Improving Pediatric Experience of Pain During Vaccinations at the North Bay Nurse Practitioner-Led

Clinic

Terri MacDougall, MScN (Cand), NP-PHC

North Bay Nurse Practitioner-Led Clinic

Disclosure Statement

Presenter: Terri MacDougall, MScN (cand), NP-PHC Relationships to commercial interests: Advanced Clinical Practice Fellow- Registered Nurses Association of Ontario 2015-2016 Grants/Research Support: 13 000 Speakers Bureau/Honoraria: None Consulting Fees: None Other: None

Disclosure Statement Disclosure of Relationship Company/Organization

I am a member of an Advisory Board or equivalent with a commercial organization.

NO

I am a member of a Speaker Bureau. NO

I have received payment from a commercial organization (including gifts or other consideration or ‘in kind’ compensation).

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I have received a grant(s) or an honorarium from a commercial organization.

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I hold a patent for a product referred to in the CME/CPD program or that is marketing by a commercial organization

NO

I hold investments in a pharmaceutical organization, medical devices company or communications firms.

NO

I am currently participating in or have participated in a clinical trial within the past two years.).

NO

Reflection

Excellent guidelines on how to mitigate pain are available

Why did the North Bay Nurse Practitioner Led Clinic embark on

improving pediatric experience of pain during painful procedures?

Why is this important? Our clinic gives, on average 9 needles per week

In the first 18 months children get 12 needles

Inflicting pain is upsetting for our healthcare team

10% of the population fear needles, we cannot predict

Know better… do better

AIM Statement

• We will reduce procedural (needle) pain in children aged 0-16 years attending the NBNPLC by 50% (pain score) at procedure (0 minutes) and post procedure (5 minutes) by March 4, 2016 (6 month quality improvement project- IDEAS).

• OVER-ARCHING GOAL: Implement RNAO Assessment and Management of Pain Best Practice Guideline

Measures

• Outcome Measures: Pain Score, Parent/Patient Experience – Recovery from Pain

• Process Measures: Number of interventions used to mitigate pain →PDSAs

• Balancing measures: Staff satisfaction Cost of EMLA or sugar water (impact on budget)

Changes

• Use age appropriate assessment tool to score pain at procedure (r-FLACC)

• Use Sucrose as a pain mitigation strategy • Standardized sucrose product is available to purchase

• Use of topical anesthetic (EMLA) patches from stocked supply

• Increased staff knowledge/confidence in topical anesthetic, enhanced education of parents, costly to offer free patches to all parents. Encouraged parents to purchase own patch, discovered product monograph is inadequate…. We created a easy to read handout

Changes

• Implement as many pain mitigation strategies as indicated for age group • Educate staff about the guideline, visual reminder in well baby/child file and

on Electronic Medical Record

• Website update www.nbnplc.com

• Obtain feedback from parents/patients about their experience • Help refine our techniques (tootsweet); inform our improvement plan

Results- EMLA

UCL 11.9

CL 5.1

LCL -1.6

-4.0

-2.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Pai

n S

core

rFL

AC

C

Patient

Pain Score Ages 0 to 36 months

Start Emla

Results -TootSweet

UCL 9.7

CL 5.3

LCL 0.9

0.0

2.0

4.0

6.0

8.0

10.0

12.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Pai

n S

core

rFL

AC

C

Patient

Pain Score Ages 0 to 24 months

Start Tootsweet

Impact

18 month immunization

• Concept of Polarity--- some parents and providers feel that pain is just apart of the experience and accept pain, feel we are doing enough… Important to address why

• Engagement of staff is imperative, use influencing strategies- Presentations to staff: IDEAS Coach- Shawna Cunningham- PDSA thinking

& Pain Expert – Mona Sawhney, PhD, NP, emphasized that pain is mitigated with multiple strategies

• To make practice change…is a dynamic process, QI principles-PDSA thinking…Process and data analysis, Adaptive leadership (when to raise the heat)….staff engagement and education (hands on, pathophysiology- presentations)

• Make changes easy - visual reminders help ie) Health Care Provider Documentation Tool, EMR cues

Overall Learning

Next Steps to Progress Improvement

Culture change… expected level of care at the NPLC

• Sustained use of pain assessment tool

• Optimal management of pain utilizing multiple pain mitigation strategies (EMR and visual reminders)

• Advocate for pain management to parents– Address Culture of Pain Acceptance -- communication

• Spread to interested providers

• Breastfeeding during immunization reduces pain

• Baby Friendly Initiative… to improve Breastfeeding Rates at the North Bay Nurse Practitioner Led Clinic

Next Steps to Progress Improvement

Questions?

Thank you for the opportunity!