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Collaboration for Comfort: Helping Children Cope Julie Piazza, MS, CCLS University of Michigan C.S. Mott Childrens Hospital And Ben Miller, BS, CCLS University.

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Presentation on theme: "Collaboration for Comfort: Helping Children Cope Julie Piazza, MS, CCLS University of Michigan C.S. Mott Childrens Hospital And Ben Miller, BS, CCLS University."— Presentation transcript:

1 Collaboration for Comfort: Helping Children Cope Julie Piazza, MS, CCLS University of Michigan C.S. Mott Childrens Hospital And Ben Miller, BS, CCLS University of Iowa Childrens Hospital

2 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

3 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.

4 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

5 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

6 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

7 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 dont have to see the whole staircase just take the first step -Martin Luther King, Jr.

8 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

9 Patient and Family Centered Care The Poke Program supports the principles of Patient-Family Centered Care

10 What does the literature say? Preparation Distraction Positioning Parents as helpers and coaches Positive recognition Drugs and Devices Place your information into synthesis tables.

11 Change Package: Best Practices Lucile Packard Childrens 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

12 Reducing Anxiety/Pain and Providing Comfort C.S. Mott Childrens 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 comfort 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 Pain conferences and CE programs 6.Pain order set in MiChart helps guide multimodal approach

13 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

14 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 15

16 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 %.

17 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

18 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.

19 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

20 Drugs and Devices Buzzy® Vibration and cold

21 Poke-A-Dot The Comfort Dog Poke –A –Dot becomes the messenger.

22 The Poke and Procedure Plan Includes best practice Patient centered Parent participation Simple Team oriented Communication Empowering

23 Making the Poke Plan Work Team Work – Phlebotomy, Physicians, RNs – Child Life, Psychologists, Social Work – MAs, Techs, Unit host, clerical staff Communication – Planning and organization – Feedback – Asking for help and identifying problems/solutions

24 Work Flow for UMHS

25 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

26 Poke Program – Growing Fast! Poke-a-Dot has Friends! University of Iowa - Perky Munson Medical Center – Poky the Penguin Sparrow Hospital – Pokey the Turtle Westchester Childrens Hospital - Ladybug Hawaii – Kapiolani Childrens Hospital Wisconsin Childrens Hospital – Cow

27 Process Audit Poke/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 pt Did the poke plan have past experiences assessed? Yes No Did the poke plan have preferred positions identified Yes No Did the poke plan have at least one distraction technique Yes No Did 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 NA Comment: Monitoring and measuring work process and work flow.

28 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

29 Transferring Ideas

30 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

31 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 EVERYBODYs job. EVERYBODY thought ANYBODY could do it but NOBODY realized that EVERYBODY wouldnt do it.

32 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

33 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

34 Handouts Workflow – C.S. Mott – UI Childrens Comfort Plan – Similarities and differences Education for Parents – Comfort positioning – Advocating – Pain relief options – Distraction techniques

35 Education The 5 Cs – 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.

36 Education How to Evaluate What worked / what did not? What can be done better in the future? Documenting modifications

37 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

38 Workflow for U of Iowa I liked the way you held still like a statue during your poke.

39 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

40 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

41 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

42 Introducing a Comfort Plan I think the numbing cream really helped… Child Life Video Placeholder

43 More Bridges Mascot Promotion – Perky = UICH Mascot (Herkys Cousin) – Increased public awareness – Positive role model Medical Team Inclusion – Nurse to nurse bedside handoff – Daily medical rounds

44 Doesnt the numbing cream makes the veins disappear? Nurse Handoff Video Placeholder

45 Doesnt 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 doesnt get stuck so much. And I think we can skip his labs today. Medical Rounds Video Placeholder

46 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.

47 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 patients preference for: – numbing cream – poke location Offering of comfort/distraction – Comfort Position – Assigned distractor

48 Parental Discharge Questionnaire Parents perception of childs fear Parents anxiety Overall satisfaction of pokes Love the Perky Feather Idea!!! :) – Satisfied Parent

49 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 childs pokes (20% unsure) 90% felt the CP raised awareness of options to decrease pain and fear

50 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 – Didnt need numbing cream or distraction. Wasnt offered numbing cream – I feel like some of the IV's left in for multiple days are not checked daily for redness.

51 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 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 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.

52 Nursing Incentives Raffles Stickers to show participation Leadership positions Unit celebrations UI Childrens 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

53 Role Play Questions RN: kids are always going to HATE pokes how do you think this can be a positive experience? P: Ive already filled out so much paperwork and just dont want to have to do any more. Do I really need to do this? C: But I already have a IV! Im scared. Does this mean I have to get a poke right now?

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