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Collaboration for Comfort: Helping Children Cope
Julie Piazza, MS, CCLS University of Michigan
C.S. Mott Children’s Hospital And
Ben Miller, BS, CCLS University of Iowa Children’s Hospital
Objectives• Explore the evidence based research and
benefits of developing a “Comfort Plan” for pokes and procedures
• Identify personnel & financial resources required to develop a “Comfort Plan” through education initiatives
• Discuss bridges and barriers to implementation, provide strategies through staff/family partnerships that help to overcome them providing direction for future growth
Sharing the Problem & the History
• Memory of early immunization pain is evident• Venipuncture and IV insertions are the 2 most
common sources of pain in hospitalized• Children demonstrated high levels of pain and
distress with needlesticks• Parents reported anxiety and distress when their
child undergoes needlestick procedures.• Health care providers find performing needlestick
procedures in fearful and anxious children a challenge.
Key Components of the University of Michigan Poke Program
Needle phobia is a reality for many !
• Building relationship through Patient Family Centered Care • Communication and Preparation• Non-Pharmacological Therapies• Drugs and devices• Positive Recognition• Evidence based practice (EBP)• Comfort, Distraction = Improved Satisfaction• Poke Program Networking: University of Iowa &
others
Differences Between Conducting Research and Using Research (EBP)
Conducting Research• Purpose: to generate new
knowledge• May or may not benefit the
subjects in the research• Review by a Review Board
to protect the subjects• Typically done by PhD
prepared researchers
Research Utilization• Purpose: to put existing
knowledge into practice • Done expressly to benefit
the patient• Does not need approval by
a Review Board• Expected of all staff nurses
Improving Practice: Through Evidence Based Practice
• Triggers for the change– Clinical Problem– Organizational Problem– Knowledge
• Outcomes of the change– Decreased pain and anxiety– Decreased time for procedure
• Increase satisfaction– Patient and parent– Staff
A Systematic Approach for Success
• Assemble and critique relevant literature– Synthesis tables
• Translate the evidence– Select outcomes – Guidelines, policies, processes
• Pilot• Evaluate and modify• Institute the change and monitor
You don’t have to see the whole staircase just take the first step-Martin Luther King, Jr.
Patient and Family Centered Care
• Dignity and Respect• Information Sharing• Participation• Collaboration• Empowerment
The “Poke” Program supports the principles of Patient-Family Centered Care
Ellie's Story
Patient and Family Centered Care
The “Poke” Program supports the principles of Patient-Family Centered Care
What does the literature say?
• Preparation• Distraction• Positioning• Parents as helpers and coaches• Positive recognition• Drugs and Devices
Place your information into synthesis tables.
Change Package: Best PracticesLucile Packard Children’s Hospital at Stanford
1. Assess and communicate about pain routinely with families and patients.
2. Ask patients and families daily how well pain is controlled.
3. Create an individualized pain plan for every patient, including family input.
4. Educate patients and families about pain management practices and options.
5. Educate staff about how to talk to children & families about pain and its treatment
6. Use standard protocols/order sets to manage anticipated (e.g. procedural) pain.
The Poke Program includes these best practices
Reducing Anxiety/Pain and Providing ComfortC.S. Mott Children’s Hospital
1. Assess and communicate about pain routinely with families and patients: Collaborative practice guidelines: Spinal fusion surgery, Duramorph
analgesia for urological patients, PRC screen, PACU pre-op call
2. Create an individualized plan with input from the child/parent Poke Program
3. Ask patients and families about pain and comfort4. Educate patients and families about pain management practices and
options5. Educate staff about how to talk to children & families about pain and
its treatment Pain conferences and CE programs
6. Pain order set in MiChart helps guide multimodal approach
Preparation and Information
• Poke and procedure preparation• Use “Best Words”• High distress and anxiety• Emphasize coping skills vs. information
• Practice skills and processes• Deep breathing/blowing bubbles• Positioning
Comfort Positions Help• Position correlates with development• Comfort positions make it easier for all• Teach parents to hold securely • Teaching others how to hold • Articulate the research on comfort positions• Sell the idea of parents as partners
Parental holding and positioning decreases distress
15
Distraction is a powerful tool
• Take a stimulus and reframe it• Developmental appropriate• Stimulus needs to be engaging• Individualize• Distraction is used• Before• During• After: speed the recovery/decrease the memory
Distraction can reduce pain by 50 %.
Parents as Partners
• Acknowledge their expertise• Need to be supported through their own
anxiety• Help parents to learn best words• Guide them to function as a coach and helper• Encourage them before, during and after• Positive recognition of behaviors that
worked• Eye contact and affirmative body language
Partner with a parent to achieve better outcomes
Positive Recognition• Be specific about what went well• Calling out positive behaviors helps the child
remember and reinforce future success• Prizes do not keep a behavior reinforced• Involve child in the plan and refine the plan for
next time
“I liked the way you held still like a statue during your poke.”
Drugs and Devices• Breasting feeding• 24 % sucrose (infants 6 mos. and younger)• Drops on anterior tongue with use of a pacifier
• Vapocoolant spray• Short duration and shallow effect
• Topical Anesthetics• LMX4 and LMX5 (20 minutes at least)• J-tip (a few seconds)
• Intradermal Injections• Buffered Lidocaine• Normal Saline
Poke-A-Dot The Comfort Dog
Poke –A –Dot becomes the messenger.
The Poke and Procedure Plan
• Includes best practice
• Patient centered• Parent participation• Simple• Team oriented• Communication• Empowering
Making the Poke Plan Work• Team Work– Phlebotomy, Physicians, RNs– Child Life, Psychologists, Social Work– MA’s, Techs, Unit host, clerical staff
• Communication– Planning and organization– Feedback– Asking for help and identifying problems/solutions
Work Flow for UMHS
Poke Program – Growing Fast!
• Audio Education On GetWell for Parents / Kids
• Digital Whiteboard Education
• Roll outs to CES, Peds Infusion, & PACU!!
• M Learning Module Available: NSG__68
• Pilot Rounding with Phlebotomy
• Info Sheet: Family Center Comfort Zone Pilot
Poke-a-Dot has Friends!
University of Iowa - Perky
Munson Medical Center – Poky the Penguin
Sparrow Hospital – Pokey the Turtle
Westchester Children’s Hospital - Ladybug
Hawaii – Kapi’olani Children’s Hospital
Wisconsin Children’s Hospital – Cow
Process AuditPoke/Procedure unit audit (v. #2) Date: Unit:
Census:
Patient # ______ (room and bed number) Subject number:How old is the patient? 1-6mos 7 -12mos 1 – 3yrs 4- 6yrs 7-12y 13-18y adult
Did the patient have a poke plan on the door? Yes No Refused by ptDid the poke plan have past experiences assessed? Yes NoDid the poke plan have preferred positions identified Yes No
Did the poke plan have at least one distraction technique Yes NoDid the poke plan include a topical anesthetic? Yes No (written in the notes section)
Was sucrose checked marked for infants 6 months or younger? Yes No NAComment:
Monitoring and measuring work process and work flow.
Learning New Skills: Poke Plan Implementation
• How to introduce the poke plan on patient care rounds?
• We all do better with instruction and education when learning new skills
• Utilize the team huddle for psychosocial rounds and poke plan updates
• Positive recognition
A round man cannot be expected to fit in a square right away. He must have time to modify his shape. Mark Twain
Transferring Ideas
Resources Required
• Recommended Staff– Nurse Manager– Pediatric Pain Team– Phlebotomy Team– Nurse Educator– Child Life Specialist– Nurses– Nursing Assistants
“None of us is as smart as all of us.” – Ken Blanchard
Resources Required
• Personnel Assignments– Who?
It ended up that EVERYBODY blamed SOMEBODY when NOBODY did what ANYBODY could have done.
This is a story about four people named EVERYBODY, SOMEBODY, ANYBODY and NOBODY.
EVERYBODY was asked to do it.
EVERYBODY was sure SOMEBODY would do it, but NOBODY did it.
SOMEBODY got angry about that because it was EVERYBODY’s job.
EVERYBODY thought ANYBODY could do it but NOBODY realized that EVERYBODY wouldn’t do it.
Resources Required
• Personnel Assignments– Who?• Initiates the education• Follows up to ensure completion• Reviews the plans prior to needlesticks• Advocates for patient preferences• Provides education regarding
– Comfort positioning– Distraction coaching– Best words– Empowerment and skills development
Resources Required
• Office supplies– Printed Comfort Plans– Printed educational handouts– Printed evaluations– Stickers
“Hope is the thing with feathers, that perches in the soul And sings the tune without the words, and never stops at all” - Emily Dickinson
Handouts
• Workflow– C.S. Mott– UI Children’s
• Comfort Plan– Similarities and differences
• Education for Parents– Comfort positioning– Advocating– Pain relief options– Distraction techniques
Education• The 5 C’s – Mantra of the Unit– Care: We care about you – Comfort: We want you to be comfortable– Create: We are going to create a plan– Choices: We have choices to make this a positive
experience– Cope: Working together as a team we can help
you and your child cope.
Education
• How to Evaluate• What worked / what did not?• What can be done better in the future?• Documenting modifications
Workflow for U of Iowa
“.”
• Receives comfort plan• Fills out what they can• Reviews cares with child life and/or admitting nurse
Procedure
• Using the plan chose comfort cares for procedure• Mark on plan what cares worked best• Patient adds “feather” sticker to perky for each poke
Review
• Comfort plan stays outside of patient room• Will be reviewed by the entire healthcare team prior to
any painful procedure
Patient Admission
Workflow for U of Iowa
“I liked the way you held still like a statue during your poke.”
Barriers and Bridges
• Resistance• Changes in workflow• Overnight Admissions• Perceived (?) lack of time• Consistency in use• Readmissions• Availability of Child Life
“Sometimes you put walls not to keep people out, but to see who cares enough to knock them down.” – Socrates
Barriers and Bridges
• Resistance = Opportunity for Education– Benefits • Patient/parent satisfaction
– Funding based on satisfaction scores
• Staff satisfaction– Happier patients– Reduced procedure time
• Changes in workflow = Innovative Roles– Provides staff with new roles that promote family
centered care
Barriers and Bridges
• Overnight Admissions– First impressions have lasting consequences
• Lack of time = Greater Collaboration• Inconsistency = Room for Improvement• Readmissions = Repeat Success• CL Unavailability = Increased Advocacy
“ ”
Introducing a Comfort Plan
“I think the numbing cream really helped…”
• Child Life Video Placeholder
More Bridges
• Mascot Promotion– Perky = UICH Mascot (Herky’s Cousin)– Increased public awareness– Positive role model
• Medical Team Inclusion– Nurse to nurse bedside handoff– Daily medical rounds
“Doesn’t the numbing cream makes the veins disappear?”
• Nurse Handoff Video Placeholder
“Doesn’t the numbing cream makes the veins disappear?”“ I think the thing to do in this situation is to arrange for him to get a PICC line, so he doesn’t get stuck so much. And I think we can skip his labs today. ”
• Medical Rounds Video Placeholder
Evaluation and Sustaining
• Parental Discharge Questionnaire– Overall perceptions of Comfort Plan
• Nursing Incentives– Promoting collaborative efforts through incentives– Satisfaction score increases– Preparedness reduces staff uncertainty
“I liked the way you held still like a statue during your poke.”
Parental Discharge Questionnaire
• Asked about their perceptions on a 5pt Likert scale– Always, Most of the Time, Sometimes, Rarely, Never– “Unsure” also an option
• RN Awareness of patient’s preference for:– numbing cream– poke location
• Offering of comfort/distraction– Comfort Position– Assigned distractor
Parental Discharge Questionnaire
• Parent’s perception of child’s fear• Parent’s anxiety• Overall satisfaction of pokes
“Love the Perky Feather Idea!!! :) ” – Satisfied Parent
Parental Discharge Questionnaire
• 95% felt the CP was explained in a way they could understand
• 77% felt (A/M) the CP helped tell staff how to do pokes with less pain/fear for their child
• 65% felt as a parent the CP helped them feel less anxious about their child’s pokes (20% unsure)
• 90% felt the CP raised awareness of options to decrease pain and fear
Parental Discharge Questionnaire
• Parents’ free responses:– “Kourtney did an excellent job drawing blood. She
listened to my son's preferences and explained what she was doing”
– “Didn’t need numbing cream or distraction. Wasn’t offered numbing cream”
– “I feel like some of the IV's left in for multiple days are not checked daily for redness.”
Parental Discharge Questionnaire
• “All the staff at U of IA hospitals were awesome. I felt they really listened to me on how to best care for my child. Very impressed.”
• “During the IV poke @ night, he was not offered numbing cream and we had to hold him down on the bed. it took nearly 30+min and was stressful. on the flip side, he got an IV by sedation team down @ MRI. He was given numbing cream but was held in a position of comfort and the nurse got in the IV quickly and efficiently so I felt that IV poke was very acceptable.”
• “Although my child did not have to use his comfort plan, i felt better knowing that there is one available if needed.”
Nursing Incentives• Raffles• Stickers to show participation• Leadership positions• Unit celebrations• UI Children’s Incentives:
– Audits done after AM>PM and before PM>AM RN shift change• Looking for Comfort Plan offered and placed outside room
– When 100% all nurses on that shift entered into raffle• Weekly drawings• Union limits incentives to <$3/prize
– 3 Keureg K-Cups and 2 disposable cups
Role Play Questions
• RN: kids are always going to HATE pokes how do you think this can be a positive experience?
• P: I’ve already filled out so much paperwork and just don’t want to have to do any more. Do I really need to do this?
• C: But I already have a IV! I’m scared. Does this mean I have to get a poke right now?
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