Providing Cost-Effective Access to Adequate Pain Relief for Neonatal Intensive Care Unit (NICU) Patients
Recent studies show neonatal intensive care units (NICU) patients are not receiving appropriate pain treatment compared to their adult and pediatric counterparts. Untreated pain in the compromised infant results in long and short-term physical, emotional and mental complications. An opportunity exists among all the key players involved in infant care to benefit by collaborating to overcome barriers to achieving infant pain relief. A proposed solution that involves creating a systematic framework integrating health care provider education, policies and protocols, as well as conflict resolution resources that are regulated and monitored by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is described and evaluated. Through empowerment, guidance, evaluation and legitimacy, the proposed solution provides an enduring means to ensure that NICU infants receive cost-effective adequate pain relief.
The Problem of Untreated Pain in NICU Infants
More than 370,000 neonatal intensive care unit (NICU) patients in the United States each year rely on their caregivers to provide for all their basic needs to help them sustain life. However, recent studies show that NICU infants are not medicated prior to procedures for which adults are routinely medicated (Rouzan, 2001). Pain management differences also exist between neonatal and pediatric patients. For example, "66% of pediatric intensive care unit patients…[compared to] 26% of NICU patients are likely to receive analgesia (Rouzan, 2001, p.59). Another study demonstrated that neonates "from 109 NICUs in the United States and 14 NICUs in Canada that underwent a variety of painful procedures did not receive pharmacological treatment or comfort measures" (Stevens, 2000, p.634).
Untreated pain in NICU infants results in short and long-term complications. In the compromised NICU patient, pain inhibits the body's ability to fight infection, resulting in longer and more expensive hospital stays. Research shows that the infant's neurological ability to create long-term memories is well developed (Furdon, 1998). Long-term studies following the development of infants showed that behavioral reactions, such as "disruptions in sleep, feeding patterns and maternal-infant interactions can persist long after the noxious stimuli has ended," demonstrating recall of pain (Rouzan, 2001, p.58).
Why is Pain Untreated in NICU Infants?
Several reasons exist for untreated pain in NICU patients. Medically accepted definitions of pain, such as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, " provided by the International Association for the Study of Pain, are not applicable to NICU infants since they are unable to voice their perceptions of pain. Moreover, parents are often unaware about the availability of infant pain relief medication or may fear the adverse side effects of drugs used to treat neonatal pain (Franck, 1997).
Similarly, a lack of awareness among health care providers contributes to ineffective pain relief among NICU infants (Available at: http://www.jcaho.org/standards_frm.html). Until the mid-1980s, NICU patients did not receive any analgesia or anesthetic before undergoing surgery or diagnostic procedures. While recent studies show that NICU infants do experience pain and the health care community has recognized a need to treat it, current research findings do not always coincide with health care provider and public beliefs about neonatal pain management (Franck, 1997, p.83). While there are no legal cases of a health care provider violating the standards of care for neonatal pain, research suggests that disciplinary actions may have occurred but are rarely reported (McGrath, 2000). Providing a means to assess, evaluate and reinforce health care providers' accountability is crucial to delivering adequate neonatal pain relief.
Cost also affects access to pain relief for NICU infants. With the advent of costly medical technologies to improve neonatal outcomes, the median cost per day is about $1,115 per day with the average length of a NICU stay being 49 days, adding up to a median total of $49,457 (Rogowski, 1999). Literature searches in the last five years revealed no figures about the cost of neonatal pain therapy. NICU infants, regardless of condition, race, gender, and socio-economic background are at a high risk of not receiving access to adequate pain therapies.
Policy makers and medical associations have also been slow to create and adopt standards supporting neonatal pain management (Stevens, 2000). Further, hospitals are often slow to adopt evidence-based research and use the data to develop protocols. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) passed new pain assessment standards for health care institutions on January 1, 2001, addressing adult and pediatric clients (available at: http://www.jcaho.org/standards_frm.html); however, neonatal pain assessment was virtually ignored. Thus, many hospitals lack neonatal pain management protocols or a regulatory body to reinforce NICU pain management implementation.
Key Players in Neonatal Pain Management
For a neonatal pain management policy to be created, such a policy must take into consideration all of the stakeholders. Health care providers are expected to "do no harm" according to the Hippocratic Oath. Parents aim to protect their children. Insurers and hospital administrators seek to provide quality, cost-effective access to health care. Pharmaceutical companies seek to increase their product market share by expanding the application of therapy to various patient populations. Policy makers aim to create solutions to address the unmet needs of vulnerable populations. Most importantly, patients have a right to have their pain treated. There is a collaborative need and opportunity for the key players to provide cost-effective access to adequate pain relief to the NICU population.
A Proposal for Solving the NICU Pain Management Problem
One proposed solution to the NICU infant pain control problem is a synthesis of suggestions that integrates Carlson's nationwide mandated NICU health care provider education, led by neonatal nurse practitioner staff, with Franck's development and implementation of health care institution neonatal pain assessment and management protocols, and conflict resolution resources (Carlson, 1996, p.68, Franck, 1997, p.85). This author recommends that all of these components should subsequently be evaluated by JCAHO. "Much of the work required to improve the management of pain in infants must occur at the organizational level" (Franck, 1997, p.84). One study supported the strength of a regional medical center's NICU's pain assessment, management and evaluation protocols and policies by demonstrating a "decreased length of time of extubation, decreased length of stay, better fluid management, and reduced side effects of narcotics" (Furdon, 1998, p.58). Health care institution protocols provide a standard that would include "a minimum standard frequency of pain assessment, standardized method of documentation, [and] guidelines for starting and escalating therapy" (Franck, 1997, p.85). Additional benefits included "improved pain management documentation, decreased cost, and decreased nursing time" (Furdon, 1998, p.58).
The proposed program reaches individuals who influence hospital policy, such as hospital administrators and executives. Conflict resolution methodologies would involve ethicists, parents and NICU health care providers to help facilitate open, multidisciplinary discussion of cases for which usual methods do not resolve a patient's pain (Franck, 1997). JCAHO can specifically create neonatal pain assessment and treatment standards to monitor and reinforce health care institutions' policies and protocols. The integration of health care provider education, institutional protocols, policies, and conflict resolution resources, with JCAHO reinforcing and regulating neonatal pain assessment, diagnosis and treatment, creates a system that can effectively provide adequate neonatal pain management.
As "clinicians, educators, researchers, advocates, managers and consultants" -- roles that are necessary for "greater understanding of the neonatal pain phenomenon" -- neonatal nurse practitioners are well suited to educate other health care team members (Carlson, 1996, p.65). The combination of skills required within these roles uniquely positions neonatal nurse practitioners to assess, diagnose, treat and emotionally support neonatal patients and their families. Through health care provider education, parents would be empowered to serve as advocates for their infants. Health care providers would be better equipped to handle the demands of families and patients by being educated about the latest in neonatal pain therapies, fulfilling their professional commitment to reduce suffering, and patients would have their pain treated.
Evaluating the Proposal: Strengths and Limitations
The greatest strength of the proposed solution is that it presents advantages to all the key players involved in neonatal pain management, including patients, families, health care providers, insurers, pharmaceutical companies, regulatory bodies and ethicists. First, health care providers would be able to better discern how, when and what treatment method should be used. Pharmaceutical companies could collaborate with health care providers to fund medical education programs, which will ultimately drive product usage and increase market share. To maintain their JCAHO accreditation status, hospital administrators would monitor the implementation of neonatal pain management protocols and policies to meet JCAHO standards cost-effectively and to attract patients to the hospital. Families would benefit by knowing that a JCAHO-accredited hospital is caring for their infant, has passed certain pain management standards, and could use accreditation as a factor in selecting a health care facility for treatment. Insurers would benefit by having established protocols serve as pain management reimbursement guidelines. Patients would have a system of protocols, policies and conflict resolution resources, providing many opportunities to obtain pain relief. Involving ethicists in conflict resolution would provide a different perspective to address problems. Most importantly, this program would provide the necessary long-lasting systematic framework to cost-effectively reinforce access to adequate neonatal pain relief.
Used in isolation, educational campaigns, protocols and policies do not provide the necessary framework to provide adequate pain relief for NICU patients. Education alone does not always result in a lasting change in behavior, particularly for health care providers who have an ingrained way of performing procedures (Franck, 1997). To ensure implementation, protocols and policies need to be reinforced and monitored through a designated regulatory body. Moreover, patients with a complicated clinical profile, requiring care that is not met by the health care institution's policies and protocols, need conflict resolution resources.
However, there are limitations to the proposed policy program. First, such a program may take years to create and implement because it would need to pass through a bureaucratic approval process involving hospitals, health care providers, medical organizations, JCAHO, pharmaceutical companies and insurers. Thus, many patients may miss the benefits of such a program. Large costs may be associated with creating educational materials and developing protocols.
Yet, the program's long-term viability incrementally lessens the sunk cost in the establishment of the program. Thus, the lasting effect of the proposed solution significantly outweighs and justifies the time and costs it will take to implement. The program creates an educational platform to empower, standards to guide and evaluate care, as well as a reinforcement body to ensure legitimacy. By providing advantages to all the major players, the proposed program motivates all of the stakeholders to help achieve the delivery of cost-effective access to adequate neonatal pain relief, resulting in a long-term solution.
Untreated pain leads to suffering and further complications, which ultimately results in longer hospital stays as well as greater costs to society at large. While assessing and diagnosing pain in neonatal patients is challenging, it is a problem that can be resolved through the proposed systematic framework of protocols, conflict resolution resources and enforcement that involves and benefits all the key players. The system is sustained by protocols that help define and guide the roles of all the key players, conflict resolution offers an outlet to deal with ambiguity, and enforcement through JCAHO lends legitimacy, providing a collaborative win-win situation for all players that will encourage them to perpetuate the continuation of the system. Despite the long road it will take to create and implement such a program, the promise of cost-effective access to adequate neonatal pain management will outweigh the emotional and financial costs that we currently and will continue to pay without having one in place.
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This paper was prepared as a paper on April 24, 2001 for Professor Kristine M. Gebbie's, DrPh, RN Health and Social Policy class at Columbia University School of Nursing. Dr. Gebbie's comments were helpful in developing the edited version of this manuscript.
Final note: This paper was presented to Dr. Gebbie under my maiden name Jennifer E. Altmann on April 24, 2001. My name was legally changed to Jennifer E. Moyer on June 29, 2001. Further, this paper was significantly edited to conform to the journal's publishing guidelines.
Jennifer E. Moyer RN, BSN is a 2001 graduate of the Columbia University School of Nursing Entry-to-Practice program. Mrs. Moyer is currently a freelance writer. Prior to her nursing career, Mrs. Moyer was director/senior account supervisor of a health care public relations firm in Cambridge, Massachusetts.
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