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

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.