Evidence-Based Medicine
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. Feb 8, 2017; 6(1): 81-88
Published online Feb 8, 2017. doi: 10.5409/wjcp.v6.i1.81
Using quality improvement methods to increase use of pain prevention strategies for childhood vaccination
Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Jolynn Parker, Kristi Williams, Dustin Wallace, Mark Connelly, Lynn Anson, Kevin Mroczka
Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children’s Mercy, Kansas City, MO 64108, United States
Jolynn Parker, Primary Care Clinic, Children’s Mercy, Kansas City, MO 64108, United States
Kristi Williams, Division of General Academic Pediatrics, Children’s Mercy, Kansas City, MO 64108, United States
Lynn Anson, Comprehensive Pain Management, Children’s Mercy, Kansas City, MO 64108, United States
Kevin Mroczka, Department of Pediatrics, Children’s Mercy, Kansas City, MO 64108, United States
Author contributions: Schurman JV contributed to the design of the quality improvement study and interventions, coordinated and supervised data collection, carried out the analysis and initial data interpretation, and drafted the initial manuscript; Deacy AD and Johnson RJ contributed to the design of the quality improvement study and interventions, data interpretation, and drafting of the initial manuscript, and critically revised the manuscript for important intellectual content; Parker J, Williams K, Wallace D, Connelly M, Anson L, and Mroczka K contributed to the design of the quality improvement study and interventions, and data interpretation, and critically reviewed the manuscript; all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Supported by the Pfizer Medical Education Group in part.
Conflict-of-interest statement: There are no conflicts of interest arising from this work.
Data sharing statement: No further data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jennifer Verrill Schurman, PhD, ABPP, Division of Developmental and Behavioral Sciences, Children’s Mercy, 2401 Gillham Road, Kansas City, MO 64108, United States. jschurman@cmh.edu
Telephone: +1-816-2343675
Received: July 15, 2016
Peer-review started: July 16, 2016
First decision: August 4, 2016
Revised: October 20, 2016
Accepted: November 1, 2016
Article in press: November 2, 2016
Published online: February 8, 2017
Processing time: 203 Days and 8.3 Hours
Abstract
AIM

To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology.

METHODS

Specific intervention strategies (i.e., comfort positioning, nonnutritive sucking and sucrose analgesia, distraction) were identified, selected and introduced in three waves, using a Plan-Do-Study-Act framework. System-wide change was measured from baseline to post-intervention by: (1) percent of vaccination visits during which an evidence-based pain prevention strategy was reported as being used; and (2) caregiver satisfaction ratings following the visit. Additionally, self-reported staff and caregiver attitudes and beliefs about pain prevention were measured at baseline and 1-year post-intervention to assess for possible long-term cultural shifts.

RESULTS

Significant improvements were noted post-intervention. Use of at least one pain prevention strategy was documented at 99% of patient visits and 94% of caregivers were satisfied or very satisfied with the pain prevention care received. Parents/caregivers reported greater satisfaction with the specific pain prevention strategy used [t(143) = 2.50, P≤ 0.05], as well as greater agreement that the pain prevention strategies used helped their children’s pain [t(180) = 2.17, P≤ 0.05] and that they would be willing to use the same strategy again in the future [t(179) = 3.26, P≤ 0.001] as compared to baseline. Staff and caregivers also demonstrated a shift in attitudes from baseline to 1-year post-intervention. Specifically, staff reported greater agreement that the pain felt from vaccinations can result in harmful effects [2.47 vs 3.10; t(70) = -2.11, P≤ 0.05], less agreement that pain from vaccinations is “just part of the process” [3.94 vs 3.23; t(70) = 2.61, P≤ 0.05], and less agreement that parents expect their children to experience pain during vaccinations [4.81 vs 4.38; t(69) = 2.24, P≤ 0.05]. Parents/caregivers reported more favorable attitudes about pain prevention strategies for vaccinations across a variety of areas, including safety, cost, time, and effectiveness, as well as less concern about the pain their children experience with vaccination [4.08 vs 3.26; t(557) = 6.38, P≤ 0.001], less need for additional pain prevention strategies [3.33 vs 2.81; t(476) = 4.51, P≤ 0.001], and greater agreement that their doctors’ office currently offers pain prevention for vaccinations [3.40 vs 3.75; t(433) = -2.39, P≤ 0.05].

CONCLUSION

Quality improvement methodology can be used to help close the gap in implementing pain prevention strategies during routine vaccination procedures for children.

Keywords: Pediatrics; Quality improvement; Distraction; Pain management; Immunization; Vaccination; Sucrose analgesia; Pain prevention; Non-nutritive sucking; Comfort positioning; Primary care

Core tip: Application of quality improvement methodology can help close the gap in implementing evidence-based pain prevention strategies during routine medical procedures, such as childhood vaccination. A key element to the adoption and maintenance of practice change appears to be building a meaningful partnership with key staff (e.g., nurses who routinely deliver vaccinations) within the target clinic to elicit their expertise and input, as well as facilitate their ownership of the process. Development of project “champions” among key staff can help reduce barriers to implementation, increase uptake of practice change, and shift culture to support long-term maintenance of gains.