Simple Steps Reduce Pain During IV Placement in Children

Norra MacReady

March 09, 2017

Venipuncture and intravenous cannulation are significant sources of pain and stress for pediatric patients, and are often stressful for caregivers as well. However, quality improvement methods can increase the use of jet-injected lidocaine (JIL) in pediatric emergency departments, with robust results, a new study shows.

Key elements to the project's success were simplification of the JIL ordering process, explaining to hospital staff the rationale and methodology for increasing JIL use, easing access to the JIL devices, and changing the standing order sets to facilitate JIL ordering, Shobhit Jain, MD, from the Children's Mercy Hospital, Kansas City in Missouri, and colleagues write in an article published online March 9 in Pediatrics.

Within 7 months from implementation of the recommended changes, JIL use with intravenous (IV) line placements went from 11% to 54%. Moreover, JIL use has remained at more than 50% for more than 12 months, with no significant change in the rate of line placement on the first attempt, the authors report.

Before initiating the quality improvement project, Dr Jain and colleagues collected baseline data on patients presenting to the emergency department (ED) in a pediatric tertiary care center from January to June 2014. They also conducted an anonymous, online needs assessment survey of ED nurses and physicians that included the question, "What is the one intervention that would lead you to use JIL with IV placements?"

Using this information, the team identified six opportunities for improvement. Revising the standing order sets was the factor most commonly cited by physicians and nurses alike that would facilitate use of JIL. As a result, the first intervention, initiated in August 2014, was to ensure that all order sets with an IV placement option included an option for JIL as well.

Other interventions included online education about JIL and IV-related pain, 5- to 10-minute workshops to provide hands-on experience, installation of easily accessible wall refrigerators so JIL devices could be stored in multiple locations in the ED, and changes to standing order policies to make it easier for nurses to order topical anesthetics. The final intervention, implemented in January 2015, was placement of a placard on all ED workstations to remind the staff to consider using JIL with every IV insertion.

All ED patients with orders for peripheral line placement were included in the study unless they were urgent cases or allergic to lidocaine. The outcome measure was any change in the proportion of patients who received JIL associated with IV placement.

A total of 12,791 IV placements occurred during the entire observation period. Before the initiative, JIL was used in only 11% of IV placements. "Within 14 measurement cycles (7 months) of the first intervention, 54% of IV placements were associated with JIL use." During the observation period after the final intervention (24 cycles, or 12 months), JIL placement remained at or above 50%.

Nurse-initiated JIL orders increased from 15% during the baseline period to 60% after all the interventions, the authors add. "The number of JIL devices ordered by [other] providers also increased during this period."

Of 9793 IV placements without JIL, 7420 (75.8%) were successful on the first attempt. Of 2998 placements with JIL, 2289 (76.4%) were placed successfully the first time (Χ2 1degrees of freedom, 0.33; P = .56).

The authors did not measure changes in pain perception associated with use of JIL, but "increased use of JIL seems a good proxy for reduced pain," given the evidence of its efficacy shown in other studies, they write. They also did not study the cost implications of using JIL, although its cost efficacy has been demonstrated by other investigators.

A third limitation was assuming that the number of JIL devices ordered accurately reflected the use of these devices, when in fact, "we did not have a reliable measure of actual administration," the authors state.

Despite these limitations, the "results of this project are likely generalizable to other institutions and clinical settings," they conclude. These findings are promising, because the adverse effects of "pain in the acute care setting are being increasingly acknowledged, and pain management needs to be urgently addressed."

The authors have disclosed no relevant financial relationships.

Pediatrics. 2017;139(4):e20161697. Abstract

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