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Friday, July 22, 2011
Parents and caregivers know how children feel about medical procedures involving needles: “Kids universally dislike them,” says Lisa Watt, PNP, of the Massachusetts General Hospital Pain Service. Even so, adults may underestimate the extent of those feelings. “When you look at the literature, kids actually rate needle insertion procedures as one of the worst things about the hospital experience, right up there with surgery, and they considered the procedure to be very painful,” Watt says. Studies have shown that even a simple blood test can have lasting effects, and negative experiences can result in more painful and distressing procedures later. They can also lead families to avoid medical care altogether. With this knowledge in mind, the MassGeneral Hospital for Children (MGHfC) Quality and Safety Committee, in collaboration with the Pain Service and Child Life, created an initiative to improve the experience for pediatric patients undergoing needle insertion procedures.
A patient undergoes a procedure with help from his caregiver and Senior Child Life Specialist Marilyn Gifford (right).
“The ultimate goal of the initiative is to help children, family members and staff work together to make the procedure go as smoothly as possible,” says Watt, who has been instrumental to the organization and implementation of the program.Adds Denise Lozowski, RN, another key figure in the initiative: “If the child has an overall positive experience with their medical visit, they won’t go into the next visit with quite as much distress.” She says many factors play a role, from the person at the front desk to communications with the staff and even the décor of the room. “Those things all get pieced together by the child.”
Preparation, Distraction, Numbing
The three-part initiative uses preparation, distraction and numbing the skin for children and adolescents undergoing procedures involving needles. All MGHfC clinical staff will be taking part in training specific to the initiative. MGHfC Child Life specialists, led by Marilyn Gifford, CCLS, prepare children for medical procedures through developmentally appropriate information given in a step-by-step process with a focus on the sensory elements of the procedural process. “Through ‘medical play’ children have the opportunity for a hands-on experience with appropriate medical materials and expression of feelings,” Gifford says. Child Life specialists can assess the child’s coping style and help them practice coping and distraction methods, such as special breathing techniques or guided imagery, prior to the procedure.With input from the MGHfC Family Advisory Council, the Child Life department developed a parent handout (PDF) that explains how to help the child before, during and after a procedure. “Distraction is one of the best ways to decrease the pain and distress of needle stick procedures,” Watt says. “Kids are coachable and parents have a big role to play. With a little instruction, most children can learn simple techniques to keep their mind off the procedure itself. For example, toddlers can sing a favorite song with their parent; school-age children and teens can listen to music or watch a video. Hand-held video games work extremely well for many age groups,” she adds.The parent handout also explains the importance of letting the child know that he/she did a good job. Praise is an important tool in pediatric care, even for small efforts. It helps children gain confidence in their own ability to cope with a scary or painful procedure. The final component of the MGHfC program is the use of local anesthetic to numb the area of the skin where the needle will be inserted. Many patients have been given EMLA, a skin cream that numbs the skin in about an hour. Now many patients also have access to the “J-Tip,” a new device that delivers the anesthetic as a pressurized spray. The J-Tip makes a loud “pop” noise and takes just three to five minutes to numb the skin. Although it is not advised for use in young infants and children undergoing chemotherapy, the J-Tip provides many patients pain relief comparable to topical anesthetics, in much less time. EMLA is still available for patients who prefer it as well as those who are unable to receive the J-Tip.“This is more than just a nice thing to do-- we aim to prevent delays to care,” Watt says of the speedier J-Tip.MGHfC staff who provide care to patients have been undergoing a two-part training, firstly to learn how to improve the management of procedures involving needles, and secondly to learn how to use the J-Tip.
The new initiative has been rolled out to all of MGHfC’s inpatient areas, including the Emergency Department and the Pediatric Intensive Care Unit, and the next stop is procedural areas like endoscopy and radiology. Eventually the initiative will make its way to the outpatient areas. By creating positive experiences for patients early in their lives, the initiative could have long-term effects, Watt says. “With 10% of the general population known to have needle phobia, we may be in a position to help young patients avoid such long-term negative effects.” The initiative also receives support from Padma Gulur, MD, director of the Pediatric Pain Service; Esther Israel, MD, Quality and Safety Committee; and the Pediatric Clinical Nurse Specialist group.Parent Handout: Helping Your Child through an IV or Blood Test (PDF)
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