September 16, No Pain, Yes Gain!: Assessing and Reducing Pain in Pediatric Outpatient and Emergent Settings

Transcription

1 No Pain, Yes Gain!: Assessing and Reducing Pain in Pediatric Outpatient and Emergent Settings September 16, 2016 Kim Stephens, MPA, CCLS Robert Stephens, MD, FAAP

2 Policies and standards of the Texas Medical Association, the Accreditation Council for Continuing Medical Education, and the American Medical Association require that speakers and planners for continuing medical education activities disclose any relevant financial relationships they may have with any entity producing, marketing, re selling, or distributing health care goods or services consumed by, or used on, patients whose products, devices or services may be discussed in the content of the CME activity. The planners and speakers have no relevant relationships to disclose.

3 Objectives At the end of this session, participants will: Understand the common causes of pain in the pediatric outpatient setting and the benefits of relieving this pain Understand non-pharmacologic comfort-measures that can be used to relieve pain Identify the pharmacologic tools that can be used to relieve pain and understand how to implement these tools in the office setting Understand behavioral and pharmacological options for analgesia for emergent procedures, including sedation. Best practices for monitoring and managing adverse reactions will also be discussed.

4 What Are We Doing That Hurts? Vaccinations Intramuscular Subcutaneous Venipuncture Capillary Blood Draws Newborn Screens Bilirubins Leads Hemoglobins Suturing

5 Why Bother? This stuff is brief, limited, and minor. Trying to mitigate pain from these things is more work than it's worth. WRONG!

6 Why Bother? First, it's the right thing to do. If we have the tools, it's unethical not to use them Second, it's to our benefit Who's in a competitive healthcare environment? Urgent Care Pharmacies Health Departments School-Based Immunization Clinics Other Medical Practices This is something you can do that's easy, cheap, and will set your practice apart.

7 The Three P s: Creating a Positive, Pain free, Patient Centered Experience 7

8 The Key to a Successful Experience is PREPARATION for the patient and/or their parents. 9/9/2016 The Children s Hospital of San Antonio 8

9 Prior to the Patient s Arrival Review the patient s chart for notes on medical and behavioral issues Prepare the exam room Upon the Patient s Arrival Remember to create an inviting, calm and relaxed atmosphere 9/9/2016 The Children s Hospital of San Antonio 9

10 Why Prepare? Just as you would like to know what kind of visit you are in for with your patient your patient (and/or parent) would like to know what is in store for them too Try to think no surprises! this will foster further trust for the patient in their future medical experiences 07/22/16 9/9/2016 The Children s Hospital of San Antonio 10

11 5 Aspects of Preparation 1. Developmentally Appropriate Explanations 2. Patient Friendly Language 3. Job Assignment 4. Positioning for Comfort 5. Coping Strategies 9/9/2016 The Children s Hospital of San Antonio 11

12 Developmentally Appropriate Explanations Gear explanations towards a patient s developmental age, not chronological age People tend to regress during stressful situations Children (and some adults) need short, concrete explanations and descriptions Include sensory information in the explanation Use time descriptors, if needed 9/9/2016 The Children s Hospital of San Antonio 12

13 As your mother used to say WATCH YOUR LANGUAGE!!! 9/9/2016 The Children s Hospital of San Antonio 13

14 Patient Friendly Language The medical setting is usually a foreign land for families Use patient friendly wording without medical jargon or hidden meanings in your descriptions and explanations Children (and some adults) can be very literal they may not understand playful teasing, sarcasm, tickling or humor 9/9/2016 The Children s Hospital of San Antonio 14

15 The Art of Reframing Not so therapeutic Pain Shot Be quiet and don t cry Therapeutic discomfort unpleasant experience uncomfortable feeling bother Put some medicine in your arm Poke Prick Pinch You have such great lungs and big beautiful tears! 9/9/2016 The Children s Hospital of San Antonio 15

16 The Art of Reframing Not so therapeutic I know this is going to hurt, but Get ready for the ouch on the count of three Therapeutic I wonder if you are going to let it bother you a lot, bother you just a little, or not bother you at all You can notice the poke if you want, or ignore it altogether either way it doesn t need to bother you 9/9/2016 The Children s Hospital of San Antonio 16

17 Everyone Has a Job to Do A Parent s Job to comfort their child A Child s Job hold their body still as they can A Health Care Professionals Job... to complete the procedure in the most effective and least stressful way! 9/9/2016 The Children s Hospital of San Antonio 17

18 Parents Need to Know What helps What to avoid 9/9/2016 The Children s Hospital of San Antonio 18

19 Positioning for Comfort What is PFC? 9/9/2016 The Children s Hospital of San Antonio 19

20 Why use PFC? Provides a safe and secure hold from the caregiver Incorporates family centered care Provides a sense of control and mastery for the child Offers more comfort to the child A more positive medical experience for all Lower self reported pain in children 9/9/2016 The Children s Hospital of San Antonio 20

21 POSITIONS FOR COMFORT: The Bear Hug Used for IV starts, intramuscular injections, and examination, etc. Hold arm or leg securely down on table. Parent hugs child to body Appropriate methods of distraction provide an overall positive experience 9/9/2016 The Children s Hospital of San Antonio 21

22 POSITIONS FOR COMFORT: The Sitting Joey Position Used for blood draws, IV starts, injections, examinations, etc. Sitting in the parent s lap against the table provides support and immobilizes the child s legs Child can choose to watch or look away from the procedure 9/9/2016 The Children s Hospital of San Antonio 22

23 POSITIONS FOR COMFORT: The Sitting Position Used for blood draws, injections, IV starts, examinations, etc. Older children can choose to sit in a chair or on the exam table Parent can provide physical support or distraction from procedure 9/9/2016 The Children s Hospital of San Antonio 23

24 POSITIONS FOR COMFORT: The Froggy or Butterfly Position Used for urine catheterization Parent sits on exam table with child between the legs and the child s head resting on the parent s leg Parent assists by holding child s legs like a frog or butterfly 9/9/2016 The Children s Hospital of San Antonio 24

25 POSITIONS FOR COMFORT: The Swaddling Position Used for blood draws, injections, IV starts, examinations, etc. Infants 0 3mo find the most comfort being swaddled You can leave arm/leg you are working with out and swaddle the rest of the infant s body 9/9/2016 The Children s Hospital of San Antonio 25

26 POSITIONS FOR COMFORT: The Cradle Position Used for NG tube placement, nasal swab, examination, or for smaller children, IV start in the foot Child sits on parent s lap on top of exam table or in chair and leans back. Head is secured by staff while arms and legs are secured by parent 9/9/2016 The Children s Hospital of San Antonio 26

27 Coping Strategies What are coping strategies? Coping strategies are tools used to help the child cope with stressful medical procedures and situations. Strategies include: Imagery and Visualization Breathing and Relaxation Techniques Distraction (books, toys, games, etc.) 9/9/2016 The Children s Hospital of San Antonio 27

28 Imagery and Visualization What is imagery and visualization? How do I use imagery with patients? 9/9/2016 The Children s Hospital of San Antonio 28

29 Imagery and Visualization Exercises An ice cube on your skin makes that part of your body feel numb, so you don t have any feeling there. Close your eyes and imagine that your hand is getting cold, like an ice cube. Can you feel it tingle? Which finger tingles first? Imagine that your hand is getting colder and colder and it s getting numb. 9/9/2016 The Children s Hospital of San Antonio 29

30 Imagery and Visualization Exercises Imagine that your brain has switches, and you can help to control discomfort by turning off the switches. Turn off the switch to your hand. As the switch goes off, you can feel your hand getting heavy, tingly, numb, and you may find it hard to feel anything at all 9/9/2016 The Children s Hospital of San Antonio 30

31 Breathing and Relaxation Techniques What are breathing and relaxation techniques? How do you use breathing and relaxation with your patients? 9/9/2016 The Children s Hospital of San Antonio 31

32 Breathing and Relaxation Techniques Just thinking about needles can make you worried. When you re worried, your breathing gets short and shallow. But long, slow breaths help make you feel more comfortable and relaxed. The first step in relaxing is deep breathing. Blow the air out first. More more more. Now let the air in s.l.o.w.l.y Now let the air out s.l.o.w.l.y It helps to count slowly too /9/2016 The Children s Hospital of San Antonio 32

33 Breathing and Relaxation Techniques Being tight and worried can make the discomfort feel worse. But, when you relax your body, you can make any discomfort feel better. Make your arm stiff and tight...tighter tighter Now relax your arm. Let it flop like a loose noodle. 9/9/2016 The Children s Hospital of San Antonio 33

34 Breathing and Relaxation Techniques Take a very deep breath and gather up the discomfort into one big red cloud. Now, with all your strength, blow the red cloud out of you. 9/9/2016 The Children s Hospital of San Antonio 34

35 Distraction What is distraction? How do you use distraction with patients? 9/9/2016 The Children s Hospital of San Antonio 35

36 Distraction Tools Bubbles (ex. mini Bubble Tumbler with new bubble liquid after each patient use; unopened wedding bubbles) Books: I Spy books (simple and advanced), Push button music/sounds/noise books, Flap books Infant, toddler, preschool cause & effect toys (pop up, musical and lights; V tech toys) Find It! (bead filled cylinder with objects hidden within) Meteor Storms (hand held lighted spinning globes) Push button water games Magna Doodle Magic wands and magic wands with kaleidoscope Pin wheels Stress balls/squishy balls (latex free) I Pad or Tablet with a variety of games and applications pre loaded Portable DVD player with various DVDs Music on tablet or I Pad (lullabies, nature, children s songs, teenoriented etc.) 9/9/2016 The Children s Hospital of San Antonio 36

37 What Else? Pharmacologic and Device Interventions Tactile/Sensory Devices Anesthetic Devices

38 Standardized Procedures We deliver a lot of injections Let's do it in a way that minimizes pain Don't aspirate first Give the most painful shots last Give them simultaneously

39 Oral Sucrose

40 What is It? 24% Sucrose Solution in Water Mechanism of Action is Unclear It seems to work by stimulating endogenous opioid recepters. There is a well-documented calming/analgesia effect in infants given sucrose before procedures Probably best for heel-lances and infant immunizations

41 Meet Buzzy!

42 How Does Buzzy Work?

43 How Does Buzzy Work?

44 Buzzy In Action

45 Topical Anesthesia

46 Topical Anesthesia Eutectic Mix of Local Anesthetics (EMLA) Lidocaine 2.5%/Prilocaine 2.5% Cream EMLA must be applied 1 hour before the procedure Lidocaine 4% Cream (LMX) LMX must be applied 30 minutes before the procedure Effective for venipuncture, IV starts. Not effective for heel lances LMX is available on Amazon for parents to purchase

47 Topical Anesthesia

48 Cryospray

49 Cryospray How Does It Work? It's based on Gate Control Theory as well. The data are mixed but a Cochrane Review did demonstrate some reduction in pain during the procedure. However, the downside is that there is pain upon application of the cryospray.

50 Gas Injection

51 Gas Injection How Does It Work? Needleless injection of lidocaine into the subcutaneous tissues provides local anesthesia Most appropriate for venipuncture, IV starts It is a single-use device, raising concerns about cost

52 Gas Injection Can also be used for immunizations Needleless injection of subcutaneous vaccines Appropriate for MMR, Varivax, MMRV Avoids risk of needlestick injuries and sharps disposal Again, cost can be an issue

53 Now What? We have shown you a lot of tools. The challenge is to incorporate them into your office workflow. How?

54 Making Change Happen Incorporating these tools into workflow is a Quality Improvement Process, like any other. There are recognized steps for success.

55 Making Change Happen Needs Assessment This provides the rationale Identify Champions Need to be from all levels of the organization Use a pilot This makes the change manageable Leadership Accountability This makes the change happen Peers Train Peers Maximizes buy-in Measure It! This makes the change endure

56 We Can Reduce Pain We have the tools We have the skills We have the incentive Questions?