A Survey of Interventions for Needle Procedures in a Pediatric Hospital

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Selling Comfort: A Survey of Interventions for Needle Procedures in a

Pediatric Hospital

Pain Manag Nurs 5(4):144-152, 2004. © 2004 W.B. Saunders

NOTE: To view the article with Web enhancements, see:

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A. Ellis, RN, PhD; Diane Sharp, RN, CINA; Kym Newhook, RN,

BScN; Janice Cohen, PhD

Abstract

Needle procedures are a necessary component of the treatment of

hospitalized children. However, for many children they can be both

painful and distressing. There was concern among the nurses at our

pediatric hospital that we were not adequately controlling pain from

needle procedures. We were interested in obtaining more information

about the incidence and types of needle procedures and the current use

of topical analgesics.

A survey was designed to describe the frequency, type, time to complete,

and perceived ease of needle procedures. The use of topical anesthetics

and other comfort measures was also examined. The most common needle

procedures performed were venipunctures for blood work, followed by

intravenous cannulations, capillary sticks, port-a-cath access, and

intramuscular injections. In total, 387 procedures were performed over a

23-day period.

The majority of the procedures were perceived as easy, and the modal

time to complete the procedures was 5 minutes. A topical anesthetic was

used for 74 procedures (i.e., 19%), and the majority of these procedures

were performed on the medical day unit with oncology patients.

Results of the survey provided information about the day-to-day practice

of needle procedures in order to identify both the supports and the

barriers to providing these procedures atraumatically. Examining needle

procedures within a framework of atraumatic care broadened our

perspective and enabled us to integrate the use of topical anesthetics

as just one of a number of strategies to minimize the pain and distress

associated with needle procedures.

Introduction

Invasive procedures, particularly procedures that involve needles, can

cause substantial anxiety and pain in a pediatric setting. Many children

view receiving needles as one of the most traumatic aspects of being in

the hospital (Cordoni & Cordoni, 2001; Cummings, Reid, Finley, McGrath,

& Ritchie 1996). Parents rate needle procedures as the

second-most-distressing event during their child's hospitalization,

second only to waiting for their child during surgery (Caty, Ritchie, &

Ellerton, 1989).

The most frequent needle procedures that hospitalized children encounter

include venipuncture for laboratory blood sampling, intravenous (IV)

cannulation, and intramuscular injections. The amount of pain caused by

these procedures varies across studies, and reports range from mild to

severe (Arts et al., 1994; Eland, 1981; Goodenough et al., 1997;

Fowler-Kerry & Lander, 1987; McGrath et al., 1990).

On average, younger children experience more pain and anxiety than older

children (Fowler-Kerry & Lander; Fradet, McGrath, Kay, , & Luke

1990). For some individuals, a fear of needles persists into adulthood

and may have lifelong negative repercussions, such as preventing them

from donating blood (Oswalt & Napoliello, 1974) or precipitating

fainting episodes in response to a needle (Pavlin, Links, Rapp, Nessley,

& Keyes 1993).

Studies that predate the widespread use of conscious sedation for bone

marrow aspirations and lumbar punctures indicate that children's pain

and distress may escalate over time with successive procedures (Ellis &

Spanos, 1994; Jay, Ozolins, Elliott, & Caldwell, 1983; Katz, Kellerman,

& Siegel, 1980; Kellerman, Zeltzer, Ellenberg, & Dash, 1983).

Furthermore, research suggests that if painful procedures are not

adequately managed, children may suffer negative short- and long-term

psychological effects, such as anticipatory nausea and vomiting,

insomnia, eating problems, and treatment nonadherence (Ross & Ross,

1988; Walco, Cassidy, & Schechter, 1994; Weisman, Bernstein, &

Schechter, 1998). Taken together, these studies highlight the importance

of ensuring that children's distress during needle procedures is

recognized and that efforts are made to control the pain and minimize

the distress.

A significant development in minimizing children's pain and distress

during needle procedures has been the dramatic increase in the use of

topical anesthetics such as EMLA cream (eutectic mixture of local

anesthetics; Astra Pharmaceutical Products) or Ametop Gel ( &

Nephew). In many hospitals, it is standard practice to use some type of

topical anesthetic for all procedures that involve needles (Finley,

2001). These products provide pain relief at the insertion point of the

needle and are relatively inexpensive and easy to use (Fetzer, 2002;

Taddio, Gurguis, & Koren, 2002).

EMLA cream is a mixture of equal parts of 2.5% lidocaine and 2.5%

prilocaine and is applied to the skin, then covered with an occlusive

dressing and left in place for at least 60 minutes. The peak action for

EMLA occurs at 2 hours and lasts for as long as 4 to 5 hours. A

disadvantage of EMLA is that vasoconstriction of the vein has been

documented, but this effect is reduced if the cream remains in place for

longer than the minimum 60 minutes (Moureau & Zonderman, 2000). The most

common side effects of EMLA include local skin reactions, such as

itching or a minor skin rash, which quickly disappears when EMLA and the

occlusive dressing are removed. Allergic reactions to EMLA are extremely

rare, but mild systemic reactions have appeared in a small percentage of

patients with known allergies to lidocaine. Ametop Gel (tetracaine 4%)

provides analgesia similar to EMLA's but has the advantage of a more

rapid onset of action. It works in about 30 to 45 minutes, lasts for 4

to 6 hours after a single application, and does not cause

vasoconstriction. Ametop Gel is more expensive, at $2.97 per dose, than

EMLA, at $1.31 per dose.

The use of a topical anesthetic was not mandatory for needle procedures

at this hospital, and there was a perception among the nurses that

needle pain was not adequately controlled and that topical anesthesia

was not being used in a systematic manner. Two recent studies conducted

within our hospital indicated that procedural pain, and in particular

needle pain and associated anxiety, warranted closer examination.

In the first study (Ellis et al., 2002), the pain intensity of a variety

of procedures including needles was described as part of a hospitalwide

pain prevalence survey that included 237 medical and surgical patients.

Procedural pain ratings were obtained from either the child or the

parent immediately after a potentially painful procedure. The average

procedural pain rating was 4.38/10 (SD = 3.7), which is indicative of

moderate pain. In a more recent study (Ellis et al. 2004), nurses'

attitudes about procedural pain were assessed, and although they

strongly agreed that nurses could make a difference in how children

coped with painful events, they agreed only somewhat that they

adequately prepared children and parents for painful procedures. Taken

together these two findings indicated that the management of procedural

pain in our hospital at least warranted further investigation and

potentially intervention, including changes in institutional policies,

to improve practice.

An obvious direction would be the development of a policy that required

the use of topical anesthetic for all needle procedures. However,

questions were raised as to whether this approach was necessary for all

procedures, noting that such a policy has financial and human resource

implications.

In addition, anecdotal evidence suggested that for a few children, EMLA

actually added to their distress. For these children, the application

and removal of the occlusive dressing was perceived as a traumatic

aspect of the needle procedure. Similarly, Cohen and colleagues (1999)

reported high distress scores in an EMLA group compared with a group

receiving standard care and distraction and suggested that waiting for

60 minutes before inserting the needle might increase anticipatory anxiety.

A detailed examination of the issue was undertaken before a decision

about a policy to require a topical anesthetic for all needle

procedures. This naturalistic study was designed to capture typical

practice as it happens and not to alter it in any way for the purposes

of the study. The objectives of the study were (a) to describe the

frequency and types of needle procedures performed over a 5-day period;

( to describe the current use and perceived effectiveness of EMLA and

Ametop Gel; © to describe the use of nonpharmacologic comfort measures

during needle procedures; and (d) to describe the time to complete and

the perceived ease of needle procedures. The goal of the study was to

provide data that would inform the development of a policy with regard

to the use of EMLA or Ametop Gel in conjunction with nonpharmacologic

measures to manage needle pain.

Methods

Setting

The hospital is a 150-bed pediatric teaching hospital that serves

patients and families from eastern Ontario and western Quebec. The

hospital offers a full range of inpatient medical and surgical services

as well as ambulatory, emergency-department, and rehabilitation services.

The hospital has an IV team composed of two full-time and six part-time

nurses who perform all of the venipunctures and IV starts throughout the

hospital. The specialty units, such as the medical day unit (MDU),

emergency, and the intensive care units, also perform venipunctures and

IV starts in their respective areas. The Blood Drawing Laboratory has

three lab technicians who perform venipunctures for outpatient and

clinic referrals. The IV team provides support in all areas of the

hospital for difficult procedures, as required.

Measures

The IV team nurses, laboratory staff, and four nurses from the MDU were

involved in the study. A log was developed to record information about

each procedure performed, and staff members carried the log with them on

their daily rounds. Each page of the log had space to record 20

procedures on one side and instructions about how to use the log on the

reverse side. The variables recorded are included in Table 1. Data were

collected over a 3-week period, and each staff member who participated

kept a record of all procedures for a 5-day period. The survey log was

developed with consultation from the hospital's multidisciplinary pain

committee and the members of a subcommittee on procedural pain. The

survey log and data collection methods were piloted with one member of

the IV team.

Results

Procedures

In total, 387 procedures were recorded over a 23-day period, and 374

procedures were needle procedures. Procedures that did not involve a

needle included blood work via an existing line (8 procedures) and IV

assessment for patency (5 procedures). The IV team nurses performed 183

procedures (47%), laboratory staff performed 121 procedures (31%), and

staff on the MDU performed 83 procedures (21%). The patients ranged in

age from 10 days to 20 years, and the median age was 6.0 years. There

were no preterm or newborn infants in the study because the neonatal

intensive care unit nurses are responsible for inserting IVs and drawing

blood on their own patients. Table 2 presents the type and frequency of

needle procedures.

Topical Anesthetics

EMLA was used for 72 procedures (19%) and Ametop Gel was used for 2

procedures (0.5%). The average age of the children who received EMLA was

6.7 years (SD = 3.9), and for those who did not receive EMLA it was 7.5

years (SD = 5.5). The difference in age between the two groups was not

significant (p = .27). Ametop Gel was used for one 9-year-old child and

one 13-year-old child. No topical analgesic was used for any child under

1 year of age.

Of the 72 procedures in which EMLA was used, 50 procedures took place on

the MDU with oncology patients. EMLA was applied for all of the 18 IM

injections, the 25 port-a-cath access procedures, the 5 lumbar

punctures, and 2 insuflon procedures. There was no discernable pattern

to the remaining 22 procedures, which were primarily IV cannulation and

blood work. Parents were present for 63 out of 72 procedures in which

EMLA was used (88%) and for both of the procedures for which Ametop was

used (100%).

The effectiveness of EMLA/Ametop Gel was based on the judgment of the

person performing the procedure and was categorized as yes, no, or

unsure. For 67 procedures (93%) the topical anesthetic was judged to be

effective, for 2 procedures (2.5%), not effective; and for 4 procedures

(5%), the nurse was unsure if it was effective. For most procedures the

nurse or lab technician who performed the procedure requested that

EMLA/Ametop Gel be used (48 procedures, 69%), followed by parental

request (17 procedures, 24%), and parents applied EMLA at home before

coming to the hospital for 5 procedures (7%). One parent refused EMLA

for the child.

Comfort Measures

Parents were present for 75% of the procedures (289) and absent for 25%

(98) of the procedures. The average age of the children who had parents

present was 6.5 years (SD = 4.7), and for children without parents

present, the average age was 9.8 years (SD = 6.1). The most commonly

used comfort measures were verbal reassurance (289 procedures, 75%) and

distraction (108 procedures, 28%).

Procedure Time

The average time for completion of a procedure was 9.3 minutes, the

median time was 10 minutes, and the times ranged from 2 minutes to 90

minutes. The average time for procedures with EMLA (n = 72) was 8.6

minutes (SD = 4.2), and for procedures without EMLA (n = 315) it was 9.5

minutes (SD = 7.3), a nonsignificant difference (p = .34). The procedure

time for Ametop Gel was 20 minutes and 90 minutes for the 2 procedures

in which it was used, respectively.

Ease of Procedure

A number of criteria were used to classify a procedure as easy,

moderate, or difficult: the time required to perform the procedure, the

cooperation of the child and parent, the number of sticks required, and

the context of the encounter. For example, an anxious child and parent

coupled with the perception that the child " has terrible veins and they

can never get it " adds to the perception, on the part of the staff, that

a procedure is more difficult.

The majority of the procedures (318, 82%) were considered easy and were

accomplished with one stick, followed by 62 procedures (16%) that were

classified as moderately difficult, and finally 6 procedures (2%) that

were considered to be difficult and required more than four sticks. EMLA

was used for 10 of the 62 (16%) moderately difficult procedures, and

Ametop Gel was used for 1 procedure. EMLA was used for 1 of the

difficult procedures with questionable effectiveness.

The procedures classified as difficult are described in more detail in

Table 3.

Discussion

The purpose of this survey was to provide nurses in senior management at

a pediatric hospital with information that would aid in policy

development with respect to the management of needle pain. Before the

survey, there was a perception among bedside nurses that topical

anesthetics were not being used appropriately, and as a result needle

pain was poorly managed. No information was available about the

frequency and types of needle procedures performed or the number of

children who were distressed or those who were coping well with these

procedures. There was discussion about developing a policy that would

mandate the use of topical analgesic for all children undergoing a

needle procedure. The cost and human resource implications of such a

policy needed to be considered in addition to the issues related to

implementation hospitalwide. The day-to-day practice of needle

procedures was examined in order to better understand the issues related

to providing these procedures atraumatically.

The concept of atraumatic care provides an appropriate framework from

which to examine needle procedures with respect to the impact on the

child and family. Atraumatic care is the provision of therapeutic care

in such a way as to minimize the physical and emotional distress to

children and families (Wong, 1989). The goal of atraumatic care is to

" first do no harm " (Wong), and two principles that lead to achieving

this goal are applicable to needles: (a) prevent or minimize bodily

injury and pain and ( promote a sense of control (Wong). The results

of this survey will be discussed as they relate to these two principles.

Prevent or Minimize Bodily Injury and Pain

The majority of needle procedures were venipunctures for blood samples

or for IV cannulation. Eighty-two percent of the procedures were

categorized as " easy, " and the time to complete the procedure was

relatively short, with a modal time of 5 minutes. Sixty-two procedures

(16%) were considered moderately difficult, and 6 procedures (2%) were

classified as difficult. EMLA was used for 10 of the moderately

difficult procedures, and Ametop Gel was used for 1 procedure. EMLA was

used for only 1 of the 6 difficult procedures. It was encouraging to

note that the majority of the needle procedures were performed with

relative ease and efficiency. The classification of a procedure as easy

meant that it was accomplished with one needle stick and that the child

was calm and experienced minimal distress.

The low use of topical analgesic, especially Ametop Gel, for the

moderately difficult and difficult procedures was problematic and

suggested a need for improvement with respect to identifying children

who might benefit from a topical anesthetic. The fact that topical

anesthetics were well used with the oncology patients suggested that the

nurses were able to target children at risk and were also able to plan

for the added time it takes to use a topical anesthetic. Subsequent to

this survey, the barriers and supports for providing atraumatic needles

were examined to identify strategies for improvement.

A number of barriers contributed to the low use of EMLA and Ametop Gel.

For many nurses this approach was simply not part of their routine for a

needle procedure; consequently, there was a general lack of experience

and familiarity with using a topical analgesic. In addition, these drugs

were not readily available on the patient service units, and there was a

perception that Ametop Gel was too expensive. Discussions with the

operations directors indicated that they supported the increased use of

topical analgesics and that the added cost was not an issue.

Subsequent to the survey, there were presentations at nursing rounds

about procedural pain management and the use of topical analgesics. To

monitor changes in practice with respect to how frequently topicals were

being used, purchasing information was obtained from the pharmacy. The

use of Ametop Gel has increased from 48 doses per month in 1998 to 170

doses per month in 2004, and EMLA usage has increased from 34 tubes and

66 analgesic patches per month in 1998 to 47 tubes and 275 patches per

month. Interestingly, nurses on the psychiatry unit readily adopted

topical analgesics in their practice, and they are currently offered to

all children who require a needle procedure. The nurses felt that the

anxiety and emotional reactivity that these children experience related

to their diagnosis puts them at high risk for traumatic needle procedures.

The service provided by the IV team and laboratory technicians was

viewed as an essential support for providing atraumatic needle

procedures. A centralized IV team and laboratory technician service

provide safe, cost effective, and expert care, which decreases the

trauma and risk of complications associated with infusion therapy

(Meier, Fredrickson, Catney, & Nettleman, 1998; , Goetz, Squier, &

Muder, 1996). Their high standards of performance contribute to

atraumatic venipunctures and conservation of veins for future use, along

with decreased infection rates (Scalley, Van, & Cochrane, 1992). There

were hours during holidays and weekend evenings when the IV team was not

available. During these hours, pediatric residents and nurses in

specialty units such as the emergency department and intensive care unit

performed venous cannulations as needed. This system works well for the

most part, but everyone relies on the IV team for backup when faced with

difficult patients. Subsequent to the study, the IV team hours were

increased, and the team is now available from 0730 to 2330 hours, 365

days of the year. In addition, the IV team and laboratory technician

service aim to minimize the number of redraws by revising blood specimen

collection and handling procedures to conform to those developed by the

National Committee for Clinical Laboratory Standards (http://www.nccls.org).

One barrier to effectively implementing the increased use of topical

analgesics hospitalwide was a general lack of coordination and

communication among the multidisciplinary team, including the

physicians, IV team nurses, and bedside nurses. Bedside nurses often

identified a child as being at risk for traumatic needle procedures, but

this information was not always conveyed to the IV team nurse who

performed the procedure. In addition, both the IV team nurses and the

bedside nurses identified children who received unnecessary needles

simply due to a lack of coordination among the various medical

specialties. Blood tests were ordered by one service when they made

rounds in the morning, then by a second or even a third service when

they made afternoon rounds. No formal mechanisms were in place to share

information among nurses or with other members of the multidisciplinary

team about providing needles atraumatically.

Communication links have been developed to ensure that relevant

information is considered when planning needle procedures. Nurses now

urge physicians to coordinate their requests for blood tests or request

a saline lock for children who must undergo multiple blood draws. In

addition, bedside nurses work collaboratively with the IV team to

identify children who they think should have EMLA or Ametop Gel before a

needle. Table 4 describes the criteria used to identify these children.

All requests for IV team services are recorded in a logbook, and the

notation " use EMLA or Ametop Gel " is added to the request for services

as necessary. The plan of care specific to needle procedures is

discussed with the patient and family at the time of admission and is

documented on the patient kardex, the IV team workbook, and the report

board in the IV team office. The plan includes information on the use of

topicals, favorite imagery or distraction strategies, and for a few

particularly fearful children the instructions to have a child-life

specialist attend all needle procedures. Child-life specialists are

health care professionals with extensive knowledge of children's

psychosocial needs related to coping with the stress of hospitalization.

Upon arriving on the patient service unit, the IV team nurse speaks with

the patient's nurse before performing the procedure to ensure that the

treatment plan is current and can be implemented in a consistent manner.

Overall, there has been a strengthening of communication among all

members of the team and a much better understanding of the logistics of

implementing strategies to provide atraumatic needle procedures.

Promote a Sense of Control

An important factor in facilitating children's coping during a needle

procedure is to enable them to have some control in the situation.

Eliciting children's preferences, whenever possible, with respect to the

timing and sequence of events is a way of allowing them to participate

in the procedure. In addition to being able to offer topical

anesthetics, nurses were interested in increasing their repertoire of

cognitive behavioral techniques for managing procedural pain. The nurses

felt strongly that anxiety-reducing strategies such as relaxation

techniques, imagery, distraction, and positive reinforcement should not

be abandoned once the topical anesthetic was in place.

A comment by one of the IV team nurses suggested that we needed to be

vigilant about combining the " high tech " of topicals with the " high

touch " that encompasses the human-connection aspect of procedural pain

management. Kazak and Kunin-Batson (2001) suggest that the commonality

among all types of cognitive and behavioral approaches to pain

management is the " therapeutic alliance " that develops among the child,

the family, and health professionals. They suggest that pain management

interventions are most effective within the context of a mutually

respectful relationship in which the child, the family, and the health

care providers are working with the child to achieve comfort. For some

children it is the connection and sense of feeling supported in their

efforts to cope with needle procedures that contributes to their well-being.

Barriers to utilizing a variety of cognitive behavioral strategies more

varied than verbal reassurance were identified subsequent to the survey.

Nurses felt they needed more education about the different techniques

and requested workshops that provided an opportunity to practice

different imagery and distraction techniques. Dr. Leora Kuttner from

British Columbia Children's Hospital was invited to lead a workshop that

focused on cognitive behavioral techniques for pain management. Sixty

staff members attended the workshop from nursing, child-life,

psychology, anesthesia, and physiotherapy. Techniques such as the " magic

glove " and " going to a special place " (Kuttner, 1996), were practiced

among the workshop participants with the expectation that these

relatively simple but powerful strategies could become part of the

repertoire of all staff involved with painful procedures, including

needle procedures. Additional cognitive behavioral techniques described

by age group are listed in Table 5.

The purpose of the survey was to understand practice with respect to

needle procedures in order to develop recommendations to inform

practice. The goal of the recommendations was to ensure that EMLA and

Ametop Gel, along with cognitive behavioral strategies and other comfort

measures, were used liberally throughout the hospital in order to

minimize the pain and distress associated with needle procedures. Taken

together, information from the survey and subsequent discussions with

members of the multidisciplinary Pain Committee and the Pain Resource

Nurses steered us away from a policy that mandated the use of topical

analgesics for all needle procedures. We felt that such a policy would

be difficult to implement and monitor and ultimately would prove

unnecessary. Instead we opted for a process of education and social

marketing to " sell " the notion that atraumatic needle procedures can

become standard practice.

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Funding Information

This study was supported by a research grant from the Children's

Hospital of Eastern Ontario, Research Institute and the Canadian Nurses

Foundation.

Address correspondence and reprint requests to A. Ellis, RN,

PhD, Associate Professor, School of Nursing, University of Ottawa, 451

Smyth Rd., Ottawa, ON, K1H 8M5. Email address: jellis@...

( A. Ellis).

A. Ellis, RN, PhD*, Diane Sharp, RN, CINA*, Kym Newhook, RN,

BScN*, Janice Cohen, PhD†

*Department of Nursing, Children's Hospital of Eastern Ontario, Ottawa,

Ontario, Canada

†Department of Psychology, Children's Hospital of Eastern Ontario,

Ottawa, Ontario, Canada