BLOOD DRAW TOOLKIT - Surrey Place · Blood Draw Tool Kit Initiative, Surrey Place for its support...

BLOOD DRAW TOOLKITA resource for individuals with Developmental Disabilities

FEBRUARY • 2019

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Introduction and AcknowledgementsThis initiative has brought together the clinical services of Behaviour Therapists,

Nurse Practitioners as well as other health care professionals who support and

service people with developmental disabilities and Autism Spectrum Disorders

(ASD) in a variety of clinical settings. Their names, areas of expertise, and place of

practice are listed below:

Jessica FoxM.ADS, Senior Behaviour Therapist – Children & Youth Program, Surrey Place, Toronto ON

Kimberley TaylorM.ADS, BCBA, Senior Behaviour Therapist – Adults Program, Surrey Place, Toronto ON

Leeping TaoRN (EC), MN, Nurse Practitioner - Adults Program, Surrey Place, Toronto ON

Editorial Staff / Copy Editor(s) Jessica FoxM.ADS, Senior Behaviour Therapist – Children & Youth Program, Surrey Place, Toronto ON



Review Committee Jessica FoxM.ADS, Senior Behaviour Therapist – Children & Youth Program, Surrey Place, Toronto ON



Contributors to the Blood Daw Tool Kit Initiative Cynthia CabreraSupervisor, Collaborative And Individualized Resources, Transitional Support Services (Adult), Griffin Centre, Toronto ON

Vaso CharitsisCommunications and Marketing Advisor – Communications Department, Surrey Place, Toronto ON

Michael DemiGraphic Design, Surrey Place, Toronto ON

Leonard EdwardsClinical Facilitator, Collaborative And Individualized Resource, Centre for Addiction and Mental Health (CAMH), Toronto ON

Katherine CooperMedical Media St. Michael’s Hospital, Toronto ON

Steven FinlayChief Executive Officer, Surrey Place, Toronto ON

Terri HewittVice President Community Program, Surrey Place, Toronto ON

Malgorzata KisielManager – Diagnostic Laboratories, St. Michael’s Hospital, Toronto ON

Shirley McMillanRN, MN, Clinical Nurse Specialist, Surrey Place - Adults Program, Toronto ON

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Suzanne MeagherDirector – Children & Youth Program, Surrey Place, Toronto ON

Antonie MentoneSt. Michael’s Hospital, Toronto ON

Maria D’SouzaSt. Michael’s Hospital, Toronto ON

Louise NgDirector – Adult’s Program, Surrey Place, Toronto ON

Katherine RidolfoCoordinator of Family Support, Community Living Toronto, Toronto ON

Elizabeth ScottExecutive Vice President Clinical Programs, Surrey Place, Toronto ON

Dr. William SullivanMD, PhD, Medical Services, Surrey Place, Toronto ON

June WatkinsLaboratory Administration – Diagnostic Laboratories, St. Michael’s Hospital, Toronto ON

AcknowledgementsWe would like to acknowledge the sponsors of the

Blood Draw Tool Kit Initiative, Surrey Place for its

support of this initiative since 2013.

A special thank you to those listed in the prior pages

who have contributed to the development, design

and review of this tool kit. Thank you also to parents

of clients living with developmental disabilities and/

or autism spectrum disorders, and caregivers who

have contributed generously in various ways to the

review of this project.

On behalf of all those who have contributed to

this project, we hope that this tool kit will help, in

some way, to improve the health and well-being of

individuals living with developmental disabilities

and/or autism spectrum disorders.

Sincerely,

Jessica Fox & Kimberley Taylor

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About the Blood Draw Tool Kit InitiativeThis tool kit was created with the intent to support in the successful completion of

a blood draw (also known as venipuncture) procedure for an individual who has a

fear of such procedures. Many individuals exhibit different behaviours (e.g. crying,

screaming, refusal, hitting, kicking, etc.) when they are told of upcoming blood

work and/or are exposed to certain related environments and items (i.e. nurse/

phlebotomist, needle, waiting room).

This type of fear, called blood-injury phobia, is very common in the general

population (10%) (Raghvendra et al., 2010). This prevalence is likely underestimated

due to the lack of reporting of such fears and/or individuals failing to seek

appropriate medical care. Further, it is estimated that the prevalence is much higher

among individuals with a developmental disability due to additional deficits.

In general, individuals often become fearful of not only the sight of the needle or

injection, but also from being exposed to physical restraint of themselves or others

(Raghvendra et al., 2010). Some of the symptoms of blood-injury phobia include

increased heart rate combined with changes in blood pressure, fainting, aggression/

physical resistance, avoidance of the environment, and flight/escape from the

current situation (Raghvendra et al., 2010). These symptoms are more likely to

occur when physical restraint is used.

In addition to physical restraint, chemical restraints, such as anxiety-reducing

medication or general anaesthesia, are often used as immediate first-line

interventions (Raghvendra et al., 2010). Restraint of either type, however, does not

reduce the existing phobia on a long-term basis as it only masks the fear and can

actually result in increased fear over time. Ultimately, the persistence of needle

phobia over time can result in the individual avoiding any or all necessary medical

treatment, leading to poor health outcomes. Behavioural interventions including

systematic desensitization focus on teaching the individual to tolerate blood draw

procedures by removing the fear response and ensuring consistent success of

such procedures while remaining calm. Behavioural interventions can offer a more

proactive approach as opposed to the reactive approach often used in medical

settings.

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Systematic Desensitization ProcedureThe following procedure is intended as a guideline for

desensitizing an individual to blood draw procedures.

Depending on the level of functioning, the extent of the fear

itself, as well as the frequency and consistency of practice,

this procedure may vary in terms of length of time in order

for successful results to be obtained. Please ensure to read

the entire procedure and ensure all necessary materials are

prepared before beginning. This procedure may be carried out

by any type of caregiver, such as a parent, sibling, guardian,

support/respite staff, friend, or involved medical professional.

Phase 1: Exposure and Teaching A video, as well as a social story will be used to expose the individual to the steps

that he/she would go through in the blood draw process. The individual will be

taught muscle tension and relaxation strategies while in a calm state so that he/

she will be able to reliably use these strategies to prepare prior to engaging in

the training procedure, as well as to encourage him/her to remain calm during

subsequent steps of the procedure.

Step # Objective/Expectation Start Date Acquired Date

1 Comply appropriately to sit down in the home environment to review the relaxation strategies

2 Comply appropriately with reviewing relaxation strategies

3 Comply appropriately with reviewing the social story related to venipuncture

4 Comply appropriately with reviewing the video related to venipuncture

5 Comply appropriately with travelling with assistance to the clinic site

*Use first/then board with visuals at this point*

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Phase 2: Blood draw (venipuncture) process This phase should be carried out within a new/different medical setting to which

the individual has never been exposed. During this phase, the individual will

progressively move through various steps of exposure to both the feared object

(i.e. needle) and the blood draw procedure. Movement from one step to the next

will be based upon the individual’s ability to remain calm according to criteria using

an arousal rating scale (see below) for a specified duration of time and number of

sessions.

NOTE: All steps from Phase 1 must be repeated each session before beginning the steps below.

Step # Objective/ Expectation Start Date Acquired Date

1 Enter waiting room

2 Register

3 Sit down on chair

4 Wait to be called

5 Stand up from chair

6 Walk towards treatment area/room

7 Sit down in “chair”

8 Wait for nurse to prepare materials

9 Places arm on arm-rest & nurse may check vein

10 Elastic band placed onto arm

11 Nurse checks personal information

12 Nurse cleans skin with alcohol

13 Nurse picks up needle

14 Needle point touches surface of skin

15 Needle punctures skin

16 Waits for blood to be collected into testing tube(s)

17 Needle is removed from arm

18 Cotton ball and bandage/tape are applied

19 elastic is released

20 Pressure is applied to the site

21 Individual waits until nurse says its ok to leave

22 Individual exits room/area

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Phase 3: Generalization Once the individual is able to remain calm during the entire blood draw procedure

and meet criteria with the support of additional staff (if applicable), the steps that

follow will encourage generalization and maintenance of these skills across other

people, places, and time. This will ensure that in the future if any changes occur

such as a different environment, who goes with the individual to the appointment,

or there is an emergency, that the individual will continue to be able to successfully

complete the steps of the blood draw procedure which has already been learned.

NOTE: Repeat steps from Phase 1 each session before beginning the steps below.

Target # Objective/Expectation Start Date Acquired date

1 *if applicable*

Fade out support staff and fade in primary caregiver (within current setting) carrying out steps 1-22

2 *if applicable*

Fade out primary caregiver as support to increase independence (within current setting) carrying out steps 1-22

3 Complete steps 1-22 within a known blood lab (eg. Family physician’s office or other)

4 Complete steps 1-22 generalizing within a novel setting such as a local hospital

MAINTENANCE *COMPLETE THESE STEPS IF BLOOD WORK IS NOT COMPLETED REGULARLY*

5 Following 1 month, complete steps 1-22 within any learned or novel setting

6 Following 3 months, complete steps 1-22 within any learned or novel setting

7 Following 6 months, complete steps 1-22 within any learned or novel setting

8 Following 1 year, complete steps 1-22 within any learned or novel setting

Materials• Square breathing visual

• Progressive Muscle Relaxation

(PMR) visual

• Squeeze ball, or other preferred

fidget toys

• Arousal rating scale

• Social story (My Blood Test)

• Arm diagram

• Video

• Data sheets

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Preference AssessmentIn order to determine items or activities that will motivate

the individual to proceed through the steps of this procedure,

it is necessary to complete a preference assessment prior

to starting with Phase 1 of the above procedure. Follow the

steps below:

Step 1:1. Fill out the Reinforcer Assessment for individuals with Severe Disabilities

(RAISD) (see attached). Ensure that the person completing the assessment

knows the individual well.

2. Using the items/activities from the hierarchy generated, gather relevant items

and activities for Step 2.

Step 2:a. Using the items/activities from the hierarchy, present a group of 2-3 items to the

individual at one time in order to determine highest level of preference. Record

the most preferred choice from this group.

» Pick a time of day when the individual is calm and likely to be motivated to

engage with the items/activities. This should be completed in advance and not

just prior to starting a training session.

» Start with items that the individual has been known to have a strong

preference towards in the past and that are easily portable.

b. Continue to present groups of 2-3 items/activities until all items from the

hierarchy list have been presented. Record the most preferred choices from each

subsequent group. Keep this list of highly preferred items for later.

Step 3:a. When starting a training session, tell the individual what they are about to do (i.e.

according to current step in desensitization procedure). Use visuals such as first/

then board with pictures, provided in attachments.

b. Present the top 2 highly preferred items from this second list generated above

and ask the individual to choose (verbally or physically) what they would like to

earn after completing relevant steps of the procedure.

c. Ensure that item/activity chosen, as well as visuals, are available to be presented

to the individual upon completing relevant steps of the procedure (see delivery of

reinforcement below).

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d. In addition to the highly preferred chosen item, ensure to bring one other

less preferred item from the original hierarchy, as a back-up (see Delivery of

Reinforcement --differential reinforcement below).

* Do not proceed with training session if no preferred items are determined *

Indicators of high preferenceIndividuals show preference in various ways, depending on their level of

functioning. The following information outlines how to identify that an individual

finds something to be highly preferred, beyond verbal communication.

APPROACH: Reaching, walking toward, gazing toward item/activity.

ENGAGEMENT: For activities, amount of time played with or talked about.

CONSUMPTION: For food/drink, if they consume the item or not.

Delivery of ReinforcementIn order to effectively and efficiently reinforce (i.e. reward) the completion of steps

of the training procedure, it is important that the chosen highly preferred item is

presented in a very specific way:

IMMEDIACY: Give the individual access to the preferred item/activity as soon as

the current steps of the training procedure are completed (ideally within only a

few seconds).

CLARITY (DISTINCTIVE): Ensure that what is said or what is given as a reward/

reinforcer for successful completion of the training procedure is clearly

different than other things said or given to the individual typically. To increase

the clarity of reinforcement, always combine the delivery of the reward with

descriptive social praise (e.g. give the toy while saying “Great job! You had your

blood test!”).

VARIATION: Ensure to use many different types of reinforcers/rewards from

session to session in order to keep the individual motivated and reduce the

likelihood that they will get bored with the item or that the value of that item

will fade, making it ineffective at reinforcing the expected behaviour(s).

CONSISTENCY: Ensure to reinforce/reward the successful completion of the

training procedure every session in order to maximize learning potential.

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DIFFERENTIAL REINFORCEMENT: It is important that the individual receives

the highest quality and amount of reinforcement for successfully completing

the training procedure and a lesser quality and amount of reinforcement for

unsuccessful attempts. Give the individual the highest preferred item/activity

from your preference assessment above if they are able to complete the current

step of the training procedure successfully. Give the individual one of the less

preferred items instead, if they do not successfully complete the current step of

the training procedure.

Arousal Rating ScaleThe following is a sample of an arousal rating scale that may

be applicable to the individual. This is a Likert-type rating

scale that is intended to be used for assessing and scoring

level of arousal throughout each phase of the training

procedure, as well as for data collection purposes. Based on

the ratings recorded and a pre-determined criteria (below),

the individual will move on to subsequent steps of the

program.

State Description Score

CalmClient will engage in minimal movement with neutral or happy expression. ➊

SadClient will engage in whining and/ or crying which may be combined with tears. ➋

TenseClient will engage in rocking, shaking and/or clenching of his body, which may or may not occur in combination with crying/whining.

➌

Agitated/ProtestingClient will engage in fast, jerky movements with significant displacement from his calm position. ➍

Acting out aggressivelyClient attempts to or successfully engages in aggressive acts such as hitting, kicking, pinching, biting, scratching or grabbing (alone or in combination).

➎

If changes are necessary to the above sample scale this can be done with the

attached blank copy that can be filled out according to how a particular individual

escalates.

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Data CollectionBefore starting a new phase it will be appropriate to

determine if the individual can already complete any of the

steps. This can be done by proceeding through the steps of

the training procedure with the individual and determining

if they complete each step of that phase according to the

criteria below. Once criteria cannot be met for a particular

step (i.e. the individual escalates, refuses or does not have the

skills to move forward), this will be the step where the training

procedure begins. This will ensure that the training procedure

will not frustrate the individual and will work from his/her

current level of success.

A data sheet has been provided for each phase (see attachments). Proceeding

from one step to the next will be based upon the requirement that criteria outlined

below are fulfilled. A maximum of up to three trials (i.e. attempts) can be carried out

within one daily session following the outlined criteria, allowing the individual ample

opportunity to practice the skill.

CriteriaArousal rating scale:

Using the arousal rating scale tailored to the individual, follow the steps of the

training procedure according to each phase outlined above. The individual will

be expected to remain at an arousal level no higher than a rating of 2 before the

individual can move on to the next step of that phase.

If the individual later completes a step that has already been learned and he/she

reaches any arousal rating higher than 2 then the training procedure must be

stopped and the individual must be brought back to the previous successful step

on the next attempt to ensure the individual’s safety, and so as not to increase

agitation.

Arm diagram: From Phase 2 onward, the individual will be expected to keep his/her arm within the

allowable limits of the arm diagram (see attached). This will include that his/her arm

can move from the original position (white area) to the outer limits of the adjoining

area (yellow area). Once the individual’s hand and/or arm moves into the red area,

this will indicate that the attempt should end.

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ReferencesFisher, W. W., Piazza, C. C., Bowman, L. C., & Amari, A. (1996). The Reinforcer

Assessment for individuals with Severe Disabilities (RAISD). Integrating

caregiver report with a systematic. Choice assessment to enhance

reinforcer identification. American Journal on Mental Retardation, 101, 15-25.

Raghvendra, S., et al. (2010). Trypanophobia – An Extreme and Irrational Fear of

Medical Procedures: An Overview. International Journal of Pharmaceutical

Sciences Review and Research, 4 (1), 18-21.

Doan, B.D. (1994). Relaxation Training and Anxiety Management for Children with

PDD and Their Parents. Workshop Developed for Geneva Centre for Autism,

Toronto.

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Decision Tree

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Arm Diagram

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Retrieved from: http://visuals.autism.net/main.php?g2_itemId=138

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Progressive Muscle Relaxation visual, retrieved from: http://visuals.autism.net/main.php?g2_itemId=92 Doan, B.D. (1994). Relaxation Training and Anxiety Management for Children with PDD and Their Parents. Workshop Developed for Geneva Centre for Autism, Toronto.

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AttachmentArousal Rating

State Description Score

➊

➋

➌

➍

➎

Data Sheet - Phase 1Step # Objective/Expectation Start Date Acquired Date

1 comply appropriately to sit down in the home environment to review the relaxation strategies

2 comply appropriately with reviewing relaxation strategies

3 comply appropriately with reviewing the social story related to venipuncture

4 comply appropriately with reviewing the video related to venipuncture

5 comply appropriately with travelling with assistance to the clinic site

*Use first/then board with visuals at this point*

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Data Sheet - Phase 2Date: Staff:

Step # Objective / Expectation

Arousal Rating

Movement Outside Arm

Diagram

1 Enter waiting room 1 2 3 4 5

2 Register 1 2 3 4 5

3 Sit down on chair 1 2 3 4 5

4 Wait to be called 1 2 3 4 5

5 Stand up from chair 1 2 3 4 5

6 Walk towards treatment area/room 1 2 3 4 5

7 Sit down in “chair” 1 2 3 4 5 Y / N

8 Wait for nurse to prepare materials 1 2 3 4 5 Y / N

9 Places arm on arm-rest & nurse may check vein 1 2 3 4 5 Y / N

10 Elastic band placed onto arm 1 2 3 4 5 Y / N

11 Nurse checks personal information 1 2 3 4 5 Y / N

12 Nurse cleans skin with alcohol 1 2 3 4 5 Y / N

13 Nurse picks up needle 1 2 3 4 5 Y / N

14 Needle point touches surface of skin 1 2 3 4 5 Y / N

15 Needle punctures skin 1 2 3 4 5 Y / N

16 Waits for blood to be collected into testing tube(s) 1 2 3 4 5 Y / N

17 Needle is removed from arm 1 2 3 4 5 Y / N

18 Cotton ball and bandage/tape are applied 1 2 3 4 5 Y / N

19 elastic is released 1 2 3 4 5 Y / N

20 Pressure is applied to the site 1 2 3 4 5 Y / N

21 Individual waits until nurse says its ok to leave 1 2 3 4 5 Y / N

22 Individual exits room/area 1 2 3 4 5 Y / N

NOTES:

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Data Sheet - Phase 3Target#: Date: Staff:

Step # Objective / Expectation

Arousal rating

Movement outside arm

diagram

1 Enter waiting room 1 2 3 4 5

2 Register 1 2 3 4 5

3 Sit down on chair 1 2 3 4 5

4 Wait to be called 1 2 3 4 5

5 Stand up from chair 1 2 3 4 5

6 Walk towards treatment area/room 1 2 3 4 5

7 Sit down in “chair” 1 2 3 4 5 Y / N

8 Wait for nurse to prepare materials 1 2 3 4 5 Y / N

9 Places arm on arm-rest & nurse may check vein 1 2 3 4 5 Y / N

10 Elastic band placed onto arm 1 2 3 4 5 Y / N

11 Nurse checks personal information 1 2 3 4 5 Y / N

12 Nurse cleans skin with alcohol 1 2 3 4 5 Y / N

13 Nurse picks up needle 1 2 3 4 5 Y / N

14 Needle point touches surface of skin 1 2 3 4 5 Y / N

15 Needle punctures skin 1 2 3 4 5 Y / N

16 Waits for blood to be collected into testing tube(s) 1 2 3 4 5 Y / N

17 Needle is removed from arm 1 2 3 4 5 Y / N

18 Cotton ball and bandage/tape are applied 1 2 3 4 5 Y / N

19 elastic is released 1 2 3 4 5 Y / N

20 Pressure is applied to the site 1 2 3 4 5 Y / N

21 Individual waits until nurse says its ok to leave 1 2 3 4 5 Y / N

22 Individual exits room/area 1 2 3 4 5 Y / N

NOTES:

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Reinforcement Assessment for Individuals with Severe Disabilities (RAISD)

Student’s Name:

Date:

Recorder:

The purpose of this structured interview is to get as much

specific information as possible from the informants (e.g.,

teacher, parent, caregiver) as to what they believe would be

useful reinforcers for the student. Therefore, this survey asks

about categories of stimuli (e.g., visual, auditory, etc.). After

the informant has generated a list of preferred stimuli, ask

additional probe questions to get more specific information on

the student’s preferences and the stimulus conditions under

which the object or activity is most preferred (e.g., What

specific TV shows are his favorite? What does she do when she

plays with a mirror? Does she prefer to do this alone or with

another person?)

We would like to get some information on ’s preferences

for different items and activities.

1. Some children really enjoy looking at things such as a mirror, bright lights, shiny objects, spinning objects, TV, etc. What are the things you think most likes to watch?

Response(s) to probe questions:

2. Some children really enjoy different sounds such as listening to music, car sounds, whistles, beeps, sirens, clapping, people singing, etc. What are the things you think

most likes to listen to?


3. Some children really enjoy different smells such as perfume, flowers, coffee, pine trees, etc. What are the things you think most likes to smell?

Response(s) to probe questions:Fisher, W. W., Piazza, C. C., Bowman, L. G., & Amari, A. (1996). Integrating caregiver report with a systematic choice assessment. American Journal on Mental Retardation, 101, 15–25.

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4. Some children really enjoy certain food or snacks such as ice cream, pizza, juice, graham crackers, McDonald’s hamburgers, etc. What are the things you think

most likes to eat?


5. Some children really enjoy physical play or movement such as being tickled, wrestling, running, dancing, swinging, being pulled on a scooter board, etc. What activities like this do you think most enjoys?


6. Some children really enjoy touching things of different temperatures, cold things like snow or an ice pack, or warm things like a hand warmer or a cup containing hot tea or coffee. What activities like this do you think most enjoys?


7. Some children really enjoy feeling different sensations such as splashing water in a sink, a vibrator against the skin, or the feel of air blown on the face from a fan. What activities like this do you think most enjoys?


8. Some children really enjoy it when others give them attention such as a hug, a pat on the back, clapping, saying “Good job”, etc. What forms of attention do you think

most enjoys?


9. Some children really enjoy certain toys or objects such as puzzles, toy cars, balloons, comic books, flashlight, bubbles, etc. What are ’s favorite toys or objects?


10. What are some other items or activities that really enjoys?


Fisher, W. W., Piazza, C. C., Bowman, L. G., & Amari, A. (1996). Integrating caregiver report with a systematic choice assessment. American Journal on Mental Retardation, 101, 15–25.

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After completion of the survey, select all the stimuli which could be presented or

withdrawn contingent on target behaviors during a session or classroom activity

(e.g., a toy could be presented or withdrawn, a walk in the park could not). Write

down all of the specific information about each selected stimulus on a 3” x 5” index

card (e.g., likes a female adult to read him the ‘Three Little Pigs’ story.) Then have

the informant(s) select the 16 stimuli and rank order them using the cards. Finally,

list the ranked stimuli below.

1. 9.

2. 10.

3. 11.

4. 12.

5. 13.

6. 14.

7. 15.

8. 16.

Notes:

Fisher, W. W., Piazza, C. C., Bowman, L. G., & Amari, A. (1996). Integrating caregiver report with a systematic choice assessment. American Journal on Mental Retardation, 101, 15–25.

Surrey Place2 Surrey Place

Toronto M5S 2C2

(416)925-5141

www.surreyplace.ca

Surrey Place© August 2018

All rights reserved. No part of this publication may be reproduced,

distributed, or transmitted in any form or by any means, including

photocopying, recording, or other electronic or mechanical methods,

without the prior permission of Surrey Place. For permission

requests, contact Surrey Place Communications and Marketing

Advisor at the address below or by phone.

BLOOD DRAW TOOLKIT - Surrey Place · Blood Draw Tool Kit Initiative, Surrey Place for its support...

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