1

9/16/2015 1

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

9/16/2015 2

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.

9/16/2015 3

2

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

9/16/2015 5

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

9/16/2015 6

3

Evidence for Management of Procedural Pain

9/16/2015 7

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.”

9/16/2015 8

9/16/2015 9

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

4

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?

9/16/2015 10

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

9/16/2015 11

Implementation

9/16/2015 12

Is a little like a famous three-hour tour

5

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

9/16/2015 13

Staff SurveyPilot Surgical Unit-40 RNs, all shifts

9/16/2015 14

Staff SurveyPilot Surgical Unit-40 RNs, all shifts

9/16/2015 15

6

Staff SurveyPilot Surgical Unit-40 RNs, all shifts

9/16/2015 16

Staff SurveyPilot Surgical Unit-40 RNs, all shifts

9/16/2015 17

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

9/16/2015 18

7

Riley Comfort Bundle for Needlestick Procedures

9/16/2015 19

9/16/2015 20

PARiHS Framework(Promoting Action on Research Implementation in Health Services)

8

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

9/16/2015 23

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

9/16/2015 24

9

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

9/16/2015 25

Market the Message

9/16/2015 26

Develop a Vision and Strategy

9/16/2015 27

10

Empower the Front-line staff

9/16/2015 28

Empower Parents/Caregivers

9/16/2015 29

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%)

9/16/2015 30

11

9/16/2015 31

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

9/16/2015 32

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

9/16/2015 33

12

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

9/16/2015 34