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Back to the Blood Drawing Board:

Creating and Implementing a Comfort-BasedPhlebotomy Experience

Pnina Grauman MS, CCLSFACLP Conference 2012

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What I hope will “stick” with you…

• The pain experience: patients and Child Life Specialists• Team-building skills• The Child Life “tool kit” for phlebotomy• Building blocks for your own comfort-based initiatives• Incorporating the phlebotomy experience into your

culture of family-centered care

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“Owwies” from a young age

• Initial experiences with pain can be as early as shortly after birth

• These experiences can then impact a child’s overall responses to later exposures to pain

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Pain and Tears Through the Years

• Neonates and Infants• Toddlers and Preschoolers• School-age children• Adolescents

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Easing Pain Without a Pill

• Child Life• Parent/child involvement• Positioning for comfort/therapeutic positioning• Post-procedural interventions• Bed as a safe space

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Pain Relief From the Pharmacy

• EMLATM Cream

• SyneraTM Patch

• Sweet EaseTM

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Our Mission Statement on Pain

• “The Children’s Hospital at Montefiore respects and supports every child’s right to pain assessment and optimal pain management”

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In CHAM, we believe that…

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Prior Approaches to Pediatric Pain Management

• “Making Needles Easier to Bear” pain committee• The “A.C.T.” Approach:

-Assess/Analgesics-Child Life-Teamwork

• Therapeutic positioning posters• I.V carts in treatment rooms• Noting parents’ concerns

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Setting Our First Goals

• Improve the phlebotomy experience for patients and families

• Increase the use of comfort measures• Create a culture of pain control across the

children’s hospital

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From Meetings to Methodology

• Proposal submitted to the IRB: “Parental Perception of Child’s Comfort During Blood Drawing: A Before and After Interdisciplinary Approach to Improving the Inpatient Phlebotomy Experience” (O’Connor, K., Liewher, S.K., Kelly, M., & Skae, C. (2009))

• Background• Objectives• Design

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Initial Pre-Test Findings

• Of 71 parents surveyed:-18% reported the use of numbing medicine-32% reported presence of Child Life Specialist-51% reported blood draws were performed by a phlebotomist-average Wong-Baker score: 3.4/5

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What does this all mean?

• Comfort based techniques were being underutilized for patients, which is likely related to their parents’ perceptions of significant pain

• The education about and availability of analgesics alone were not enough!

• Interdisciplinary team initiatives were necessary to create a culture of pain-free procedures

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These were our goals—how did we meet them?

• Increase the efficacy of venipunctures and decrease the frequency of unnecessary, ill-timed blood draws

• Improve the usage and floor presence of topical anesthetics

• Increase the presence of Child Life Specialists during routine blood draws

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Sitting Down and Strategizing

• Schedule: phlebotomy rounds twice a day in the floor treatment rooms for patients who received EMLA cream at least 1 hours prior to blood draw; Child Life Specialist present

• Supplies: need for adequate EMLA for all patients who were ordered for blood draws

• Initial Concerns: patient transport, patient list, timing, adequate EMLA, delaying discharge, evidence-based practice

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Start Your Engines!

• Program Initiation: October 3, 2008• Original plan involves Child Life Specialists in

phlebotomy rounds at 9:30 AM and 3:30 PM on one “pilot” unit

• All draws performed in the treatment room• All patients should have numbing cream• Child Life Specialist to provide parents and patients

with support/education (distraction, coping, positioning, Sweet Ease, etc.)

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Bumps Along the Way

Preliminary barriers faced:• Timing• Staffing logistics• Ongoing education and training of medical staff• Technical/pharmacy complications• Drops in pain committee attendance• Families mis/uninformed• Staff not optimally receptive

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Continued…

• Ethical complications• Containment of EMLA with TegadermTM was

uncomfortable for the infant/toddler population

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If at first you don’t succeed…

Adjustments and improvements:• Timing/scheduling/staffing/location changes• Ongoing nursing and resident education• Document, document, document!!• Advocacy of topical anesthetics with the pharmacy

staff• Emphasizing patient/family education

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Setting Goals After Our First Year

• Universal comfort measures• Making EMLA readily accessible• Ensuring standing orders for all admitted patients• Expanding the pilot unit to other inpatient areas• Involving doctors and nurses in the planning process• Daily documentation• Establish a computerized EMLA prompt in patient

orders

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Continued…

• Assign an educational pain module• Researching other materials to contain EMLA• Using other, quicker-acting topical anesthetics• Improved interdisciplinary communication• Hiring a pediatric phlebotomist

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And now, a brief movie…

(Thank you to Katherine O’Connor, MD and Charlotte Pharr, MA, MT-BC for your filming expertise as well as

to my adorable patients and their families!)

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So, how are we doing?

• Upon admission, each patient has standing orders for EMLA

• EMLA readily stocked in med rooms and PyxisTM machines

• Rounds with Child Life Specialists on all four inpatient units beginning at 9:30 AM

• Educational procedural pain management module assigned to all medical staff

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Continued…

• Pain-Ease trial on inpatient unit, now used regularly in outpatient radiology

• CHAM floors designated with “Comfort Zone” signage

• July 1, 2011: a CHAM-only pediatric phlebotomist is hired!

• Phlebotomist conducts daily morning rounds to remind medical staff to apply EMLA and documents each blood draw done on the day shift

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And finally…

• Coming soon: automatic computerized prompt and designation of patients ordered for blood draws

• Faster-acting anesthetics still being investigated • July 1, 2012: overnight pediatric phlebotomist hired!

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And the results are in!• Post-test findings, August 2012: significant results found in the

following areas:-Child Life presence during blood draws

(2008: 32% 2012: 63%)-Numbing medicine used prior to blood draw

(2008: 19% 2012: 43%)-parents perceived their children’s pain as adequately controlled

(2008: 3.8/5, fair-to-good 2012: 4.2/5, good-to-very good!)-Average rating on Wong-Baker FACES pain scale decreased

(2008: 3.4 2012: 2.9)• Publication of the study is in our future!

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Getting Your Own Comfort Zone off the Ground

• Determine your needs: -survey families and medical staff

• Mobilize your resources: -interdisciplinary communication is key (include MDs, RNs, phlebotomy, child life, pharmacy, etc.)-establish a hospital-wide task force-ensure visibility of your efforts and publicize your initiative (flyers, posters, stickers, pins, etc.(

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Continued…

• Educate:-staff AND patients/families-hands on staff experiential sessions

• Validate your efforts:-document, document, document!-videos/photos-track parental and staff responses/compliance-cost/benefit analysis

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Recommended Reading

• Leahy, S., Kennedy, R., Hesselgrave, J., Gurwitch, K., Barkey, M., & Millar, T. (2008). On the front lines: Lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics 122(3): 5161-5170.

• Kuttner, L. (1996). The child in pain: How to help, what to do. Washington: Hartley & Marks.

• Cavender, K., Goff, M.D., & Hollon, E.C. (2004). Parents’ positioning and distracting children during venipuncture: Effects on children’s pain, fear, and distress. Journal of Holistic Nursing 22(1): 32-56.