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Implementation of the Riley Comfort Bundle for Needlestick Procedures
Marti Michel, PCNS-BC, CPNP
Riley Hospital for Children
• Available beds: 314
• Total admissions: 10,00
• Total ambulatory visits: 263,000
• Emergency medicine & trauma visits: 38,110
• Indiana’s only nationally ranked pediatric hospital, Riley Hospital for Children at IU Health is recognized in 9 pediatric specialties by U.S.News & World Report in 2014
• Magnet designation (as a system with IU Health University Hospital and IU Health Methodist Hospital) since 2006
• Level one trauma center designation
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Objectives
• Describe the evidence-based elements of theRiley Hospital for Children Comfort Bundle
• Analyze the current practice within theirhealthcare organization to determine if theelements of the Comfort Bundle areconsistently used to control procedural pain.
• Discuss the variables that influence adoption ofa comfort bundle within a healthcareorganization.
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Conflict of Interest Disclosure
•No conflicts of interest to disclose
Needlestick Pain and Distress
• What is known– Needlesticks are the
biggest fear children have during healthcare encounters
– Needle procedures cause distress beyond the immediate procedure
– It is estimated that 25% of adults have fear of needles
• Most of these fears develop in childhood
Hamilton, JG. (1995)Needle Phobia: a neglected diagnosis. J of Family Practice, 41: 169-75
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Consequences of Untreated Pain
• Untreated pain can have long-termconsequences– Needle fears– Anxiety related to procedures– Hyperalgesia– Avoidance of healthcare including
immunizationsWeisman, S. (1998) Consequences of inadequate analgesia during painful procedures in children. Arch Pediatric Adolescent Medicine, 152: 147-149
Taddio, A. (2009) Inadequate pain management during childhood immunizations: The nerve of it Clinical Therapeutics, S2: S152-167
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Evidence for Management of Procedural Pain
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Procedural Pain: Understanding the data
• Telephone follow-up with parents who rated “Would notrecommend” and low pain score in 2005 andvalidation in 2011– No families reported inadequate post-op pain
management– Theme: inconsistent or poor experiences in managing
procedural pain• “Some of the nurses used the numbing cream. I didn’t like
when they didn’t use it because it helped.”• “When they explained (in IR) that they couldn’t give a baby
pain medicine when they put in a PICC line, I guess I understood.”
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Imperative for Change
•We must get to an “always” culture for managingprocedural comfort
•We must make transformational changes abouthow we “always” think and act in managingchildren’s comfort
•It doesn’t have to hurt
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Needlestick Pain and Distress
• What is also known– Despite evidence, providers do not consistently
adhere to guidelines•Provider-centric rather than patient-centric
– Bundles have emerged as method to ensureadherence to all elements of a best practice
•Would a comfort bundle be an effective way tohardwire a multimodal approach to needlestickpain?
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Evidence Summary-what helps
• Topical anesthetics, sucrose solution for infants
• Non-pharmacolgical interventions– Distraction, combined cognitive-behavioral
interventions, and hypnosis– Positioning
• Words matter-avoid reassurance, apology, orcriticism
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Implementation
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Is a little like a famous three-hour tour
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The Challenge
• Provider-centric approach to needlestick pain– Staff did not know about or use comfort
positioning– Topical anesthetics not used routinely– Staff lacked confidence in distraction
techniques
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Staff SurveyPilot Surgical Unit-40 RNs, all shifts
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Staff SurveyPilot Surgical Unit-40 RNs, all shifts
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Staff SurveyPilot Surgical Unit-40 RNs, all shifts
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Staff SurveyPilot Surgical Unit-40 RNs, all shifts
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Riley Comfort Bundle
• Would a bundle of comfort interventions forneedlestick procedures reduce pain anddistress and increase patient/family and staffsatisfaction with procedural pain managementcompared to usual care?– 2001 Institute for Healthcare Improvement introduced
bundles to reduce variation and increase reliability(Resar, Griffin, Haraden, & Nolan, 2012)
– Concept that the bundle elements work in a synergistic way to improve outcomes
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Riley Comfort Bundle for Needlestick Procedures
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PARiHS Framework(Promoting Action on Research Implementation in Health Services)
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Comfort Positioning
• Evidence– Research-guidelines– Clinical Experience-Child Life
Specialist consensus– Patient Preferences-strong
family-centered care
• Context– Culture-learning organization– Leadership-effective &
supportive– Evaluation-audit feedback
processes– Resources
• Facilitation– Characteristics of the
facilitator• Champions and ‘Train the
Trainer’ Model• Local experts
– Role-clear roles– Style-consistent and flexible
Kotter’s “Leading Change”
• Create a sense of urgency
• Develop a Vision and Strategy
• Communicate the Vision
• Empower the front-line staff
• Celebrate short-term wins
• Embed the change
Kotter, J. P. (1996). Leading Change. Boston: Harvard Business School Press
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Create a Sense of Urgency
• Patient satisfactionwith pain key driver foroverall satisfaction
• Family rounds validated importanceof procedural painmanagement
• Utilized lean tools tomap current and futurestate
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Develop a Vision and Strategy
• Organizational experience with CLABSI andCAUTI bundles
• Nurses engaged in auditing of bundles andimprovement activities
• Nurses and PCA staff invested in providingquality care and having high patient/familysatisfaction
• Leadership aligned and supportive
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Market the Message
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Develop a Vision and Strategy
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Empower the Front-line staff
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Empower Parents/Caregivers
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Evaluate the Change
• IRB approved study
• Convenience sample on surgical inpatientunit:– N=35– Age, mean (range),
5.9 (1 month-21 years)
– Male, no (%)18 (51%)
• Reason for Needlestick– Lab draw 18 (51%)– IV start 15 (43%)– IM vaccine 2 (6%)
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35 Patients Pre Procedure During Procedure After Procedure
Assessment & Education
88.6% RN/Child Life: Develop
Procedural Comfort Plan ofCare: consider past experiences, child/family preferences
Provide education to child/family as appropriate
94.3% Assess pain/anxiety Provide ongoing coaching to
caregiver Maintain calm environment
54%• Debrief with
patient/family• Document
procedure &patient experience
Revise Plan ofCare
Environmental 67.9% Use treatment room if < 9
years of age (consider child/family preference)
97.1% One voice Minimal noise & interruptions Remain calm & confident
Pharmacologic 14.3% LMX4
8.6%• Pain Ease
Non-pharmacologic
77.1% Comfort Positioning Prepare coping techniques
82.9% Sucrose 23% infants <6 months of
age Buzzy Distraction Comfort positioning Validate child with words
91.4% Support child’s
return to baseline Praise child for
what they did well during procedure
SHORT-TERM OUTCOMES
• Comfort standard of care for needlesticks
• Increase in procedures using comfortpositioning
• Increase in procedures using age-appropriatedistraction
• Increase in child/parent satisfaction
• Continue to spread and sustain
• Topical anesthetic usage remains low
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SHORT-TERM OUTCOMES
• Gaps– Topical anesthetic usage remains low
•Accountability
– Collaboration with families in choosinginterventions for Comfort Menu
•Need to start Comfort Menu at point of entry
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Lessons Learned
• Changing culture requires time, leadershipalignment and commitment
• Use an implementation framework to assessevidence, context and facilitation and leveragestrengths and close gaps
• Empower, increase participation, support, shareinformation—develop champion model
• Use storytelling and hoopla to communicateand celebrate
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