale for 

neonates. Early Human Development, 78: 125-131. 

Duhn, L.J. & Medves, J.M. (2004). A systematic integrative review of infant pain assessment tool. Advances in Neonatal Care, 4(3): 

126-140. 

A9: PAIN ASSESSMENT AND QUALITY IMPROVEMENT Page 1 of 9


Evans, J., Vogelpohl, D., Bourguignon, C. & Morcott, C. (1997). Pain behaviors in LBW infants accompany some nonpainful 

caregiving procedures. Neonatal Network, 16(3). 

Fillingim, R.B. (2003). Class lecture: Introduction to pain. (8/25/03). 

Franck, L.S. (2002). Some pain, some gain: Reflections on the past two decades of neonatal pain research and treatment. 

Neonatal Network, 21(5): 37-40 

Hummel, P. & Puchalski, M. (2002). N-PASS: Neonatal pain, agitation, and sedation scale. Retrieved May 24, 2009 from 

http://www.n-pass.com 

Schecter, N.L., Berde, C.B. & Yaster, M. (2003). Pain in infants, children, and adolescents. An overview. In: N.L. Schecter, C.B Berde 

and M. Yaster, (Eds.), Pain in Infants, Children, and Adolescents (pp. 3-18). Philadelphia: Lippincott Williams & Wilkins. 

Simons, S.H.P., VanDijk, M., Anand, K.S., Roofthooft, D., VanLingen, R.A. & Tibboel, D. (2003). Do we still hurt newborn babies? 

Archives of Pediatric and Adolescent Medicine, 157: 1058-1064 

Spence, K., Gillies, D., Harrison, D., Johnston, L. & Nagy, S. (2005). A reliable pain assessment tool for clinical assessment in the 

neonatal intensive care unit. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 33(5): 80-86. 

Stevens, B.J. & Franck, L. (2001). Assessment and management of pain in neonates. Paediatric Drugs, 3(7): 539-558. 

Stevens, B, Johnston, C, Petryshen, P. & Taddio, A. (1996). Premature infant pain profile: development and initial validation. The 

Clinical Journal of Pain, 12(1): 13-22. 

The Joint Commission: personal email communication April 14, 2009. 

Thoman, E. (1990). Sleeping and waking states in infancy: A functional perspective. Neuroscience and Behavior Reviews, 

14(1): 93-107. 

Walden, M. (2001). Pain assessment and management. Guideline for practice. Glenview: National Association of Neonatal Nurses. 

Walden, M. & Gibbins, S. (2008). Pain Assessment and Management. Guideline for practice (2nd ed.). Glenview: National 

Association of Neonatal Nurses. 

Warnock, F. & Lander, J. (2004). Foundations of knowledge about neonatal pain. Journal of Pain and Symptom Management, 

27(2): 170-179. 

Session Outline 

See handout on the following pages. 



Breaking Through the Wall 

to Pain Assessment 

THE WALL 

Quality Improvement 

Elizabeth A. Gyland, DNP, NNP, PNP 

Manager, WCH NP/PA Services 

elizabeth.gyland@bmcjax.com 

Pain in Infants 

Background Study 

• Inherent quality that serves as a 

signaling system for tissue damage as it 

is protective and crucial for survival 

(Stevens and Franck, 2001) 

• Simons et al documented 20,000 pain-producing 

procedures of a sample of 151 neonates during 

the first 14 days of life in a neonatal intensive 

care unit (NICU). This averaged 196 procedures 

per infant, or between 12 and 15 procedures per 

day and less than 35% of these procedures were 

associated with some form of analgesia (Simons, 

van Dijk, Anand, Rofhooft, vanLingen, & Tibboel, 

2003). 

Pain Assessment and 

Management Guidelines for 

Practice, 2nd edition 

• According to NANN (National Association of Neonatal 

Nurses): 

– Guideline II-Pain is assessed and reassessed at 

regular intervals throughout the infant’s 

hospitalization 

– Guideline V-Pain assessment and management 

practices should be documented in a manner that 

facilitates regular reassessment and follow-up 

intervention 

¯ (Walden & Gibbins, 2008) 

Assessment to Management 

• Pain assessment is an essential 

component of pain management (Walden 

& Gibbins, 2008) 

• Reliable and valid pain assessment is the 

CORNERSTONE to effective pain 

management! 



Goal 

How? 

• To effectively assess and manage 

postoperative, procedural, and diseaserelated 

pain in hospitalized infants 

(Walden, 2001; Walden & Gibbins, 2008) 

• There is currently NO GOLD STANDARD 

BIOLOGICAL MEASURE FOR INFANT 

PAIN! 

The Focus for Pain 

Assessment 

• Physiological indicators of pain (VS, O2 

sats, ICP, MAP, HR variability, skin color 

• Biochemical indicators of pain (cortisol, 

epinephrine, norepinephrine, glucagon, 

aldosterone, insulin) 

• Behavioral indicators of pain (cry, muscle 

tone, behavioral state changes, body 

movements, facial expression) 

• (Warnock & Lander, 2004) 

Clinical Question 

• For an infant in a level III NICU in 

Northeast Florida, is the current pain 

assessment tool, the Neonatal Infant 

Pain Score (NIPS), the most appropriate 

and evidence-based infant pain 

assessment tool when compared to other 

tools recommended by the National 

Association of Neonatal Nurses? 

Framework 

• Six Sigma methodology uses 5 key 

stages: 

– Define 

– Measure 

– Analyze 

– Improve 

– Control 



Define Phase 

Committee Survey 

• Objective: To identify and/or validate the 

improvement opportunity 

• Activities: 

– Committee survey on pain assessment in our 

NICU 

– PowerPoint presentation of history of pain and 

the development of the pain pathways in the 

infant 

– Development of an overall theme aim 

statement for the project 

• Do infants experience pain? 

• How do you know that an infant is experiencing pain? (List 

factors that you use to determine if an infant is in pain) 

• At what point(s) during the NICU stay do you witness an infant 

experiencing pain? (List specifically) 

• What pain scale is currently used in our NICU? 

• What are the individual parameters of the NICU pain scale? 

• How does one interpret the total pain score? 

• How often do you do a pain assessment in a shift? 

• What guides how many pain assessments that you do in a shift? 

• Do you consistently report an abnormal pain score to a Neo NNP 

or PA-C? 

• What are your results of reporting an abnormal pain score? 

• Do you currently teach our NICU parent(s) or caregivers 

about pain? 

Results 

Theme Aim Statement 

• 19 surveys completed 

• All agreed infants experience pain 

• Both behavioral and physiologic signs were known by 

nursing 

• Understood when an infant may experience pain 

• 74% knew name of current pain scale used 

• No consistency in knowledge of parameters of pain scale 

• Extreme variability in how to interpret pain score 

• Pain assessments only done once per shift 

• 79% of RNs consistently report an abnormal pain score 

• Extreme variability outcomes of reporting abnormal 

score 

• No consistency in parent teaching 

• We aim to improve the accuracy, functionality, 

and consistency of pain assessment of the 

neonate. 

• The process will end with a recommendation of a 

pain assessment tool to the NICU Steering 

Committee. 

• It is important to work on this now because we 

will then be one step closer to providing 

appropriate pain management for the critically 

ill neonate. 

Measure Phase 

• Objective: Map process 


– Workflow analysis of the current 

process for pain assessment in our 

NICU 

– SWOT analysis of current process 

Current Pain Assessment 

Process Flowchart 

CURRENT PAIN ASSESSMENT FLOWCHART 

Score Under 5 Score – 5-10 

Non-pharmacologic 

intervention 

Nonpharmacologic 

and give prn 

pain meds. 

Perform a Pain Assessment Based on 

Practice and Assessment of Pain Cues 

Assign Pain Score 0 - 10 

Reassess pain score 

after 15-30 minutes 

depending on 

treatment modality. 

If no existing prn 

order or intervention 

is ineffective, inform 

extender/ 

neonatologist of 

score. 

If no order received, notify 

different extender/ 

neonatologist. 

Continue non pharmacologic 

interventions 

Continue to document 

pain score. 

Write pie note -include 

no orders received, 

extender/neonatologist 

notified. 

If reassessment 

score still >5, 

repeat process. 



SWOT Analysis of Current 

Process 

Analyze Phase 

Strengths 

Nurses care 

Good assessment skills 

Realization of the importance of pain 

assessment 

Patient advocates 

Some physician are proponents of pain 

management 

A IR audits reveal high scores 

Dedicated NICU pharmacist 

O pportunities 

T JC initiative for pain 

assessment/management 

Research best practice for pain assessment 

E m pow er N ICU interdisciplinary team 

Develop a standardized process for pain 

assessment 

Performance improvement 

Improve parent satisfaction scores 

T each parents developm ental care 

Increase reporting of abnormal pain scores 

Weaknesses 

Current pain assessment tool 

Lack of pain management protocol 

S om e physicians not engaged in pain 

management 

G eneral lack of knowledge of infant physical 

cues of pain 

Fear of infant addiction to pain medication 

Lack of knowledge of specific pain 

medications and the pharmocokinetics of 

pain medications 

Threats 

Lack of buy-in of staff, physicians, parents 

Possible increase of tim e infant on a 

ventilator 

Perception of addiction 

Nurses not taking time to correctly score 

• Objective: Identify specific problem(s) 


– Review Pain Assessment and Management. Guideline 

for Practice. 2 nd edition (NANN, 2008) 

– Group assignments to research the literature for 

information from our local, national, and international 

governing bodies and recommended infant pain 

assessment tools 

– Presentation by each group of info, including SWOT 

analysis 

– Development of matrix of all SWOT analyses 

– Review of matrix by committee 

Guidelines Reviewed 

• The Joint Commission 

• The International Evidence-Based Group 

for Neonatal Pain 

• American Academy of Pediatrics 

i 

• WCH Policy regarding pain assessment 

• 2008 NANN Guidelines 

Infant Pain Assessment 

Tools 

• Neonatal, Pain, Agitation, and Sedation Scale 

(N-PASS) 

• Pain Assessment Tool (PAT) 

• Scale for Use in Newborns (SUN) 

• Bernese Pain Scale for Neonates (BPSN) 

• Premature Infant Pain Profile (PIPP) 

• CRIES: Neonatal Postoperative Pain Assessment 

• Neonatal Infant Pain Scale (NIPS) 

Weaknesses of Current 

Tool-NIPS 

• The pain score is NOT adjusted for the 

gestational age of the infant 

• It does not address sedation 

• Its primary use is for procedural pain 

only 

• THE INTERPRETATION OF THE SCORE 

IS SUBJECTIVE! 

Improve Phase 

• Objective: Evaluate and select solution 


– Committee recommended further 

review of N-PASS and PIPP tools 

– Research protocol for comparison of 

ease of use of N-PASS and PIPP 

received IRC approval and NICU 

Steering Committee approval 



Comparison Study 

PIPP 

• Purpose: To compare ease of use of the PIPP and 

the N-PASS 

• Sample: 32 NICU RNs, not currently working on 

the project 

• Research Plan: 

– Each participant was presented 

information regarding each pain 

assessment tool, then assign pain scores 

for 2 case studies 

– Completed questionnaire rating ease of 

use for each tool 

N-PASS 

N-PASS vs PIPP 

Please rate each statement below on a scale of: 

1=strongly agree 

2=somewhat agree 

3=undecided 

4=somewhat disagree 

5=strongly disagree 

• This pain scale was easy to use. 

• This pain scale was not time consuming. 

• This pain scale is appropriate to assess pain. 

• This pain scale is able to differentiate the level of 

pain 

Results 

Final Question 

Question Mean PIPP Mean N-PASS Test statistic 

1 1.656 1.969 t(62)=1.34, p=0.1861 

2 1.656 2.094 t(62)=1.65, p=0.1047 

3 1.406 1.500 t(62)=0.52, p=0.6019 

4 1.344 1.677 t(61)=1.43, p=0.1566 

5 1.563 1.452 t(61)=-0.59,p=0.5552 

• Now that you have sampled using both 

tools, which tool would you like to see 

used in our NICU? 

The results are quite similar 

Statistically, neither instrument is significantly different 

All the means are between 1 and 2 

Statistically, there would be no large difference if we continued to collect data. (Question presented to statistician) 



Final Decision 

Control Phase 

• The RNs preferred the N-PASS 

– calculate both a pain AND a sedation score 

– pulls into play more assessment skills, 

therefore giving g a more comprehensive 

picture of the infant EVEN THOUGH they 

stated it may take MORE time to use, require 

MORE in-depth training, and have a GREATER 

learning curve 

• Objective: Implement change 


– Presentation of recommendation to 

NICU Steering Committee for approval 

– Development of eLearning module for 

staff training 

– Staff training 

– Audits on use of tool after Go-Live 

– Development of tool for EMR use 

eLearning Module 

Go-Live for N-PASS 

• Approval for change of tool on current 

flowsheet on downtown campus 

• Go-Live was November 16, 2010 for Level 

III NICU on downtown campus 

• Began working with IS department for 

EMR development 

• Audits: 

– Are pain assessments being done 

with every set of vital signs? 

– Does overall scoring seem appropriate? 

Further Work 

• Continued audit 

– For those with N-PASS scores >3 during FY 

2012 in NICU, average 66.4% received 

pharmacologic intervention 

• Re-inservicing re: calculation of sedation score 

• Introduce staff to N-PASS tool in the EMR 

• Overall hospital policy change for pain 

assessment to be considered 5 th vital sign 

– Audit NICU FY 2012- 93.2% completed 

• Compare cost of pain/sedation meds used in 

the NICU before implementation with after 

implementation of N-PASS

Breaking Through the WALL to Pain Assessment Quality ... - FANNP

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