Transcription:
Comfort Promise

Melanie Cole (Host): Welcome to Pediatrics In Practice with Children's Mercy, Kansas City. I'm Melanie Cole, and I invite you to listen as we discuss Comfort Promise. Joining me, is Dr. Amanda Deacy. She's a Clinical Pediatric Psychologist in the field of Gastroenterology at Children's Mercy, Kansas City.

Dr. Deacy, it's a pleasure to have you join us today. So, please tell us about the concept of Comfort Promise. Can you describe what it is, any background and really, how did this all come about?  

Amanda Deacy, PhD (Guest): Thank you for having me, first of all Comfort Promise really is the idea that healthcare providers will commit to doing anything they can to prevent or ease pain in the context of the pediatric patient care. And in practice, really what it involves is the layering of at least three evidence-based practices for every needle procedure.

So, for most people, they think of immunizations or IV starts as being the most common. These three practices, they include a topical anesthetic, so something to numb the skin. The second is comfort positioning and distraction is the third with a fourth element, either the use of sucrose or a breastfeeding that's included in the bundle for children who are under a year of age.

And Children's Mercy was originally selected to implement the Comfort Promise as a three-year QI project initially under the stewardship of Liz Edmondson, who continues to lead the project as it rolls out all across Children's Mercy's clinics and inpatient areas. Children's Mercy was one of the only sites selected initially to complete the program and implement the concept in a meaningful way.

And so, at this point, there are multiple Comfort Promise initiatives underway throughout the hospital, all with the goal of eliminating preventable harm to children, one poke or one procedure at a time.

Host: What a great program. What sparked your interest in it?

Dr. Deacy: So, my interest in Comfort Promise really stems from my previous training as a Pediatric Pain Psychologist at UCLA and subsequently here at Children's Mercy. In those two roles, I was really focused mainly on chronic pain syndrome. And what I came to learn in doing this work, is that the impact of early acute pain experiences were becoming better understood. And in fact, were increasingly being viewed as potential triggers or are precursors for the chronic pain syndromes that I was studying. And so as early as 2012 even before the official signing on of Children's Mercy as a Comfort Promise site I worked in tandem with my colleagues in Developmental and Behavioral Sciences at that time to pilot a QA project involving comfort measures for needle procedures in our primary care clinics.

And as part of that project, we learned that pediatric providers, they were familiar with some of the strategies, but not all of them. And perhaps most importantly, or what I found most interesting at that time, was that the majority of providers and nurses, they really viewed pain prevention as important and possible. But very few viewed pain as harmful and many actually indicated that learning to deal with pain could actually benefit children.

In that same year, my personal experience really further solidified my interest in Comfort Promise, as I had my own newborn who was in need of getting immunizations nearly every eight weeks. And even as an informed and hopefully healthcare savvy healthcare system savvy parent, I faced numerous challenges in communicating and advocating for my wishes for comfort measures to be used standardly during my son's immunizations. And so, this spurred me on even further to continue this work since after all my passion is really ensuring that these evidence-based interventions were accessible and available to all children. So, since that time back in 2012, I've partnered with other Comfort Promise champions like Liz Edmondson, who I've mentioned, and also Dr. Jennifer Sherman here to find innovative ways to move the Comfort Promise forward at Children's Mercy.

Host: That's so interesting. And thank you for telling us how you got involved and what sparked your interest. So, tell us about the quality improvement project you're leading in GI to assess the gaps that you've seen in documentation of the pain prevention bundle in order to measure its uptake and success rate. What does this quality improvement project you're working on entail?

Dr. Deacy: Sure. I'm very excited that GI my current home division has been an early adopter of Comfort Promise. In our clinics, we hear all the time about children with fears surrounding needle sticks, or IV starts prior to endoscopy procedure in particular. And we're also really aware that children experience anxiety and pain related to other procedures in GI, such as placement or changing of feeding tubes.

So, my project, as you said, is really designed to assess the gaps in documentation of this pain prevention bundle in order really better understand how often it's being used and how successful it is. So differently, I'm really, I'm looking to ensure first that nursing staff are aware of and supported in knowing the appropriate place in the medical record for documenting these interventions. Because like most things in medicine, if it's not in the record, it didn't happen. And so that's really a step that we need be sure it's happening. And then secondly, wanted to measure how parents are accepting of these procedures and their interventions and how they view them as effective or not.

Host: Wow. So tell us, what are some of the initial learnings? What have you found out about this?

Dr. Deacy: Sure. So, we know is that prior to the rollout of Comfort Promise in GI, the rate of the use of topical anesthetic creams in particular, for patients that we send down to lab for these needle procedures was 0%. So, this was measurement that we had obtained back for January of 2019. So, essentially what that means is zero of our patients in GI, who we were sending and docs were asking for lab work to be done, zero of them were getting the topical anesthetic.

Since we rolled out the education in October of 2019, the rate of topical application is closer to about 48% as of March. And now it's hovering in the mid to upper 30% range. And so we're making some forward progress. We've just now begun to more systematically track the rate of topical application and the use of some of those other bundle elements that I mentioned for kids that are actually having their procedures done within GI clinic.

And what we've discovered is that there's a lot of missing data. So, in other words, we're actually unsure as to whether or not the comfort measures are being used in the clinic and just not documented or whether they're not being offered to families at all. And so I've, as a result, added a secondary which really is a prerequisite goal to improve the rate of documentation of the Comfort Promise strategies as part of the project.

Host: That's so cool. So, what value do you hope or see this project bringing to the hospital and to clinical practice settings for other providers that are looking at this model, what would you like them to know about it?

Dr. Deacy: So, hope is really that my QI project is part of continuing to shine a light on elevating Comfort Promise as the expected standard of care across the hospital. And I hope that with its more consistent adoption that nursing staff, providers, parents, and children will see its role in ensuring safe, comfortable procedures and an overall decrease in procedural anxiety.

I also hope that this work contributes to what my colleagues and I have envisioned as the creation of each patient's own personalized pain prevention plan that would become part of their medical record. It would be a living document essentially with the ability to change as the patient's needs change.

And this would not only help physicians know patient's preferences prior to procedures, but would also allow young patients to trust that we are going to do what they need across clinics, across procedures, to help them feel good about the care that they're receiving.

Host: So important and as certainly as children grow, I would imagine this assessment would change as well. So as we wrap up, what would you like to summarize? What would you like us to know about Comfort Promise, your QI project and any final thoughts that you have?

Dr. Deacy: I'd just like  to reinforce this idea to my fellow healthcare providers that unmitigated procedural pain and anxiety is not benign. We used to think that if we could just get through painful procedures quickly enough, there would be no lasting ill effects. And in fact, maybe we even build some character in our pediatric patients along the way. Current evidence though tells us that we were wrong, that there are indeed long-term consequences to unmanaged pain and anxiety in situations like these.

And second, I'd like healthcare providers to know that there are strategies that exist right now to eliminate needle pain and anxiety, and that it really is our obligation to provide all pediatric patients with these interventions as standard of care, as we are called to do better on their behalf.

Host: What a great program. And thank you so much, Dr. Deacy for joining us today. I hope you'll come back on and update us as your quality improvement project continues. To refer your patient or for more information, you can visit children'smercy.org to get connected with one of our providers.

This has been Pediatrics In Practice with Children's Mercy, Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.