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Medscape: Study provides simple steps to reduce pain during IV placement in children

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 Children's Mercy 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."


Read the full article via Medscape.

Learn more about the Emergency Departments at Children's Mercy - Adele Hall and at Children's Mercy Hospital Kansas.