We Can End the Harm Caused by Preventable Needle Pain: The Promise of Quality Improvement

Needle fear is ubiquitous in children and can have serious and lifelong consequences.¹  Children who experience fear during needle procedures report more pain and are at a heightened risk of developing increasingly distressing memories of these experiences.²  This leads to a cascade of more fear, pain, and even phobias into adulthood.^3,4  Pain associated with needle procedures is one of the greatest sources of pain and distress during a child’s hospital stay, and yet, this pain continues to be undertreated, especially among racialized or marginalized families.⁵  In addition to causing immediate suffering for children and families, inadequately treated needle pain in infants and children can lead to changes in brain development, as well as the avoidance of health care in adulthood.^3,6  Inadequately treated needle pain is both unnecessary and preventable. For these reasons, inadequately managed pain has been described as a health care adverse event.⁷  Reducing harm due to needle pain, beginning from birth, should be viewed as a moral imperative in pediatric health care.

In this month’s issue of Hospital Pediatrics, Monk and colleagues undertake a multidisciplinary, multifaceted quality improvement project to improve the use of evidence-based pain management among children undergoing peripheral intravenous catheter insertion.⁸  They tested 8 unique strategies as plan-do-study-act cycles, including the development of standardized procedural pain treatment guidelines, nursing education and training, electronic health record optimization, human factors, family involvement, and weekly huddles. The primary aim was to increase the proportion of children receiving topical anesthetic, anxiolytic, or sucrose before intravenous catheter insertion within 1 year. Through the use of quality improvement (QI) methodology, including a key driver diagram, a fishbone diagram, testing of plan-do-study-act cycles, and statistical process control analysis, the team was able to achieve an impressive improvement from 17% to 61% during the intended intervention period and saw a further shift to 81% during the period intended for demonstrating sustainability. Nonpharmacological comfort measures were not measured; therefore, the proportion of children receiving any form of pain-relieving modality may have been higher.

The authors’ approach reveals numerous strengths that likely contributed to their success. First and foremost, when they suspected a problem in their institution, they chose to measure it. The QI adage that “you can’t improve what you don’t measure” is fitting for the issue of undertreatment of children’s pain. Just as pain management requires pain measurement, quality improvement requires problem measurement. Despite the fact that guidelines for the assessment and management of pediatric pain have existed for decades, the undertreatment of children’s pain and distress remains a pervasive problem in pediatric hospitals.^9,10  Guidelines are foundational for improving pain care, but without implementation through dedicated and measured improvement efforts, change is unlikely to occur. QI approaches, through the measurement of performance and the testing of changes, consistently reveal an ability to improve outcomes.^11,12  The authors of the “poke plan” used a suite of established QI methods and conducted multiple tests of change. Some changes, such as standardizing care and preselecting topical anesthesia in order sets, used high-reliability principles to guide appropriate action and reduce reliance on individual memory and motivation. They communicated progress toward aims to frontline staff by sharing data and stories. Patient-centered care was promoted with individualized plans to accommodate patient and family needs and preferences. The use of individualized plans based on patient preference acknowledges the subjective nature of children’s (past and current) experiences of pain and fear, reduces uncertainty, empowers families, streamlines communication, and promotes accountability.

It is interesting that the primary outcome measure continued to improve after active improvement efforts ended. It is possible that behavioral changes brought about by the interventions led to a tipping point effect. QI teams attempting to improve pain outcomes for children sometimes encounter outdated attitudes, beliefs, and behaviors that are transmitted through local culture; this creates barriers to change. Lessons that are culturally acquired and unintended can form a hidden curriculum.¹³  Experimental models have revealed that when a critical mass of individuals change behavior, established patterns can be overturned.¹⁴  The application of tipping point theory to pediatric pain-related QI has not been studied. One might expect that if health care providers learn to perform procedures in ways that minimize children’s pain and distress in the context of a system that facilitates effective treatment of pain, they may experience an increased sense of mastery and reduced moral distress; this in turn, positively reinforces the change. Important questions for future study include how hidden culture and curriculum in pediatric pain can be measured, how it can be improved and modernized, whether there is a tipping point effect in pain-related QI, and whether health care worker psychological factors are key drivers in improving the treatment of pain. It is also notable that the final intervention represented a higher-level reliability strategy than the previous. The first 7 strategies would have relied primarily on providers remembering and choosing to perform the appropriate action. The eighth strategy was a modification of pediatric admission order sets to have preselected orders for topical anesthetic and sucrose. This incorporation of a higher reliability strategy may have contributed to the second shift and the ability for improvement to be sustained.

Although the authors’ work certainly achieved meaningful improvement in patient experience, we noted several limitations. Although they attempted to measure patient- and parent-reported outcomes, the data collection strategy of posting a QR code linked to a survey did not lead to sufficient responses for assessing improvement. Patient-reported experience and outcome measures can ensure that improvement efforts have the intended effect. The establishment of patient preference and patient experience would have also helped to inform improvement aims, for example, by knowing the proportion of patients and families who desired topical anesthesia or anxiolytics. Because the initiative included all patients <18 years of age, it is possible that some did not desire these modalities, regardless of their efficacy. The establishment of aims should ideally be developed with knowledge of patient needs and preferences. In pursuit of the appropriate goal of eliminating pain, the importance of the development of autonomy and a sense of self-agency as children reach adolescence should also be considered.¹⁵  Balancing an understanding of a child’s cognitive and social development with an individualized understanding of their needs and preferences is optimal. The most appropriate QI target for topical anesthetic should be that every child who desires it receives it, yet, without knowing the proportion of adolescents desiring topical anesthetic use, an appropriate aim cannot be set. Knowledge of patient preference and age-stratified aims and analysis can ensure that appropriate care is being delivered.

The authors commented on their use of the term poke plan and acknowledged the uncertainty of whether the term enhanced the team’s goal of reducing distress. A poke is typically thought of as an unpleasant action done to a passive recipient, sometimes with aggressive intent. The catchiness of the term poke plan to health care providers may have come at the expense of appeal, comfort, and confidence of families. Codesign with people with lived experience at earlier stages of the project could have informed this choice. A large body of evidence reveals that language matters when it comes to talking about pain with children.^16,17  Language-based interventions (eg, emphasizing positive aspects of past procedures, avoiding the use of pain-related words) used with children undergoing painful procedures have been shown to impact how children remember pain, which could impact their future pain experiences.¹⁷  Children and parents who are more anxious before painful procedures are likely to develop increasingly distressing memories of these experiences and worse pain in the future.^2,18,19  Future work should harness the power of clinician, child, and parent language to alleviate children’s pain and distress, foster less distressing memories, and mitigate potential harm. Existing pediatric pain management resources and initiatives can be leveraged.²⁰  Patient and family engagement, expertise, knowledge, and empowerment are critical to any agenda.

The Lancet Child & Adolescent Commission identified 4 transformative goals to prevent the societal and individual harms of undertreating children’s pain: make pain matter, make pain understood, make pain visible, and make pain better.¹⁰  QI approaches can effectively address these goals. Hospitals providing care for children need to be accountable for their performance in treating pain and preventing harm due to pain. The importance of reducing pain and distress from birth and throughout the pediatric age span cannot be understated. Quality improvement approaches are our best strategy for ensuring that harm caused by preventable needle pain becomes a thing of the past. As health care providers, we must meet this moral imperative to do what is right for the next generation.