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Lorenc J, Flaucher N, Evans E, Schurman JV. Establishing a plan to improve pediatric patient comfort during PIV insertions and blood specimen collection: a quality improvement effort. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:S36-S42. [PMID: 38578933 DOI: 10.12968/bjon.2024.33.7.s36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
HIGHLIGHTS Patient comfort during peripheral intravenous (PIV) insertion and specimen collection was increased. The authors extended the contingency plan implemented for PICC insertion to include PIV insertion and specimen collection. The authors met their goals by using quality improvement methodology. Prioritizing patient comfort often requires institutional culture change. BACKGROUND Needle procedures can cause pain and distress, especially in pediatric patients.1 Retrospective data collected at a freestanding pediatric facility revealed that approximately 30% of pediatric patients were not demonstrating sufficient levels of comfort during peripheral intravenous (PIV) catheter insertion and specimen collection (lab draws) even after successful implementation of comfort measures by the vascular access team (VAT) in an adjacent procedure (eg peripherally inserted central catheter placement). The current quality improvement project was implemented to support adaptation and expansion of previous lessons learned to PIVs and lab draws specifically. DESIGN AND METHODS The VAT used the Pediatric Sedation State Scale,2 a standardized assessment tool integrated into the electronic medical record, to assess procedural comfort during PIVs and lab draws from February 2021 through April 2023. A total of 24 134 patients aged 0 to 18 years were included in the data collection. Interventions were delivered concurrently and included (1) reeducation/ongoing support for implementation of the Comfort Promise3 measures, (2) the creation and implementation of advanced comfort options, and (3) culture change. AIMS AND OBJECTIVES The goal of the interventions was to improve the percentage of pediatric patients achieving adequate levels of comfort beginning at 68% in year 1 to 90% in year 2. RESULTS From February 2021 to April 2023, the VAT team was able to improve procedural comfort scores from 68% to 90% of pediatric patients with adequate comfort for lab draws and/or PIV insertions. CONCLUSIONS While standard comfort measures are a good first step in pain management during needle procedures, they are not sufficient for every pediatric patient. Nitrous, sedation, and the use of anxiolytics and analgesics can play an important role in reducing pain and anxiety during needle procedures and should be considered for patients not achieving adequate levels of comfort with standard comfort measures.
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Affiliation(s)
- Jamie Lorenc
- Department of Patient Care Services, Children's Mercy Kansas City, Kansas City, MO
| | - Nicholas Flaucher
- Department of Patient Care Services, Children's Mercy Kansas City, Kansas City, MO
| | - Emily Evans
- Department of Patient Care Services, Children's Mercy Kansas City, Kansas City, MO
| | - Jennifer V Schurman
- University of Missouri Kansas City School of Medicine/Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO
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Lozano S, Sund G, Guimera A, Deukmedjian G, Miller PS. A Comparison of Local Anesthetics for Intravenous Catheter Insertion in Hospitalized Pediatric Patients: A Randomized Clinical Pilot Trial. JOURNAL OF INFUSION NURSING 2021; 44:346-356. [PMID: 34753154 DOI: 10.1097/nan.0000000000000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Peripheral intravenous catheter (PIVC) insertion is one of the most painful procedures pediatric patients undergo during hospitalization. To date, local anesthetics delivered via cream, patch, and needle-free injection have not been rigorously evaluated together. This study aimed to investigate feasibility and potential efficacy of local anesthetics on pain intensity during PIVC insertion in an unblinded, single-center, randomized clinical pilot trial. Between March 2017 and February 2020, 88 hospitalized children aged 12 months to 18 years in an acute pediatric unit at an academic medical center were randomized to 1 of 3 local anesthetics: 1) lidocaine/prilocaine cream, 2) lidocaine/tetracaine patch, and 3) unbuffered lidocaine needle-free injection. Feasibility outcomes were recruitment and protocol adherence. Pain intensity was measured using the Face, Legs, Activity, Cry, Consolability (age <8 years) and Verbal Numeric Rating (VNRS) scales (age ≥8 years) before, during, and after procedure. Secondary outcomes included catheterization attempts, procedure time, and parent satisfaction. Recruitment rate was acceptable (2.7 patients per month). Protocol adherence was high (92%). Preliminary clinical findings showed no significant difference in pain intensity across treatments. Procedure time to successful insertion differed in the VNRS group, favoring unbuffered lidocaine needle-free injection. Conduct of a definitive, full-scale randomized clinical trial in the hospitalized pediatric population is feasible.
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Affiliation(s)
- Sally Lozano
- University of California Los Angeles Medical Center, Santa Monica, California (Ms Lozano); University of California Los Angeles Mattel Children's Hospital, Los Angeles, California (Ms Sund); University of California Los Angeles Health, Los Angeles, California (Drs Guimera, Deukmedjian, and Miller)
- Sally Lozano, BSN, RN, CPN , has worked as a pediatric nurse for 15 years at University of California Los Angeles (UCLA) Medical Center. She was recently promoted to clinical nurse manager in the general pediatric unit. Ms Lozano has extensive experience placing and teaching techniques for successful peripheral intravenous catheter insertions
- Grace Sund, MSN, RN, CPNP, CPHON, is a clinical nurse specialist in pediatrics at UCLA Mattel Children's Hospital and has worked as a pediatric nurse for 19 years. She helped create the nurse-driven protocol for topical anesthetics prior to intravenous insertion for the pediatric population across the health system
- Allison Guimera, MD, FAAP, worked as a pediatric hospitalist at UCLA Health and currently practices outpatient pediatrics with UCLA Health. She is a board-certified pediatrician and a fellow of the American Academy of Pediatrics
- Grace Deukmedjian, MD, is a pediatric hospitalist at UCLA Health. Her expertise is in global health, social justice and equity, medical education, and humanities in medicine
- Pamela S. Miller, PhD, RN, ACNP, CNS, PHN, EBP(CH), is a senior nurse scientist in the Center for Nursing Excellence at UCLA Health, where she directs the research, evidence-based practice, and innovation programs. Her research focuses on symptom science
| | - Grace Sund
- University of California Los Angeles Medical Center, Santa Monica, California (Ms Lozano); University of California Los Angeles Mattel Children's Hospital, Los Angeles, California (Ms Sund); University of California Los Angeles Health, Los Angeles, California (Drs Guimera, Deukmedjian, and Miller)
- Sally Lozano, BSN, RN, CPN , has worked as a pediatric nurse for 15 years at University of California Los Angeles (UCLA) Medical Center. She was recently promoted to clinical nurse manager in the general pediatric unit. Ms Lozano has extensive experience placing and teaching techniques for successful peripheral intravenous catheter insertions
- Grace Sund, MSN, RN, CPNP, CPHON, is a clinical nurse specialist in pediatrics at UCLA Mattel Children's Hospital and has worked as a pediatric nurse for 19 years. She helped create the nurse-driven protocol for topical anesthetics prior to intravenous insertion for the pediatric population across the health system
- Allison Guimera, MD, FAAP, worked as a pediatric hospitalist at UCLA Health and currently practices outpatient pediatrics with UCLA Health. She is a board-certified pediatrician and a fellow of the American Academy of Pediatrics
- Grace Deukmedjian, MD, is a pediatric hospitalist at UCLA Health. Her expertise is in global health, social justice and equity, medical education, and humanities in medicine
- Pamela S. Miller, PhD, RN, ACNP, CNS, PHN, EBP(CH), is a senior nurse scientist in the Center for Nursing Excellence at UCLA Health, where she directs the research, evidence-based practice, and innovation programs. Her research focuses on symptom science
| | - Allison Guimera
- University of California Los Angeles Medical Center, Santa Monica, California (Ms Lozano); University of California Los Angeles Mattel Children's Hospital, Los Angeles, California (Ms Sund); University of California Los Angeles Health, Los Angeles, California (Drs Guimera, Deukmedjian, and Miller)
- Sally Lozano, BSN, RN, CPN , has worked as a pediatric nurse for 15 years at University of California Los Angeles (UCLA) Medical Center. She was recently promoted to clinical nurse manager in the general pediatric unit. Ms Lozano has extensive experience placing and teaching techniques for successful peripheral intravenous catheter insertions
- Grace Sund, MSN, RN, CPNP, CPHON, is a clinical nurse specialist in pediatrics at UCLA Mattel Children's Hospital and has worked as a pediatric nurse for 19 years. She helped create the nurse-driven protocol for topical anesthetics prior to intravenous insertion for the pediatric population across the health system
- Allison Guimera, MD, FAAP, worked as a pediatric hospitalist at UCLA Health and currently practices outpatient pediatrics with UCLA Health. She is a board-certified pediatrician and a fellow of the American Academy of Pediatrics
- Grace Deukmedjian, MD, is a pediatric hospitalist at UCLA Health. Her expertise is in global health, social justice and equity, medical education, and humanities in medicine
- Pamela S. Miller, PhD, RN, ACNP, CNS, PHN, EBP(CH), is a senior nurse scientist in the Center for Nursing Excellence at UCLA Health, where she directs the research, evidence-based practice, and innovation programs. Her research focuses on symptom science
| | - Grace Deukmedjian
- University of California Los Angeles Medical Center, Santa Monica, California (Ms Lozano); University of California Los Angeles Mattel Children's Hospital, Los Angeles, California (Ms Sund); University of California Los Angeles Health, Los Angeles, California (Drs Guimera, Deukmedjian, and Miller)
- Sally Lozano, BSN, RN, CPN , has worked as a pediatric nurse for 15 years at University of California Los Angeles (UCLA) Medical Center. She was recently promoted to clinical nurse manager in the general pediatric unit. Ms Lozano has extensive experience placing and teaching techniques for successful peripheral intravenous catheter insertions
- Grace Sund, MSN, RN, CPNP, CPHON, is a clinical nurse specialist in pediatrics at UCLA Mattel Children's Hospital and has worked as a pediatric nurse for 19 years. She helped create the nurse-driven protocol for topical anesthetics prior to intravenous insertion for the pediatric population across the health system
- Allison Guimera, MD, FAAP, worked as a pediatric hospitalist at UCLA Health and currently practices outpatient pediatrics with UCLA Health. She is a board-certified pediatrician and a fellow of the American Academy of Pediatrics
- Grace Deukmedjian, MD, is a pediatric hospitalist at UCLA Health. Her expertise is in global health, social justice and equity, medical education, and humanities in medicine
- Pamela S. Miller, PhD, RN, ACNP, CNS, PHN, EBP(CH), is a senior nurse scientist in the Center for Nursing Excellence at UCLA Health, where she directs the research, evidence-based practice, and innovation programs. Her research focuses on symptom science
| | - Pamela S Miller
- University of California Los Angeles Medical Center, Santa Monica, California (Ms Lozano); University of California Los Angeles Mattel Children's Hospital, Los Angeles, California (Ms Sund); University of California Los Angeles Health, Los Angeles, California (Drs Guimera, Deukmedjian, and Miller)
- Sally Lozano, BSN, RN, CPN , has worked as a pediatric nurse for 15 years at University of California Los Angeles (UCLA) Medical Center. She was recently promoted to clinical nurse manager in the general pediatric unit. Ms Lozano has extensive experience placing and teaching techniques for successful peripheral intravenous catheter insertions
- Grace Sund, MSN, RN, CPNP, CPHON, is a clinical nurse specialist in pediatrics at UCLA Mattel Children's Hospital and has worked as a pediatric nurse for 19 years. She helped create the nurse-driven protocol for topical anesthetics prior to intravenous insertion for the pediatric population across the health system
- Allison Guimera, MD, FAAP, worked as a pediatric hospitalist at UCLA Health and currently practices outpatient pediatrics with UCLA Health. She is a board-certified pediatrician and a fellow of the American Academy of Pediatrics
- Grace Deukmedjian, MD, is a pediatric hospitalist at UCLA Health. Her expertise is in global health, social justice and equity, medical education, and humanities in medicine
- Pamela S. Miller, PhD, RN, ACNP, CNS, PHN, EBP(CH), is a senior nurse scientist in the Center for Nursing Excellence at UCLA Health, where she directs the research, evidence-based practice, and innovation programs. Her research focuses on symptom science
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Russell C, Mullaney K, Campbell T, Sabado J, Haut C. Outcomes of a Pediatric Ultrasound-Guided Short Peripheral Catheter Training Program and Hands-On Poultry Simulation Course. JOURNAL OF INFUSION NURSING 2021; 44:204-215. [PMID: 34197350 DOI: 10.1097/nan.0000000000000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ultrasound guidance is an effective technique for obtaining short peripheral catheter (SPC) access but requires training and practice for proficiency. The aim of this quality improvement initiative was to develop and assess a formal training program to increase the confidence and competency of intravenous (IV) therapy nurses in the placement of ultrasound-guided SPCs. IV therapy nurses completed a didactic and hands-on training course where they practiced ultrasound-guided SPC placement techniques on a poultry phantom during simulation, followed by performing ultrasound-guided SPC insertion on patients proctored by an interventional radiology physician. Data collection included preintervention and postintervention confidence self-assessment, frequency tracker, Difficult Intravenous Access (DIVA) scale scores, and total number of ultrasound-guided SPCs placed by the nurses. Ultrasound-guided SPC placement increased significantly after the training program. The IV therapy nurses placed 29 ultrasound-guided SPCs in 2017, 391 ultrasound-guided SPCs in 2018, and 711 ultrasound-guided SPCs in 2019. Mean DIVA scores rose from 4.54 in May 2018 to 5.17 in July 2018, indicating success in placing SPCs in more difficult patients. Implementation of an ultrasound-guided SPC placement program using poultry phantom simulation is a recommended nursing resource for increasing competency in ultrasound-guided SPC placement in pediatric patients.
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Affiliation(s)
- Christina Russell
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware (Mss Russell, Mullaney, and Campbell, and Drs Sabado and Haut); Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Mss Mullaney and Campbell); Thomas Jefferson University, Philadelphia, Pennsylvania (Dr Sabado)
- Christina Russell, BSN, RN, HTCP, HNB-BC, is currently the healing touch coordinator for the Department of Integrative Medicine at Nemours/Alfred I. duPont Hospital for Children. She served as nurse manager for the intravenous (IV) therapy team during this quality improvement (QI) project. Ms Russell is also a registered yoga teacher
- Kathleen Mullaney, MSN, APRN, ACCNS-P, CRNI®, served as a clinical nurse educator for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a clinical nurse specialist at Children's Hospital of Philadelphia
- Tracy Campbell, MSN, APRN, PCNS-BC, CCRN , served as a clinical nurse specialist for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a nursing practice specialist at Children's Hospital of Philadelphia
- Jeremiah Sabado, MD, is a pediatric interventional radiologist at Nemours/Alfred I. duPont Hospital for Children. He is also a clinical instructor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University
- Catherine Haut, DNP, CPNP-AC, PC, is the Director of Nursing Research and Evidence-Based Practice at Nemours/Alfred I. duPont Hospital for Children
| | - Kathleen Mullaney
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware (Mss Russell, Mullaney, and Campbell, and Drs Sabado and Haut); Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Mss Mullaney and Campbell); Thomas Jefferson University, Philadelphia, Pennsylvania (Dr Sabado)
- Christina Russell, BSN, RN, HTCP, HNB-BC, is currently the healing touch coordinator for the Department of Integrative Medicine at Nemours/Alfred I. duPont Hospital for Children. She served as nurse manager for the intravenous (IV) therapy team during this quality improvement (QI) project. Ms Russell is also a registered yoga teacher
- Kathleen Mullaney, MSN, APRN, ACCNS-P, CRNI®, served as a clinical nurse educator for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a clinical nurse specialist at Children's Hospital of Philadelphia
- Tracy Campbell, MSN, APRN, PCNS-BC, CCRN , served as a clinical nurse specialist for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a nursing practice specialist at Children's Hospital of Philadelphia
- Jeremiah Sabado, MD, is a pediatric interventional radiologist at Nemours/Alfred I. duPont Hospital for Children. He is also a clinical instructor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University
- Catherine Haut, DNP, CPNP-AC, PC, is the Director of Nursing Research and Evidence-Based Practice at Nemours/Alfred I. duPont Hospital for Children
| | - Tracy Campbell
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware (Mss Russell, Mullaney, and Campbell, and Drs Sabado and Haut); Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Mss Mullaney and Campbell); Thomas Jefferson University, Philadelphia, Pennsylvania (Dr Sabado)
- Christina Russell, BSN, RN, HTCP, HNB-BC, is currently the healing touch coordinator for the Department of Integrative Medicine at Nemours/Alfred I. duPont Hospital for Children. She served as nurse manager for the intravenous (IV) therapy team during this quality improvement (QI) project. Ms Russell is also a registered yoga teacher
- Kathleen Mullaney, MSN, APRN, ACCNS-P, CRNI®, served as a clinical nurse educator for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a clinical nurse specialist at Children's Hospital of Philadelphia
- Tracy Campbell, MSN, APRN, PCNS-BC, CCRN , served as a clinical nurse specialist for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a nursing practice specialist at Children's Hospital of Philadelphia
- Jeremiah Sabado, MD, is a pediatric interventional radiologist at Nemours/Alfred I. duPont Hospital for Children. He is also a clinical instructor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University
- Catherine Haut, DNP, CPNP-AC, PC, is the Director of Nursing Research and Evidence-Based Practice at Nemours/Alfred I. duPont Hospital for Children
| | - Jeremiah Sabado
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware (Mss Russell, Mullaney, and Campbell, and Drs Sabado and Haut); Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Mss Mullaney and Campbell); Thomas Jefferson University, Philadelphia, Pennsylvania (Dr Sabado)
- Christina Russell, BSN, RN, HTCP, HNB-BC, is currently the healing touch coordinator for the Department of Integrative Medicine at Nemours/Alfred I. duPont Hospital for Children. She served as nurse manager for the intravenous (IV) therapy team during this quality improvement (QI) project. Ms Russell is also a registered yoga teacher
- Kathleen Mullaney, MSN, APRN, ACCNS-P, CRNI®, served as a clinical nurse educator for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a clinical nurse specialist at Children's Hospital of Philadelphia
- Tracy Campbell, MSN, APRN, PCNS-BC, CCRN , served as a clinical nurse specialist for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a nursing practice specialist at Children's Hospital of Philadelphia
- Jeremiah Sabado, MD, is a pediatric interventional radiologist at Nemours/Alfred I. duPont Hospital for Children. He is also a clinical instructor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University
- Catherine Haut, DNP, CPNP-AC, PC, is the Director of Nursing Research and Evidence-Based Practice at Nemours/Alfred I. duPont Hospital for Children
| | - Catherine Haut
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware (Mss Russell, Mullaney, and Campbell, and Drs Sabado and Haut); Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Mss Mullaney and Campbell); Thomas Jefferson University, Philadelphia, Pennsylvania (Dr Sabado)
- Christina Russell, BSN, RN, HTCP, HNB-BC, is currently the healing touch coordinator for the Department of Integrative Medicine at Nemours/Alfred I. duPont Hospital for Children. She served as nurse manager for the intravenous (IV) therapy team during this quality improvement (QI) project. Ms Russell is also a registered yoga teacher
- Kathleen Mullaney, MSN, APRN, ACCNS-P, CRNI®, served as a clinical nurse educator for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a clinical nurse specialist at Children's Hospital of Philadelphia
- Tracy Campbell, MSN, APRN, PCNS-BC, CCRN , served as a clinical nurse specialist for the IV Therapy Team at Nemours/Alfred I. duPont Hospital for Children during this QI project. She is currently a nursing practice specialist at Children's Hospital of Philadelphia
- Jeremiah Sabado, MD, is a pediatric interventional radiologist at Nemours/Alfred I. duPont Hospital for Children. He is also a clinical instructor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University
- Catherine Haut, DNP, CPNP-AC, PC, is the Director of Nursing Research and Evidence-Based Practice at Nemours/Alfred I. duPont Hospital for Children
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