March 10, 2017
By David Douglas
NEW YORK (Reuters Health) - The use of jet injection of lidocaine to control intravenous (IV) placement-related pain in children greatly increased at a tertiary pediatric ED after it made ordering easier and provided staff with education on the method.
Better pain control is associated with significantly improved outcome, note Dr. Shobhit Jain and colleagues of Children’s Mercy Hospital in Kansas City, Missouri, in Pediatrics, online March 9. In contrast, poor pain control may lead to complications, including hyperalgesia and needle phobia.
However, say the researchers, "studies continue to demonstrate insufficient pain management, particularly for children in EDs."
"We wanted to help children in the ER by reducing the pain and anxiety they feel with painful procedures,” Dr. Jain told Reuters Health by email. “We chose to address pain with IV placement - a common procedure - by using a quick-acting, needle-free numbing method - jet-injection of lidocaine (JIL)."
To examine its utility in this setting and to assess possible barriers to use and increase employment, the researchers first analyzed data obtained from 85 nurses and 105 medical providers.
Leading barriers to JIL use among the nurses included concern about "blown veins" and IV placement failure. Among providers, the main reasons included lack of knowledge and a complicated ordering process as well as nursing staff’s reluctance to use the approach.
In response, the researchers helped develop a simplified ordering procedure, and made a JIL resource document available online. They also recruited 10 experienced ED nurses and trained them to be "JIL super users." Workshops for nurses and physicians were instituted and a small placard was placed on all ED workstations to remind staff to consider JIL when using IV.
At baseline, ED use of JIL with IV placements was 11%. Within seven months of the first intervention, the proportion had risen to 54%. At 12 months, after all interventions were in place, use has remained at or above 50%.
In more than 12,000 IV placements which were eligible for JIL, placements were successful on the first attempt in 76.4% of those when JIL was used and 75.8% when it wasn’t.
"The results of this project are likely generalizable to other institutions and clinical settings," the researchers write, adding, "We are expanding the project to other parts of the institution."
The good results, Dr. Jain explained, were achieved by "educating and empowering our staff, and addressing several barriers. Our methods have been successfully used in other locations, and we remain committed to continuing our work to make ER visits easier for children and their families."
Dr. Gary Andolfatto, who studies analgesics and sedation in the ED, told Reuters Health by email, "I would commend these authors for pursuing the laudable goal of inflicting less pain whenever possible. Nice to see the demonstration of an intervention that does not adversely affect the ability to do the procedure in question."
"It's also a good demonstration of the type of effort required to institute a change in practice - their use of multiple venues and persistent follow-up should be a model for others wishing to institute positive practice change,” said Dr. Andolfatto of the University of British Columbia in Vancouver, Canada. “It takes a lot of work and persistent effort to be successful. Having a good idea alone is never enough."
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