in 150 - 200 words summarize and rephrase this article, and write one sentence the most takeaway and one-sentence criticism from this article (Improving pain management in a neonatal intensive care unit with single-family roomA quality improvement project) Preterm birth is a risk factor for early experience of pain. Despite advances in neonatal care, evidence-based knowledge of the importance of adequate pain management and strong international guidelines for assessment and treatment of neonatal pain, only 10% of sick term and preterm infants were assessed for pain and stress on a daily basis. The aim of this quality improvement (QI) project is evaluation of implemented guidelines for pain assessment and management, and increased parental involvement in a Norwegian single-family room NICU. Method: The different steps of the project entailed translation of the English version of COMFORTneo, development and implementation of guidelines with flowcharts for pain management, and pain assessment certification of the interprofessional staff. Part two of the project is supervision of the interprofessional staff in parental involvement in stress- and painful procedures. Our study showed that one year after implementation, 88.8% of the COMFORTneo assessments were performed according to the pain management guidelines. The staff used the flowcharts to assess, treat and reassess pain and stress. There was a high interrater reliability with linearly weighted Cohen's kappa values ranging from 0.81 to 0.95, with a median of 0.90. In addition, our study showed increased parental involvement in procedures, from 50.3% before to 82.3% after the quality improvement project. The success of this quality improvement project is explained by systematic use of flowcharts and implemented guidelines for pain management, interprofessional collaboration, and cultural change agents. Theoretical lectures and practical bedside supervision to interprofessional staff increased parental involvement in stress- and painful procedures. 3 RESULTS Study 1. Staff interrater reliability. Three nurse assistants, 60 registered nurses, 20 clinical nurse specialists, and seven neonatologists working at the unit at the time of the QI project were certified. Linearly weighted Cohen's kappa values ranged from 0.81 to 0.95, with a median of 0.90. The members of the pain Group had a median value >0.95.

Study 2. Compliance with PMG. Patients demographic is available in Table 3. All admitted infants were systematically assessed with the COMFORTneo scale. 4 DISCUSSION The QI project results showed high compliance with guidelines and increased parental involvement in pain- and stressful procedures. The compliance with guidelines in our study remained high one year after the QI project. It is nevertheless important to keep evaluating the implementation as sustainability may decrease over the years. Aukes et al implemented a protocol for pain assessment- and management and conducted a prospective evaluation study. They reported a compliance with guidelines of 60.2% six years after implementation.23 The high compliance in our study could be due to the flowcharts with specific actions for each level of pain and stress, and protocols for non-pharmacological interventions and pharmacological treatment.

Structured pain assessment- and management strategies are shown to reduce pain,26 increase non-pharmacological interventions,27 and increase opiate prescriptions.28 Flowcharts with algorithms for pain management contributed to better communication and collaboration between nurses and doctors, which is seen as a strong predicator for successful pain management in NICUs.29 Nevertheless, a planned, systematic, and interprofessional implementation process impacted positively on the study result.

NRS was included in the flowchart to help caregiving nurses to separate pain from stress. The NRS score is based upon the nurses` expert opinion and evaluation of the infants GA, treatment, and medical history.16 The results showed that only one-third of the high COMFORTneo scores were associated with a high NRS pain, and one-half of the high COMFORTneo scores were associated with a high NRS stress. The results displayed the importance of comparing behavioral assessment with an NRS evaluation of the infants pain and stress. Patients with high COMFORTneo scores associated with low NRS pain and stress received either no intervention or non-pharmacological interventions followed by a moderate or low COMFORTneo score (Figure 1). High COMFORTneo score values associated with high NRS pain or high NRS stress interpretation received interventions according to the implemented pain management guidelines. This may indicate that the combination of COMFORTneo assessment paired with a NRS evaluation may contribute to a more targeted pain- and stress management in preterm infants.

6 CONCLUSION

All preterm and ill term infants should be systematically assessed for pain and stress, even if they are not critically ill or receiving high intensive care. Systematic pain assessment is an important step toward adequate pain management. The success of this quality improvement project is explained by the systematic use of guidelines for pain management including flowcharts, interprofessional collaboration, and cultural change agents. Parental presence in SFR NICUs, in countries with social benefits for parents after child birth, makes it possible for staff to include the parents as caregivers in stress- and painful procedures, but this depends on the interprofessional staff's knowledge and attitude, and the NICU culture. Systematic implementation with theoretical lectures and practical bedside supervision increased parental involvement in pain- and stressful procedures in our SFR NICU.