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 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 Similarities between UI program: Family Centered Care Needle phobia is a reality for many ! 4

Differences Between Conducting Research and Using Research (EBP) Research Utilization 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 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 Evidenced Based Practice We are putting evidence into practice to directly benefit patients and promote positive outcomes Uses these to change practice 5

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 Triggers: pain is a clinical problem. Not knowing preferences is an organizational problem. Knowing the best ways to address pain and increase awareness addresses these issues Decreased pain and anxiety results in higher satisfaction for patient, parent, and staff. WIN Decreased time means more efficient workers, less stressed staff. WIN 6

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 With all the research out there it is crucial to be able to interepret it effectively and apply its understanding appropriately. Continual process of evaluation and modification, doesn’t stop evolving (new methods – j-tip and new knowledge can be applied) You don’t have to see the whole staircase just take the first step -Martin Luther King, Jr. 7

Patient and Family Centered Care Dignity and Respect Information Sharing Participation Collaboration Empowerment Ellie's Story The “Poke” Program supports the principles of Patient-Family Centered Care 8

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

What does the literature say? Preparation Distraction Positioning Parents as helpers and coaches Positive recognition Drugs and Devices P- decreases anxiety by clearing up misconceptions and assigning roles D- helps to increase compliance, reduce anxiety P- increases comfort for both patient and parents, assists in successful IV Pa- increases compliance Pr- promotes effective coping skill retention D- decreases perceived and actual pain – addresses pt/family concerns about pain Place your information into synthesis tables. 10

The Poke Program includes these best practices Change Package: Best Practices Lucile Packard Children’s Hospital at Stanford Assess and communicate about pain routinely with families and patients. Ask patients and families daily how well pain is controlled. Create an individualized pain plan for every patient, including family input. Educate patients and families about pain management practices and options. Educate staff about how to talk to children & families about pain and its treatment Use standard protocols/order sets to manage anticipated (e.g. procedural) pain. The Poke Program includes these best practices 11

Reducing Anxiety/Pain and Providing Comfort C. S Reducing Anxiety/Pain and Providing Comfort C.S. Mott Children’s Hospital 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 Create an individualized plan with input from the child/parent Poke Program Ask patients and families about pain and comfort Educate patients and families about pain management practices and options Educate staff about how to talk to children & families about pain and its treatment Pain conferences and CE programs Pain order set in MiChart helps guide multimodal approach 12

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 13

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 Kim’s story about talking with nursing colleagues about comfort positions Parental holding and positioning decreases distress 14

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 Stephanie’s story about using distraction and coaching effectively Distraction can reduce pain by 50 %. 16

Partner with a parent to achieve better outcomes 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 17

“I liked the way you held still like a statue during your poke.” 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 Verbally identifying positive behaviors is more effective than prizes Involving child increases likelihood of utilization in the future. “I liked the way you held still like a statue during your poke.” 18

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 19

Drugs and Devices Buzzy® Vibration and cold 20

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

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

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 23

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 25

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

Monitoring and measuring work process and work flow. 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: Review is crucial for improvement Monitoring and measuring work process and work flow. 27

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 28

Transferring Ideas

“None of us is as smart as all of us.” – Ken Blanchard 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? 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. It ended up that EVERYBODY blamed SOMEBODY when NOBODY did what ANYBODY could have done.

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

“Hope is the thing with feathers, that perches in the soul 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 Comfort Plan Education for Parents 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 Patient Admission 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 “.”

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

“Sometimes you put walls not to keep people out, 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 Child Life Video Placeholder “I think the numbing cream really helped…”

More Bridges Mascot Promotion Medical Team Inclusion 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?”

“Doesn’t the numbing cream makes the veins disappear?” Medical Rounds Video Placeholder “ 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. ” “Doesn’t the numbing cream makes the veins disappear?”

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?