Using quality improvement methods to increase use of pain prevention strategies for childhood vaccination

If we know better, why don't we do better? A rapid quality improvement project to increase utilization of comfort measures to reduce pain and distress in children in a COVID-19 mass vaccination clinic

INTRODUCTION

Many evidence-based tools exist to address pain and distress associated with injections; however, there remains a large gap between the knowledge of these tools and their utilization. Our hospital began a quality improvement (QI) project prior to COVID-19, with the goal of increasing the utilization of Comfort Promise measures during needle procedures. When COVID-19 vaccinations were approved, our mass vaccination clinics provided an opportunity to rapidly increase utilization across the institution. The primary aim was to increase the percentage of comfort measures (CM) offered with COVID-19 vaccinations.

METHODS

Through this QI project, nurses and other professionals implemented CMs during COVID mass vaccination clinics. Clinics occurred in 3 age-based waves. Waves served as Plan-Do-Study-Act (PDSA) cycles. Families completed post-vaccination surveys to determine what CMs were offered and intention for future use with vaccinations.

RESULTS

Uptake of CMs (PainEase, ShotBlockers, Comfort Positioning, Alternative Focus, Topical Lidocaine, and Breastfeeding/Sucrose) throughout the waves increased and generally remained stable. CMs also seemed to decrease pain/distress with vaccinations (70.5 to 88.7%), and children/caregivers intended to use some combination for future vaccinations (82.5 to 98.5%).

CONCLUSIONS

Fast-paced mass vaccination clinics provided an ideal opportunity to significantly increase utilization of CMs. Across age groups CMs yielded high satisfaction and interest in future utilization. Clinic nurses returned to their own sub-specialties and became change agents.

IMPLICATIONS

If all healthcare providers can work together to achieve consensus while incorporating comfort measures into daily practice, sustained change with incorporation of these evidence-based tools can be achieved. Future directions are discussed.

Stories to Take the Edge Off Pain During Immunization for Preschoolers: A Randomized Controlled Trial

IMPORTANCE

Fear and distress during immunization may lead to long-term preprocedural anxiety and nonadherence to immunization schedules. Pictorial stories provide a way of educating the parent and child about the procedure.

OBJECTIVE

To determine the efficacy of pictorial stories in reducing pain perception among children and anxiety among mothers during immunization.

DESIGN

Three-arm randomized controlled trial Setting: Immunization clinic of a tertiary care hospital in South India.

PARTICIPANTS

Fifty children ages 5 to 6 yr, who reported to the hospital for measles, mumps, and rubella and typhoid conjugate virus vaccines. Inclusion criteria were that the child was accompanied by the mother and maternal knowledge of either Tamil or English. Exclusion criteria were child hospitalization in the past year or neonatal intensive care unit admission in the neonatal period.

INTERVENTION

Pictorial story regarding immunization before the procedure that contained information related to immunization, coping strategies, and distraction techniques.

OUTCOMES AND MEASURES

Pain perception was evaluated using the Sound, Eye, Motor Scale; the Observation Scale of Behavioral Distress; and the Wong-Baker FACES Pain Rating Scale (FACES). Maternal anxiety was measured using the General Anxiety-Visual Analog Scale.

RESULTS

Of 50 children recruited, 17 were in the control group, 15 were in the placebo group, and 18 were in the intervention group. Children in the intervention group reported lower pain scores on the FACES (p = .04) compared with the placebo and control groups.

CONCLUSIONS AND RELEVANCE

A pictorial story is a simple and cost-effective intervention to reduce pain perception among children. What This Article Adds: Pictorial stories may be a feasible, simple, and cost-effective intervention to reduce pain perception during immunization.

The Effect of Buzzy Application on Pain Level During Vaccine Injection in Infants

BACKGROUND

Nonpharmacological interventions are needed to reduce pain during vaccine administration in infants.

PURPOSE

To determine the effect of the Buzzy device, which is a combination of cold and vibration, on pain during measles-mumps-rubella (MMR) vaccine administration in 12-month-old infants.

METHODS

A prospective randomized controlled experimental research design was used.

RESULTS

A total of 60 infants were included in the study. During and after vaccine injection, pain scores of infants who had the Buzzy device were significantly lower than those of infants in the control group ( P = .001).

CONCLUSIONS

Buzzy application may be an effective method in reducing pain during MMR vaccine administration. Use of the device is recommended for infants receiving vaccinations.

Evidence-Based Quality Improvement: a Scoping Review of the Literature

BACKGROUND

Quality improvement (QI) initiatives often reflect approaches based on anecdotal evidence, but it is unclear how initiatives can best incorporate scientific literature and methods into the QI process. Review of studies of QI initiatives that aim to systematically incorporate evidence review (termed evidence-based quality improvement (EBQI)) may provide a basis for further methodological development.

METHODS

In this scoping review (registration: https://osf.io/hr5bj ) of EBQI, we searched the databases PubMed, CINAHL, and SCOPUS. The review addressed three central questions: How is EBQI defined? How is evidence used to inform evidence-informed QI initiatives? What is the effectiveness of EBQI?

RESULTS

We identified 211 publications meeting inclusion criteria. In total, 170 publications explicitly used the term "EBQI." Published definitions emphasized relying on evidence throughout the QI process. We reviewed a subset of 67 evaluations of QI initiatives in primary care, including both studies that used the term "EBQI" with those that described an evidence-based initiative without using EBQI terminology. The most frequently reported EBQI components included use of evidence to identify previously tested effective QI interventions; engaging stakeholders; iterative intervention development; partnering with frontline clinicians; and data-driven evaluation of the QI intervention. Effectiveness estimates were positive but varied in size in ten studies that provided data on patient health outcomes.

CONCLUSIONS

EBQI is a promising strategy for integrating relevant prior scientific findings and methods systematically in the QI process, from the initial developmental phase of the IQ initiative through to its evaluation. Future QI researchers and practitioners can use these findings as the basis for further development of QI initiatives.

Use of Lidocaine Cream for Pain Management During Immunizations of Infants at an Urban Health Clinic

BACKGROUND

Immunizations are a common source of pain and anxiety within the pediatric population. Implementation of lidocaine 4% cream, which has a short onset of action, as a standard of care for immunization practices may be feasible.

OBJECTIVE

The objective of this study was to assess the efficacy of lidocaine 4% cream as pain management during immunizations and to evaluate satisfaction of caregivers and nursing staff.

METHODS

This study was a prospective, randomized, placebo-controlled trial in an urban clinic, which included patients who were ≤ 14 months old accompanied by a caregiver who witnessed the patient receiving an immunization within the previous 7 months. Patients were randomized to receive either lidocaine 4% cream or placebo cream prior to vaccination. Time to cry and duration of cry were recorded. Caregivers completed surveys evaluating attitudes toward pain associated with immunizations as well as their satisfaction with the immunization process through Likert Scale ratings. Nurses completed a questionnaire assessing efficacy and feasibility of lidocaine 4% cream for pain management.

RESULTS

A total of 44 patients were included in the analysis in order to achieve 80% power with a p-value < 0.05. Mean duration of cry in patients receiving lidocaine 4% cream was 48.6 seconds in comparison to 65.9 seconds in patients receiving placebo (95%CI, -33.97 seconds to -0.48 seconds; p < 0.05).

CONCLUSIONS

Lidocaine 4% cream decreased total duration of cry following vaccinations in comparison to placebo with both caregivers and nurses willing to utilize lidocaine 4% cream in a clinic setting if available.

Immunization-Associated Pain: Taking Research to the Bedside

BACKGROUND

Immunization-associated pain is the number one cause of pain in pediatric settings. Untreated pain has many short- and long-term detrimental effects. The purpose of this project was to implement a nonpharmaceutical immunization-associated-pain prevention program.

METHOD

This project was implemented at a pediatric primary care clinic. Staff were educated about immunization-associated pain and techniques for decreasing/preventing pain. Families were educated about pain control, and the practitioner and parent/child picked interventions to decrease pain. Preimplementation and postimplementation data were collected using previously validated pain and satisfaction scales.

RESULTS

Pain prevention interventions decreased pain for children between 2 months and 7 years of age by 4.7 points on a Faces, Legs, Activity, Cry, Consolability (i.e., FLACC) scale. For children 7 years and older, pain during immunization decreased on average by 1.76 points on the visual analog scale.

CONCLUSION

Non-pharmaceutical interventions are effective in decreasing immunization-associated pain.

A Project-based Curriculum for Driving Organization-wide Continuous Improvement

Background

Creating the capacity and capability for meaningful improvement in healthcare quality is a challenge many organizations face. Before 2012, Children's Mercy sponsored 20 leaders to obtain advanced improvement training from peer organizations. Recognizing an opportunity to build upon this momentum, we developed an organization-wide curriculum for teaching continuous improvement.

Methods

A steering committee was created in 2011 to define, advise, and oversee education in improvement science. We agreed upon a framework for improvement, a program name [Continuous Quality and Practice Improvement (CQPI)], and a phased curriculum development approach, beginning with a project/experiential learning based course (Team CQPI). Course evaluation for Team CQPI consisted of a standard evaluation of objectives, pre- and post-course assessment, qualitative feedback, and serial assessment of project progress using the Team Assessment Score (TAS). The curriculum committee monitored improvement.

Results

From 2012 to 2017, 297 people participated in the project-based course, completing a total of 83 projects. TAS improved throughout the 4-month project-based course, from an average starting score of 1 ("forming a team") to 2.7 ("changes tested"). The average TAS at 12 months following completion of the Team CQPI course was 3.5 ("improvement") out of 5.

Conclusions

Development of a comprehensive curriculum for driving continuous improvement has resulted in a measurable change in TAS scores representative of local improvement efforts.

A hospital-wide initiative to eliminate or reduce needle pain in children using lean methodology

INTRODUCTION

Pain remains common, underrecognized, and undertreated in children's hospitals and pediatric clinics. Over 200,000 patients experience needle pain annually in our institution, caused by blood draws, intravenous access, vaccinations, and injections on all inpatient units, emergency departments, outpatient laboratories, and ambulatory clinics.

OBJECTIVES

We implemented a hospital-based, system-wide initiative called the "Children's Comfort Promise," and created a new standard of care for needle procedures that required staff to consistently offer 4 strategies: (1) topical anesthetics, (2) sucrose or breastfeeding for infants 0 to 12 months, (3) comfort positioning (including swaddling, skin-to-skin, or facilitated tucking for infants; sitting upright for children), and (4) age-appropriate distraction.

METHODS

The protocol was established system-wide in one of the largest children's hospitals in the United States using a staggered implementation approach over a 3-year period to allow for unit-specific customization and facilitation of knowledge transfer from one unit to another. All departments were required to offer all 4 strategies with appropriate education at least 95% of the time.

RESULTS

Comparison of baseline audits with continuous postimplementation audits revealed that wait times for services decreased, patient satisfaction increased, and staff concerns about implementation were allayed (eg, concerns about wait times and success rates of venipuncture after topical anesthesia).

CONCLUSION

This is the first report of a successful system-wide protocol implementation to reduce or eliminate needle pain, including pain from vaccinations, in a children's hospital across all inpatient units, emergency departments, outpatient laboratories, and ambulatory clinics through consistent use of topical anesthesia, sucrose/breastfeeding, positioning, and distraction.

Effect of virtual reality headset for pediatric fear and pain distraction during immunization

Aim: Fear of needles is a well-known phobia among children and adults. This study presents the rationale, feasibility and results of a pilot study applying a virtual reality (VR) headset as a fear reduction and pain distraction during immunizations. Patients & methods: 17 subjects and 17 parents rated their fear and pain level pre- and postimmunization using Wong–Baker pain scale and McMurtry children's fear scale. Immunization was provided, while subject was wearing a VR headset. Results: Ratings of anticipated versus actual fear and pain due to immunizations improved following use of the VR headset in 94.1% of pediatric subjects. Conclusion: The use of a VR headset was well received and reduced overall fear and pain in children receiving immunizations.