How a Children's Hospital Minimized Needle Pain

In pediatric settings, care bundles for needle procedures such as lidocaine administration and comfort positioning can significantly reduce pain.

Needles don't have to hurt a child.

In 2014, Minneapolis-based Children's Hospitals and Clinics of Minnesota launched an initiative to close a painful care gap. Patients and families had reported in surveys that needle procedures were their single largest source of pain and anxiety. Staff members surveyed had said needle pain was a low priority.

Over a three-year implementation period, Children's Minnesota attained 95% compliance with best practice strategies for needle procedures and achieved several other measures of success, researchers wrote this month in the journal Pain Reports.

"Comparison of baseline audits with continuous post-implementation audits revealed that wait times for services decreased, patient satisfaction increased, and staff concerns about implementation were allayed," the researchers wrote.

In surveys, the percentage of families who said hospital staff "always did everything they could to help with pain” increased from 78.3% to 85.3%. For the metric "child's pain was always well controlled," family satisfaction increased from 59.6% to 72.1%.

At Children's Minnesota, which features two hospitals as well as 26 primary and specialty clinics, more than 200,000 patients undergo needle procedures such as vaccinations and blood draws annually.

Needle procedures are more than a pain.

Vaccinations are a common needle procedure in children and needles have been associated with vaccine hesitancy. An estimated 25% of adults fear needles, with most fears developing in childhood.

Children's Minnesota followed a four-step process to implement its needle-pain initiative, which is called Children's Comfort Promise.

1. Strategy selection
 

After conducting the surveys of patients, families, and staff members in 2013, Children's Minnesota performed a review of evidence-based pain management strategies.

The organization chose four bundles of care for needle procedures that would be offered to all patients and families:

• For children 36 weeks or older, numbing of the skin with 4% lidocaine cream or needless-less lidocaine application with a disposable gas-propelled injector
   
• For infants as old as 12 months, sucrose or breastfeeding
   
• Comfort positioning such as swaddling and skin-to-skin contact for infants, and sitting on a parent's lap for children over 6 months
   
• Age appropriate distraction, including toys, books, pinwheels, and videos

2. Change management
 

To manage the quality improvement effort, Children's Minnesota chose the Toyota Production System—also known as lean or TPS—to guide the process.

A key TPS concept that Children's Minnesota embraced was "value stream," which analyzes a current state and designs a future state, as well as examines a service from its beginning to end.

At Children's Minnesota, the TPS process featured identifying multidisciplinary core team members, leadership sponsors, scope, objectives, and metrics. A nurse served as the value stream manager, with support from a lean coach and physician sponsor. Executive sponsorship featured the chief medical officer and chief nursing officer.

3. Rolling implementation
 

In early 2014, Children's Minnesota launched Children's Comfort Promise at the organization's two outpatient laboratories. The labs were chosen as pilot sites because they had relatively small staffs and high needle-procedure volumes, with more than 30,000 needle procedures annually.

The initiative was rolled out methodically through 2016:

• After the lab pilots, five inpatient medical-surgical units began the initiative later in 2014
   
• In 2015, several sites got involved, including both emergency departments, four neonatal units, three critical care units, two short-stay units, radiology, and the outpatient surgery program
   
• In 2016, all 26 ambulatory clinics implemented Children's Comfort Promise

After the pilot phase at the laboratory settings, expansion of the initiative was supported with baseline audit reviews, observations, and findings from the pilot to guide the TPS process.

The audits featured three metrics: the type of needle procedure, whether the four pain avoidance strategies were offered, and whether the staff found the strategies helpful when used.

4. Cultural shift
 

Measuring and communicating the positive performance of the needle care bundles was crucial to overcoming initial resistance to Children's Comfort Promise from staff members, the researchers wrote.

Three positive results were particularly convincing:

• Wait times went down instead of up, contrary to many staff members' expectation
   
• Lidocaine administration did not result in a single case of venous constriction impeding insertion of a needle into a vein
   
• The four care bundle strategies provided immediate benefit to patients

To cement Children's Comfort Promise organization-wide, leadership performance bonuses were tied to attaining target goals. "The new care standard was integrated into all organizational policies, the electronic medical record, and new staff orientation, making nonadherence a performance issue," the researchers wrote.