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Standardizing morphine use for ventilated preterm neonates with a nursing-driven comfort protocol

Journal of Perinatology volume 35, pages 46–51 (2015)Cite this article

Subjects

Abstract

Objective:

To test whether implementing a nursing-driven comfort protocol standardizes morphine use in one neonatal intensive care unit (NICU) and to examine how non-standard morphine (N-SM) relates to days of ventilation, days of total parenteral nutrition (TPN) and length of stay (LOS).

Study Design:

This was a retrospective/prospective observational study using pharmacy records, medical records, and an outcomes database. Comfort protocol implementation began February 2011 and was applied to preterm, ventilated neonates <1500 grams. Pre- and post-implementation proportions of N-SM days were compared using the binomial test. A percent ‘P’-chart spanning 30 quarters was constructed with statistical-process control analysis. Multivariable linear regression adjusting for acuity assessed the relationship between N-SM use and days of ventilation, TPN and LOS.

Result:

Hundred and thirty-four patients met inclusion criteria, 116 prior to and 18 after implementation. The proportion of patients given N-SM for one or more days decreased from 59 to 35% after protocol implementation (P=0.017). A 9-month period of decreased N-SM days was observed after protocol implementation. Controlling for acuity, each additional day of N-SM use was associated with 0.47 more days of ventilation (95% confidence interval (CI): 0.26–0.69, P<0.001) and 0.52 more days of TPN (95% CI: 0.35–0.68, P<0.001). Exposure to N-SM was associated with 17 additional days of hospitalization (P=0.009, 95% CI: 4.5–30).

Conclusion:

Implementing a nursing-driven comfort protocol significantly reduced N-SM use. N-SM in the NICU is negatively associated with key clinical outcomes. Testing similar protocols in other settings is warranted.

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Acknowledgements

The authors would like to acknowledge the nursing staff and leadership at the University of Washington Medical Center for their willingness to adapt their clinical practice and the faculty in the Division of Neonatology for their ongoing mentorship and flexibility with this project. Funding for this study was provided by a grant from the University of Washington, Department of Pediatrics, Division of Neonatology Neonatal Bioresearch Fund, which was used to help with statistical analytic support.

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Authors and Affiliations

  1. Division of Neonatology, St Christopher’s Hospital for Children, Philadelphia, PA, USA

    R Fleishman

  2. Department of Pediatrics, University of Washington, Seattle, WA, USA

    C Zhou, C Gleason & R Mangione-Smith

  3. Seattle Children’s Research Institute, Seattle, WA, USA

    C Zhou, C Larison, M T Myaing & R Mangione-Smith

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  1. R Fleishman
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Correspondence to R Fleishman.

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Fleishman, R., Zhou, C., Gleason, C. et al. Standardizing morphine use for ventilated preterm neonates with a nursing-driven comfort protocol. J Perinatol 35, 46–51 (2015). https://doi.org/10.1038/jp.2014.131

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