Caring Wisely FY 2023 Project Contest

Reducing Painful Procedures in the Intensive Care Nursery

Proposal Status: 
  • PROJECT LEAD(S): Katelin Kramer, MD
  • EXECUTIVE SPONSOR(S): Elizabeth Rogers, MD
  • ABSTRACT : Painful procedures are performed frequently in the Intensive Care Nursery (ICN), especially in preterm infants. There is a breadth of evidence that repeated painful procedures and blood draws cause harm in preterm infants. This includes increased rates of anemia, blood transfusions,1 and hospital acquired infections in the short term, and delays in cognitive development, abnormal pain processing, increased white matter injury, and higher future risk of anxiety and depression in the long term.2,3 Although many procedures are warranted, unnecessary screening tests are common. Other NICUs have shown success  reducing labs and procedures using QI methodology. For example, Klunk et al reduced routine labs by 27% over 2 years, which equated to a decrease in 8L of blood drawn and savings of over $250K.4 Another center developed the “POKE” program to reduce painful procedures. This QI initiative was associated with reduced “POKES” by 50%, ~$940K per year in cost savings, decreased LOS by 2 weeks, and virtual elimination of HAI, including CLABSI and VAP.5 We aim to decrease routine painful procedures in preterm infants, with a goal to eliminate waste and reduce harm for our most vulnerable patients.
  • TEAM:
    • Project lead: Katelin Kramer, MD (Neonatologist)
    • Executive sponsor: Elizabeth Rogers, MD (Neonatologist; Director, Prematurity Programs)
    • Project manager: Bridget Yeatts (Quality Program Manager)
    • CNS: Jeannie Chan, MS, RN, NNP, CNS and Gabby Byers, MSN, CNS, RNC-CIC
    • Nursing leadership: Jen Gantz, MSN, RN, RNC-NIC, Jordan Davis, PhD, MS, MPH, RN
    • Nursing: Joy Quilatan, RN, LC
    • NNP: Laurel Pershall, NNP
    • Parent Liaison: Diana Rogosa, Hailey Hibler
    • Background of the problem: Infants in the ICN are exposed to 8-17 painful procedures per day, with the highest rates in the lowest gestational ages.6 This includes frequent lab draws, IVs, and radiographs. Frequent labs precipitate anemia and increase the need for blood transfusion. Blood draws and pokes for IVs also increased the risk of hospital acquired infections. More importantly, in the long term, repeated painful procedures have a deleterious effect on cognitive and motor development, somatic growth, and pain processing, particularly when performed in the first weeks of life. Studies have shown that repeated painful procedures in the preterm infant is associated with decreased white matter volume and injury on brain MRI.2 There an association with long-term mental health problems, including anxiety and depression.3
    • Cost associated: Unnecessary labs and procedures are not only associated with neurodevelopmental harm, they also represent waste in the health system and unnecessary direct cost.
    • Urgency of the Problem: Recently published and unpublished QI work at other centers have shown a reduction in painful procedures and a subsequent improvement in outcomes and cost savings. Additionally, the UCSF Mission Bay ICN is currently wrapping up a successful QI initiative called NEOBrain aiming to improve neurodevelopmental care in preterm infants with increased parental involvement and early skin to skin care. The established QI team would like to continue QI work in this realm and tackle this important problem; however, we need more resources to do this.
    • Current condition: It is likely that we perform procedures and screening labs that are not always necessary for patient care. For example, one review showed that clinical interventions in response to a blood gas occurred in only 8% of infants <28 weeks’ gestation.7 In our ICN, infants born < 28 weeks receive an average of 1245 lab orders and 35 x-rays per infant per admission. We do not have a framework for judicious blood draws and procedures, and often labs and XRs are done per routine, at times without clinical indication. Based on review of local data and published QI literature, we believe this is an opportunity to eliminate waste and reduce harm for our most vulnerable patients.
  • TARGET: We aim to reduce painful labs and procedures by 20% for preterm infants born < 34 weeks’ gestation by June 2024. We expect to improve clinical outcomes for preterm infants, including less anemia, fewer blood transfusions, reduced incidence of infection (CLABSI, sepsis). We anticipate significant direct cost savings by reducing labs, x-rays, and IVs. As a trickle-down effect of this initiative, other centers have also shown reduced length of stay (up to two weeks in one study). Even a modest reduction (~3 days) would result in substantial cost savings and increased throughput in the often impacted ICN.
  • GAPS: Currently, there is no system to track painful procedures in the ICN. Despite these being important interventions in preterm infants that may cause harm and waste, we do not document each poke in the EHR. We do not quantify skin breaks, which is a limitation when assessing infection risk and neurodevelopmental harm. We are not monitoring the amount of blood draws and labs ordered and do not currently track if they are clinically necessary. We have protocols for routine screening labs, such as POC glucose, serum bilirubin, and nutrition monitoring labs that may be outdated. We often do labs as a “panel” when we are only interested in a single lab value. We do hundreds of POC glucose checks in preterm infants throughout the hospitalization, many of which are outside of a protocol and or done PRN without a consistent approach, and many during the particularly vulnerable early weeks of life.  We do not utilize transcutaneous bilirubin as a screening tool for jaundice in the ICN, although this is may have utility preterm infants and used in other NICUs throughout California.8,9 Finally, there is a gap in knowledge about the harms and necessity of painful procedures, with no formal educational materials on this subject or guide to inform care decisions while minimizing painful procedures.
    • Setting/Intervention: We plan to form a multidisciplinary QI team to address this problem and reduce the rate of painful procedures. The team will include disciplines in the UCSF Mission Bay ICN, including neonatologists, neonatal nurses, RTs, NNPs, hospitalists, PT/OT, neonatal fellows, pediatrics residents, and parent liaisons. Our target population is any infant admitted to the ICN (inborn or outborn within 3 days of birth) delivered < 34 weeks’ gestation. Using a tailored Apex report, we plan to review baseline data including volume of labs by lab type and x-rays in this population. We will also audit overall pokes in this population by monitoring IV sticks and blood draws. Using core QI methodology and Lean approach for improvement, we will determine key drivers for a high rate of painful procedures and identify targeted interventions. In an initial analysis, interventions will likely include unit-wide education campaign, updated protocols for screening labs and lab panels, updated guidelines for glucose monitoring and standard weekly/daily labs, education, and protocol for use of transcutaneous bilirubin. There will likely be value in EHR modifications to track data and prompt judicious blood draws.
    • Barriers: We foresee barriers with buy-in to this initiative, especially in an ICU with critically ill patients where there is often a mindset of frequent monitoring. There also may be difficulty achieving a consensus on which screening labs and procedures are deemed necessary which may lead to inconsistency. Additionally, ongoing data collection will be difficult, particularly with pokes or skin breaks, without an updated system for tracking this metric and will require new workflows for bedside staff.
    • Possible adverse outcomes: With reducing screening labs, we want to make sure we are not missing clinically important lab values that may require intervention. We will therefore monitor for increase in extreme lab values which may be associated with our interventions.
    • What are the clinical problems you are hoping to solve with APeX? Monitoring of labs, procedures, and skin breaks to make targeted interventions to reduce painful stimuli and improve neurodevelopmental care.
    • What APeX tools (patient lists, reports) or workflows (orders, documentation, alerts) are you using now to achieve this goal? How would you want these modified? Currently using an existing Apex report for only inborn infants <28W for all lab orders and XR orders during hospitalization. This report gives a general sense of lab frequency, but has a narrow population and lacks the granularity needed to target interventions and track outcomes.
    • What new APeX tools/workflows do you think you need to achieve the goals of your project? We need a new Apex report to identify patients (<34 weeks, inborn or admitted within 3 days), monitor individual labs, monitor # of blood draws, monitor # skin breaks overall. Would need updates to nursing flowsheet to document noxious stimuli and skin breaks, likely included in a section which can include other aspects of optimal neurodevelopmental care.
  • COST: The bulk of anticipated cost is for necessary protected time for project champions to design and implement the initiative. Other costs include materials for campaign dissemination/education and probable purchase of transcutaneous bilirubinometers if this practice change is approved by ICN leadership. The projected savings to the health system are significant, and include direct savings from reduction in labs and procedures, in addition to possible trickle down effects such as reduced LOS and hospital acquired infection, as shown in other centers doing similar QI efforts.4,5
  • SUSTAINABILITY: With updated protocols for screening labs and procedures, we anticipate sustained improvement in our outcome as clinical practice will have changed. We anticipate a culture shift in decision making about painful procedures. We will plan for ongoing data collection and monthly meetings after the initial year for maintenance of the project and close tracking of outcomes. The project leads (neonatologist, neonatal nurse practitioner, nursing leadership, QI project manager) will own the process. Finally, if successful, we believe this initiative could be scaled to other units, including the BCH Oakland NICU, who already has an interest in neuroprotective care as a member of the CPQCC NEOBrain collaborative.
    • Salaries for project champions: 10% FTE for Project Leader (Neonatologist), FTE for NNP lead, RN lead - ~$40,000
    • Materials/education: Protected time for staff education, advertisement, video, educational materials/flyers. Potential purchase of transcutaneous bilirubinometers - ~$10,000


  1. Widness JA, Madan A, Grindeanu LA, Zimmerman MB, Wong DK, Stevenson DK. Reduction in red blood cell transfusions among preterm infants: results of a randomized trial with an in-line blood gas and chemistry monitor. Pediatrics. 2005;115(5):1299–1306
  2. WalkerSM. Long-term effects of neonatal pain. Semin Fetal Neonatal Med. 2019;24(4):101005
  3. Valeri BO, Holsti L, Linhares MB. Neonatal pain and developmental outcomes in children born preterm: a systematic review. Clin J Pain. 2015;31(4):355–362
  4. Klunk CJ, Barrett RE, Peterec SM, et al. An Initiative to Decrease Laboratory Testing in a NICU. Pediatrics. 2021;148(1):e2020000570. doi:10.1542/peds.2020-000570
  5. McGlothlin J.P., Crawford E., Wyatt J., et al., Poke-R - using analytics to reduce patient, In: Proceedings of the 10th international Joint Conference on Biomedical Engineering systems and Technologies, 2017, SCITEPRESS - Science and Technology Publications, 362–369, doi:10.5220/0006174603620369.
  6. Cruz MD, Fernandes AM, Oliveira CR. Epidemiology of painful procedures performed in neonates: a systematic review of observational studies. Eur J Pain. 2016;20(4):489–498
  7. Carbajal R, Rousset A, Danan C, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008;300(1):60–70
  8. Nagar G, Vandermeer B, Campbell S, Kumar M. Reliability of transcutaneous bilirubin devices in preterm infants: a systematic review. Pediatrics. 2013;132(5):871-881. doi:10.1542/peds.2013-1713
  9. Bhatt DR, Kristensen-Cabrera AI, Lee HC, et al. Transcutaneous bilirubinometer use and practices surrounding jaundice in 150 California newborn intensive care units. J Perinatol. 2018;38(11):1532-1535. doi:10.1038/s41372-018-0154-3