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

Jacqueline A. Ellis, RN, PhD; Diane Sharp, RN, CINA; Kym Newhook, RN, BScN; Janice Cohen, PhD


Pain Manag Nurs. 2004;5(4) 

In This Article


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.

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.

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%).

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.

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 .


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