Back to the Blood Drawing Board:

1. Back to the Blood Drawing Board: Creating and Implementing a Comfort-Based Phlebotomy Experience Pnina Grauman MS, CCLS FACLP Conference 2012

2. What I hope will “stick” with you… • The pain experience: patients and Child Life Specialists • Team-building skills • The Child Life “tool kit” for phlebotomy • Building blocks for your own comfort-based initiatives • Incorporating the phlebotomy experience into your culture of family-centered care

3. “Owwies” from a young age • Initial experiences with pain can be as early as shortly after birth • These experiences can then impact a child’s overall responses to later exposures to pain

4. Pain and Tears Through the Years • Neonates and Infants • Toddlers and Preschoolers • School-age children • Adolescents

5. Easing Pain Without a Pill • Child Life • Parent/child involvement • Positioning for comfort/therapeutic positioning • Post-procedural interventions • Bed as a safe space

6. Pain Relief From the Pharmacy • EMLATM Cream • SyneraTM Patch • Sweet EaseTM

7. Our Mission Statement on Pain • “The Children’s Hospital at Montefiore respects and supports every child’s right to pain assessment and optimal pain management”

8. In CHAM, we believe that… • Effects of unresolved pain are physical and psychological • Pain limits progress • Pain management enhances comfort • We must evaluate and treat pain based on the child’s report • Pain response depends on developmental level • Families are crucial in pain management • A child’s bed = safe space • There are pharmacological and non-pharmacological approaches to pain

9. Prior Approaches to Pediatric Pain Management • “Making Needles Easier to Bear” pain committee • The “A.C.T.” Approach: -Assess/Analgesics -Child Life -Teamwork • Therapeutic positioning posters • I.V carts in treatment rooms • Noting parents’ concerns

10. Setting Our First Goals • Improve the phlebotomy experience for patients and families • Increase the use of comfort measures • Create a culture of pain control across the children’s hospital

11. From Meetings to Methodology • Proposal submitted to the IRB: “Parental Perception of Child’s Comfort During Blood Drawing: A Before and After Interdisciplinary Approach to Improving the Inpatient Phlebotomy Experience” (O’Connor, K., Liewher, S.K., Kelly, M., & Skae, C. (2009)) • Background • Objectives • Design

12. Initial Pre-Test Findings • Of 71 parents surveyed: -18% reported the use of numbing medicine -32% reported presence of Child Life Specialist -51% reported blood draws were performed by a phlebotomist -average Wong-Baker score: 3.4/5

13. What does this all mean? • Comfort based techniques were being underutilized for patients, which is likely related to their parents’ perceptions of significant pain • The education about and availability of analgesics alone were not enough! • Interdisciplinary team initiatives were necessary to create a culture of pain-free procedures

14. These were our goals—how did we meet them? • Increase the efficacy of venipunctures and decrease the frequency of unnecessary, ill-timed blood draws • Improve the usage and floor presence of topical anesthetics • Increase the presence of Child Life Specialists during routine blood draws

15. Sitting Down and Strategizing • Schedule: phlebotomy rounds twice a day in the floor treatment rooms for patients who received EMLA cream at least 1 hours prior to blood draw; Child Life Specialist present • Supplies: need for adequate EMLA for all patients who were ordered for blood draws • Initial Concerns: patient transport, patient list, timing, adequate EMLA, delaying discharge, evidence-based practice

16. Start Your Engines! • Program Initiation: October 3, 2008 • Original plan involves Child Life Specialists in phlebotomy rounds at 9:30 AM and 3:30 PM on one “pilot” unit • All draws performed in the treatment room • All patients should have numbing cream • Child Life Specialist to provide parents and patients with support/education (distraction, coping, positioning, Sweet Ease, etc.)

17. Bumps Along the Way Preliminary barriers faced: • Timing • Staffing logistics • Ongoing education and training of medical staff • Technical/pharmacy complications • Drops in pain committee attendance • Families mis/uninformed • Staff not optimally receptive

18. Continued… • Ethical complications • Containment of EMLA with TegadermTM was uncomfortable for the infant/toddler population

19. If at first you don’t succeed… Adjustments and improvements: • Timing/scheduling/staffing/location changes • Ongoing nursing and resident education • Document, document, document!! • Advocacy of topical anesthetics with the pharmacy staff • Emphasizing patient/family education

20. Setting Goals After Our First Year • Universal comfort measures • Making EMLA readily accessible • Ensuring standing orders for all admitted patients • Expanding the pilot unit to other inpatient areas • Involving doctors and nurses in the planning process • Daily documentation • Establish a computerized EMLA prompt in patient orders

21. Continued… • Assign an educational pain module • Researching other materials to contain EMLA • Using other, quicker-acting topical anesthetics • Improved interdisciplinary communication • Hiring a pediatric phlebotomist

22. And now, a brief movie… (Thank you to Katherine O’Connor, MD and Charlotte Pharr, MA, MT-BC for your filming expertise as well as to my adorable patients and their families!)

23. So, how are we doing? • Upon admission, each patient has standing orders for EMLA • EMLA readily stocked in med rooms and PyxisTM machines • Rounds with Child Life Specialists on all four inpatient units beginning at 9:30 AM • Educational procedural pain management module assigned to all medical staff

24. Continued… • Pain-Ease trial on inpatient unit, now used regularly in outpatient radiology • CHAM floors designated with “Comfort Zone” signage • July 1, 2011: a CHAM-only pediatric phlebotomist is hired! • Phlebotomist conducts daily morning rounds to remind medical staff to apply EMLA and documents each blood draw done on the day shift

25. And finally… • Coming soon: automatic computerized prompt and designation of patients ordered for blood draws • Faster-acting anesthetics still being investigated • July 1, 2012: overnight pediatric phlebotomist hired!

26. And the results are in! • Post-test findings, August 2012: significant results found in the following areas: -Child Life presence during blood draws (2008: 32%  2012: 63%) -Numbing medicine used prior to blood draw (2008: 19%  2012: 43%) -parents perceived their children’s pain as adequately controlled (2008: 3.8/5, fair-to-good  2012: 4.2/5, good-to-very good!) -Average rating on Wong-Baker FACES pain scale decreased (2008: 3.4  2012: 2.9) • Publication of the study is in our future!

27. Getting Your Own Comfort Zone off the Ground • Determine your needs: -survey families and medical staff • Mobilize your resources: -interdisciplinary communication is key (include MDs, RNs, phlebotomy, child life, pharmacy, etc.) -establish a hospital-wide task force -ensure visibility of your efforts and publicize your initiative (flyers, posters, stickers, pins, etc.(

28. Continued… • Educate: -staff AND patients/families -hands on staff experiential sessions • Validate your efforts: -document, document, document! -videos/photos -track parental and staff responses/compliance -cost/benefit analysis

29. Recommended Reading • Leahy, S., Kennedy, R., Hesselgrave, J., Gurwitch, K., Barkey, M., & Millar, T. (2008). On the front lines: Lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics 122(3): 5161-5170. • Kuttner, L. (1996). The child in pain: How to help, what to do. Washington: Hartley & Marks. • Cavender, K., Goff, M.D., & Hollon, E.C. (2004). Parents’ positioning and distracting children during venipuncture: Effects on children’s pain, fear, and distress. Journal of Holistic Nursing 22(1): 32-56.