The Implementation of Infant Pain Practice Change (ImPaC) Resource consists of multifaceted evidence-based (EB) implementation strategies that address the persistent knowledge-to-practice gap in procedural pain prevention and treatment in hospitalized infants. The Resource incorporates implementation science (IS) and quality improvement (QI) to support change in pain practices of healthcare providers (HCP) in the Neonatal Intensive Care Unit (NICU). Our goal was to evaluate the Resource clinical effectiveness regarding (a) the frequency of painful procedures, (b) the use of validated pain assessment tools and (c) pain treatment interventions associated with painful procedures.

 

We undertook an IS hybrid type 1 design including a cluster randomized trial. Canadian NICUs with >15 beds were eligible to participate. NICUs were stratified by care level (Levels 2 and 3) and randomized to ImPaC intervention (INT) or standard practice (SP) groups. INT NICUs received ImPaC training and had online access for six months; SP NICUs continued with usual pain practices for six months. An intention-to-treat analysis determined the clinical effectiveness of the ImPaC Resource. The study protocol received ethics approval at participating sites and was registered at ClinicalTrials.gov (NCT03825822).

23 Level 2 and 3 NICUs participated; 12 randomized to INT and 11 to SP. Medical records of ~30 infants/site (n=679; INT= 354, SP=325) were reviewed during a 24-hour interval following the 6-months implementation period. Infants differed on gestational age (GA); those in the INT group were less mature [31.6 (±4.5) vs. 33.5 (±6.1) weeks GA, p<0.001] thus all analyses were adjusted for GA. The average number of painful procedures/infant/24h was less in the INT group [2.62 (±3.47) vs. 3.85 (±4.13), p<0.001]. The proportion of procedures associated with pain assessment was greater in the INT group (34.7% vs. 25.5%, p<0.001). Overall, there was no significant difference in the proportion of procedures associated with a pain treatment intervention (INT=27.2% vs. SP=24.0%, p=0.053). However, in the Level 2 NICU INT group there was a significantly greater proportion of procedures with pain treatment interventions (INT=39.7% vs. SP=23.1%), average number of pain treatment interventions/procedure [INT=0.60 (±0.83) vs. SP=0.36 (±0.77)], use of any non-pharmacologic treatment interventions/procedure (INT=39.4% vs. SP=23.1%), and average number of non-pharmacologic treatments/procedure [INT=0.60 (±0.82) vs. SP=0.34 (±0.70)] compared to SP group (p<0.001 for all). In Level 3 NICUs, the proportion of procedures with pain treatment interventions was higher in the SP group (24.4% vs. 19.2%, p=0.015) group. 

Implementation of the ImPaC Resource was associated with fewer painful procedures and greater pain assessment. Pain treatment interventions were higher in Level 2 but not in Level 3 NICUs. Further exploration of factors that facilitate or hinder the implementation of the Resource will inform researchers and clinicians how to decrease procedural pain and improve child health outcomes.

 

1.     Bueno M, Stevens B, Rao M, Riahi S, Lanese A, Li SA; CIHR ImPaC Resource Team. Usability, acceptability, and feasibility of the Implementation of Infant Pain Practice Change (ImPaC) Resource. Paediatr Neonatal Pain. 2020 May 30;2(3):82-92. doi: 10.1002/pne2.12027.

2.     Bueno M, Stevens B, Barwick MA, Riahi S, Li SA, Lanese A, Willan AR, Synnes A, Estabrooks CA, Chambers CT, Harrison D, Yamada J, Stinson J, Campbell-Yeo M, Noel M, Gibbins S, LeMay S, Isaranuwatchai W. A cluster randomized clinical trial to evaluate the effectiveness of the Implementation of Infant Pain Practice Change (ImPaC) Resource to improve pain practices in hospitalized infants: a study protocol. Trials. 2020 Jan 6;21(1):16. doi: 10.1186/s13063-019-3782-9. 

An abundance of evidence on safe and effective interventions to prevent and treat procedural pain in infants does not guarantee use in practice. Combining EB interventions into an online resource provides clinicians with accessible and effective implementation strategies to improve pain practices in hospitalized infants.