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Back to the Blood Drawing Board:
Creating and Implementing a Comfort-Based
Phlebotomy Experience
Pnina Grauman MS, CCLS
FACLP Conference 2012
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What I hope will “stick” with you…
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The pain experience: patients and Child Life Specialists
Team-building skills
The Child Life “tool kit” for phlebotomy
Building blocks for your own comfort-based initiatives
Incorporating the phlebotomy experience into your
culture of family-centered care
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“Owwies” from a young age
• Initial experiences with pain can be as early as
shortly after birth
• These experiences can then impact a child’s overall
responses to later exposures to pain
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Pain and Tears Through the Years
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Neonates and Infants
Toddlers and Preschoolers
School-age children
Adolescents
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Easing Pain Without a Pill
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Child Life
Parent/child involvement
Positioning for comfort/therapeutic positioning
Post-procedural interventions
Bed as a safe space
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Pain Relief From the Pharmacy
• EMLATM Cream
• SyneraTM Patch
• Sweet EaseTM
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Our Mission Statement on Pain
• “The Children’s Hospital at
Montefiore respects and supports
every child’s right to pain assessment
and optimal pain management”
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In CHAM, we believe that…
• Effects of unresolved
pain are physical and
psychological
• Pain limits progress
• Pain management
enhances comfort
• We must evaluate and
treat pain based on the
child’s report
• Pain response depends
on developmental level
• Families are crucial in
pain management
• A child’s bed = safe space
• There are
pharmacological and
non-pharmacological
approaches to pain
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Prior Approaches to Pediatric Pain Management
• “Making Needles Easier to Bear” pain committee
• The “A.C.T.” Approach:
-Assess/Analgesics
-Child Life
-Teamwork
• Therapeutic positioning posters
• I.V carts in treatment rooms
• Noting parents’ concerns
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Setting Our First Goals
• Improve the phlebotomy experience for
patients and families
• Increase the use of comfort measures
• Create a culture of pain control across the
children’s hospital
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From Meetings to Methodology
• Proposal submitted to the IRB: “Parental Perception
of Child’s Comfort During Blood Drawing: A Before
and After Interdisciplinary Approach to Improving
the Inpatient Phlebotomy Experience” (O’Connor, K.,
Liewher, S.K., Kelly, M., & Skae, C. (2009))
• Background
• Objectives
• Design
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Initial Pre-Test Findings
• Of 71 parents surveyed:
-18% reported the use of numbing medicine
-32% reported presence of Child Life Specialist
-51% reported blood draws were performed by
a phlebotomist
-average Wong-Baker score: 3.4/5
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What does this all mean?
• Comfort based techniques were being underutilized
for patients, which is likely related to their parents’
perceptions of significant pain
• The education about and availability of analgesics
alone were not enough!
• Interdisciplinary team initiatives were necessary to
create a culture of pain-free procedures
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These were our goals—how did we meet them?
• Increase the efficacy of venipunctures and decrease
the frequency of unnecessary, ill-timed blood draws
• Improve the usage and floor presence of topical
anesthetics
• Increase the presence of Child Life Specialists during
routine blood draws
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Sitting Down and Strategizing
• Schedule: phlebotomy rounds twice a day in the
floor treatment rooms for patients who received
EMLA cream at least 1 hours prior to blood draw;
Child Life Specialist present
• Supplies: need for adequate EMLA for all patients
who were ordered for blood draws
• Initial Concerns: patient transport, patient list,
timing, adequate EMLA, delaying discharge,
evidence-based practice
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Start Your Engines!
• Program Initiation: October 3, 2008
• Original plan involves Child Life Specialists in
phlebotomy rounds at 9:30 AM and 3:30 PM on one
“pilot” unit
• All draws performed in the treatment room
• All patients should have numbing cream
• Child Life Specialist to provide parents and patients
with support/education (distraction, coping,
positioning, Sweet Ease, etc.)
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Bumps Along the Way
Preliminary barriers faced:
• Timing
• Staffing logistics
• Ongoing education and training of medical staff
• Technical/pharmacy complications
• Drops in pain committee attendance
• Families mis/uninformed
• Staff not optimally receptive
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Continued…
• Ethical complications
• Containment of EMLA with TegadermTM was
uncomfortable for the infant/toddler population
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If at first you don’t succeed…
Adjustments and improvements:
• Timing/scheduling/staffing/location changes
• Ongoing nursing and resident education
• Document, document, document!!
• Advocacy of topical anesthetics with the pharmacy
staff
• Emphasizing patient/family education
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Setting Goals After Our First Year
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Universal comfort measures
Making EMLA readily accessible
Ensuring standing orders for all admitted patients
Expanding the pilot unit to other inpatient areas
Involving doctors and nurses in the planning process
Daily documentation
Establish a computerized EMLA prompt in patient
orders
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Continued…
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Assign an educational pain module
Researching other materials to contain EMLA
Using other, quicker-acting topical anesthetics
Improved interdisciplinary communication
Hiring a pediatric phlebotomist
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And now, a brief movie…
(Thank you to Katherine O’Connor, MD and Charlotte
Pharr, MA, MT-BC for your filming expertise as well
as to my adorable patients and their families!)
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So, how are we doing?
• Upon admission, each patient has standing orders for
EMLA
• EMLA readily stocked in med rooms and PyxisTM
machines
• Rounds with Child Life Specialists on all four inpatient
units beginning at 9:30 AM
• Educational procedural pain management module
assigned to all medical staff
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Continued…
• Pain-Ease trial on inpatient unit, now used regularly
in outpatient radiology
• CHAM floors designated with “Comfort Zone”
signage
• July 1, 2011: a CHAM-only pediatric phlebotomist is
hired!
• Phlebotomist conducts daily morning rounds to
remind medical staff to apply EMLA and documents
each blood draw done on the day shift
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And finally…
• Coming soon: automatic computerized prompt and
designation of patients ordered for blood draws
• Faster-acting anesthetics still being investigated
• July 1, 2012: overnight pediatric phlebotomist hired!
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And the results are in!
• Post-test findings, August 2012: significant results found in the
following areas:
-Child Life presence during blood draws
(2008: 32%  2012: 63%)
-Numbing medicine used prior to blood draw
(2008: 19%  2012: 43%)
-parents perceived their children’s pain as adequately
controlled
(2008: 3.8/5, fair-to-good  2012: 4.2/5, good-to-very good!)
-Average rating on Wong-Baker FACES pain scale decreased
(2008: 3.4  2012: 2.9)
• Publication of the study is in our future!
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Getting Your Own Comfort Zone off the Ground
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Determine your needs:
-survey families and medical staff
Mobilize your resources:
-interdisciplinary communication is key (include
MDs, RNs, phlebotomy, child life, pharmacy, etc.)
-establish a hospital-wide task force
-ensure visibility of your efforts and publicize your
initiative (flyers, posters, stickers, pins, etc.(
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Continued…
• Educate:
-staff AND patients/families
-hands on staff experiential sessions
• Validate your efforts:
-document, document, document!
-videos/photos
-track parental and staff responses/compliance
-cost/benefit analysis
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Recommended Reading
• Leahy, S., Kennedy, R., Hesselgrave, J., Gurwitch, K., Barkey,
M., & Millar, T. (2008). On the front lines: Lessons learned
in implementing multidisciplinary peripheral venous access
pain-management programs in pediatric hospitals.
Pediatrics 122(3): 5161-5170.
• Kuttner, L. (1996). The child in pain: How to help, what to
do. Washington: Hartley & Marks.
• Cavender, K., Goff, M.D., & Hollon, E.C. (2004). Parents’
positioning and distracting children during venipuncture:
Effects on children’s pain, fear, and distress. Journal of
Holistic Nursing 22(1): 32-56.