The ART of DISTRACTION
Kona Pediatrics brings
Childrens Hospital Magic to KCH
February 17, 2020
A 4 year old boy named Kaleo presented early one morning to the emergency room. His parents were anxious as this was the first time he had been this sick since birth. Kaleo was diagnosed with a kidney infection and prescribed IV antibiotics. Despite several attempts, the nursing staff was unable to place an IV. Four times they tried, sticking a catheter into his arm as the child screamed, but each time they hit the vein, the catheter blew. Kaleo’s mother’s eyes were swimming with tears. She was exhausted and overwhelmed, having been up all night with her son. But she understood that her child needed this medicine to get better. The ER physician decided to give the first dose of the medicine in the form of a shot, and wait until the next shift of nurses came on at 7am to have someone else try for the IV.
Two hours later, one of the more experienced nurses on the day shift attempted the IV again. The moment Kaleo was held down, he began shrieking and clinging to his mother. It was much harder to hold him down; this time it required two nurses in addition to the one placing the IV. Finally, on the fifth attempt, the IV was secured.
Here’s the problem...
(Nobody actually wants to be in the hospital)
But if you need advanced medical care,
there’s no reason for your hospital experience to stress you out as much as the illness does.
"More Than Little Adults"
Children experience the hospital in very different ways than adults. When you’re a six year old, the hospital can be a scary place. Kona Community Hospital is a wonderful institution full of staff members who genuinely care for the West Hawaii Community. But from a pediatric standpoint, it is really an adult hospital that happens to care for children. And while the adult patient experience at KCH is comprehensive, there are many areas where we can better serve our pediatric patients and their families.
The optimal care for children requires staff that are educated and dedicated to understanding their particular needs. It means looking at the hospital experience from the point of view of a child, and tailoring our health care delivery to give them the best experience possible.
One key area we needed to address at our community hospital was vascular access in kids. When a sick child comes to the emergency room, one of the first things we need to do is place an IV. This is basically a tiny plastic tube inserted through the skin into a vein that allows us to rapidly give antibiotics, fluids and other life-saving medications. In the pediatric population, IVs can be particularly challenging. Babies often have a layer of fat underneath the skin, which makes them pudgy and cute in photographs, but this excess tissue can make it more difficult to target a vein.
Children don’t necessarily hold still when you want or need them to, and especially when sick, don’t really appreciate strangers approaching them with sharp needles. Sometimes children will show up in the ER with severe dehydration, which can occur when they have had vomiting and diarrhea, or if they haven’t felt like drinking due to their illness. In these cases, their veins, which are normally round and full, will clamp down, making it even harder to obtain an IV.
A scared sick child refusing to hold their arm still, a nurse trying to perform a critical procedure on a screaming, moving target, and a set of anxious parents upset that their baby is in extreme distress represent a perfect storm of chaos where nobody wins. Holding a child down and forcing them to stay still in order to place the IV is not only unacceptable, it traumatizes the child and makes every interaction with health care providers moving forward that much more difficult.
Recognizing these challenges, Dr. Toyin Ajose, Department Chair and CEO of Kona Pediatrics, felt it was important to create a program to address these various issues. We wanted to give our nurses specialized training with new and innovative tools to help them do their jobs better.
Enhanced Pediatric Services
In July of 2019, Kona Pediatrics invited the president of the Association of Child Life Specialists, for a site visit at Kona Community Hospital. Jill Koss, head of this international body, is a 30 year veteran in the field and has launched and overseen Child Life programs in hospitals around the world. She brought a small team to Hawaii to assess both our resources and our particular needs. The team toured our hospital and spoke with nurses and leadership in all units which care for children. Over the next several months we collaborated on a curriculum tailored specifically to the needs of our pediatric population.
During the first week of November, 2019, Kona Pediatrics hosted a team of experts from a childrens hospital in Texas. Sixteen nurses were selected from four different patient care units to participate in this three day training event. The goal was simple: to give our staff of phenomenal nurses the tools to deliver care that is sensitive to the unique needs of our community’s most precious resource, our Keiki.
Jill Koss
Kathy Greiser, Whitney Brosey, Charles Lamb and Janis Smith
Two Pediatric IV Gurus were brought in to provide specialized training to the nursing staff at KCH. Kathy Greiser heads her hospital’s department of vascular access and brought with her over forty years of experience in vascular access. She was joined by Charles Lamb, who not only boasts decades of IV placement experience, he is the known as, “The Closer.” When all the seasoned nurses on staff have been unsuccessful and obtaining access, he is the one they call, and 9 times out of 10, is able to succeed in impossible situations. Mrs. Greiser and Mr. Lamb put on an intensive training class for the 16 nurse champions, delving into all aspects of IVs in kids from optimal veins in different age groups, to proper securing and maintenance of IVs. Additionally, they held one-on-one sessions for two full days open to any nurse in the hospital interested in improving their skills.
The knowledge and expertise shared by these two individuals was extremely well received by the hospital staff. This education solved one important problem but there was still the issue of the child’s fear. To address this critical component of the pediatric hospital experience, we welcomed a team of child life specialists to educate our staff. Janis Smith and Whitney Brosey are two dynamic women with decades of experience between them. They spent the most time with our nurses and through a series of lectures, games and demonstrations, they were able to simplify the magic of Child Life into three components: Communication, Pain Control and the Art of Distraction.
Communication
In any given situation, often the fear of the unknown is worse than the thing itself. In most cases, health care workers discuss treatment plans directly with the parents. The child may not have any idea of what’s coming and the reaction can be dramatic when care begins. So Janis and Whitney began by reviewing how children experience medical situations according to their developmental age. After this foundation was laid, they gave us the first tool to combat fear: communication and direct engagement with the child.
So instead of walking in the room and saying, “Hi, I’m Nurse Janis. I’m here to start your IV,” and immediately breaking out the tape and the needle catheters, a nurse might instead get down to eye level with the child and speak in a way a six year old can understand.
“Hi, I’m Nurse Janis! What’s your name?”
“Leilani.”
“Hi Leilani. Hey do you like milkshakes?”
“Uh huh!”
“What’s your favorite flavor?”
“Strawberry.”
“Cool, mine too!. And what do we use to drink milkshakes?”
“A straw.”
“That’s right! You’re smart! So, you know your mom brought you here because you’re sick. Well, we have some awesome medicines that will help make you better, but the only thing is that your arm has to drink it . So we need to put a tiny medicine straw in your arm. In a couple of days you’ll feel much better and you get to go home! How’s that sound?”
Teenagers, on the other hand would likely roll their eyes at this. But what does matter in this age group is choice. Adolescents often value autonomy and agency over their own bodies. So in this same scenario, asking if the patient has a preference as to which arm the IV is placed could make the difference in how he experiences the hospital. A patient might want his right hand free to be able to send text messages or operate video game controls, and would appreciate being given the choice to have the IV on the left.
Appropriate engagement and direct communication with the child. Finding out what’s most important to them. Fully explaining what’s going to be done, before proceeding… All of these things can make a world of difference, not just in how a pediatric patient experiences the hospital, but also in how efficient and successful staff is in performing procedures. In the above example, the child is able to make the connection between participating in procedures and them feeling better.
Pain Control
Communication is an important first step, but talking doesn’t change the fact that needles still actually hurt. One solution the team introduced to us takes its inspiration from a honeybee. BUZZY is a small device around the size of a credit card that is placed on the skin prior to a needle stick. It is a high frequency vibration device with a cold pack attachment. By combining the numbing cold and vibration sensations, nerve signals are scrambled and patients often don’t feel the needle stick at all.
This device was invented by a pediatrician and is being used at the nation’s premiere institutions such as Childrens Hospital of Philadelphia, Childrens Hospital of Los Angeles and hundreds of other institutions in the country.
For children uncomfortable with the vibration sensation, the team introduced a numbing cold spray. Pain Ease is a liquid spray that can temporarily numb the skin in about 5 seconds. It is very effective at blocking surface pain; patients often don’t even feel the needle going in. The actual spray has been in use for some time, but for our pediatric population, we are rebranding it as “Elsa Spray,” after the popular Disney princess from the Frozen movies. So prior to placing an IV or receiving a vaccine, a child will be given the option of having some of Elsa’s magical spray so the procedure won’t hurt as much.
The Art of Distraction
A child’s imagination is one of the most powerful tools we can use to improve their experience in the hospital. If you can get them to focus on something fun or exciting for even just a few moments, procedures that used to take 25 minutes can be done painlessly in under five. To that effect, the child life specialists introduced our nurses to the wonderful art of distraction. The goal is never to trick or deceive a child. He or she will be given the information in a manner appropriate for their age. This is about alleviating anxiety by providing them with something different to focus on.
Bubbles for example:
To a toddler, bubbles have the hypnotic pull of an ice cream truck on a hot summer day.
Kids light up with smiles tracking their sizes, and trying to figure out where they will land. Each nurse who cares for children will carry a small bubble wand in their pocket and while the child’s attention is focused on a barrage of floating spheres, another nurse will carefully work on the IV without having to deal with a wiggling moving target.
For older children, we have something called an“I -spy”
kit. This is a flat transparent pouch filled with dried rice in which several small toy items are hidden. Prior to an IV stick, the child will be given the pouch and asked to find, “the flag, the letter 'E' and the sea turtle,” for example. And while she is busy searching and excited when she finds each item, the procedure can be completed. These techniques are adaptable to a multitude of clinical situations such as stitches, or splinting a broken bone. All of these techniques can be used in conjunction with Buzzy or the Cold Spray.
On the last day of the Enhanced Pediatric Services training, the group gathered in a ballroom at the Sheraton overlooking the ocean. It was an opportunity to role-play and practice the many skills and techniques learned over the week. Towards the end of the day we held a graduation ceremony. Each nurse received a Pediatric Nurse Champion certificate and was asked to identify their own nursing superpower.
Graduation
The nursing staff members who participated were so energized by the information and training that they formed a committee right there in the room. The Kona Pediatrics Nurse Champions dedicated themselves to sharing the knowledge they obtained with the rest of the nurses in the hospital and will serve as point persons for the many pediatric initiatives we will be introducing in the months and years to come.
This is just the beginning...
Every child deserves a hospital experience that reflects their unique needs and sensibilities. Community hospitals like KCH may not have all the resources of free standing Childrens Hospitals. But there is no reason why a child who needs advanced medical care on the outer islands should have an experience that is lesser. All children deserve to be treated by professionals who understand that they are not just little adults. They deserve an environment that is welcoming and conducive to healing.
When we deliver an outstanding child focused hospital experience, our pediatric patients will feel better. And when children feel better, they heal better. They recover faster and can get back to the business of just being kids.
We are extremely grateful to the Kona Hospital Foundation for their generous support of this program.
We would also like to thank the Makaha Sons for performing an amazing benefit concert to support our efforts, as well as
KAPA FM for helping us promote this important cause.