Reduction of Analgesia Duration after Tracheostomy during Neonatal Intensive Care: A Quality Initiative

INTRODUCTION: As survival has improved in the Neonatal Intensive Care Unit (NICU), there has been a 10-fold increase in the proportion of infants requiring a tracheostomy. At our institution, we observed a wide variation in the duration of opioid use posttracheostomy from 6 to 148 days. We aimed to decrease the duration of opioid exposure in postoperative tracheostomy patients in the NICU from a baseline average of 24 days to 7 days by December 31, 2017. METHODS: We established a multidisciplinary team to develop change ideas to implement in 3 Plan-Do-Study-Act cycles that focused on enhanced care plan standardization and communication in patient care rounds with subsequent documentation in the medical record and the timely addition of dexmedetomidine to the postoperative care plan. RESULTS: Baseline population was from October 2014 to December 2016. The mean posttracheostomy opioid duration was 24.6 days (range, 6–148 days); neuromuscular blockade was 2.89 days (range, 0–9 days), and benzodiazepine exposure was 20.9 days (range, 1–114 days). Following our interventions, the mean duration of posttracheostomy opioid duration was 5.4 days (range, 4–21 days); neuromuscular blockade was 3.14 days (range, 1–5 days), benzodiazepine duration was 8.88 days (range, 4–25 days), and dexmedetomidine was 4.6 days (range, 0–32 days). CONCLUSIONS: We utilized quality improvement methodology to standardize posttracheostomy management and demonstrate that we could significantly reduce the duration of opioid and benzodiazepine use after tracheostomy with the timely addition of dexmedetomidine, a structured written daily care plan, and clarification of roles and responsibilities.