MUSC Best Practices Use of EMLA Cream for Atraumatic Care

1. MUSC Best PracticesUse of EMLA Cream for Atraumatic Care NEW GRADUATE RESIDENCY PROGRAM, MUSC Shelley Grosso, RN BSN Jenny Breeden, RN BSN

2. INTRODUCTION

3. MUSC Excellence MUSC excellence is the adoption of the “Best Practices at MUSC”. Simultaneously in 2006 the Institute of Psychiatry adopted the Engagement Model which includes best practices such as: • Environmental modifications • Unit rules and healing language • Trauma informed care and healing milieu • Patient/ family involvement in treatment decisions

4. Atraumatic Care Donna Wong’s Conceptual Model of Atraumatic care defines atraumatic care in healthcare settings as care that “eliminates or minimizes the psychological and physical distress experienced by children and families”. Within this framework, there are three principles: • Prevent child’s separation from family • Promoting a sense of control • Minimizing bodily injury and pain1

5. Use of EMLA Cream as a form Atraumatic Care The use of EMLA cream on pediatric patients prior to venipuncture and/or intravenous catheterization. EMLA cream is an anesthetizing agent used to reduce the pain associated with minor hospital procedures. A less painful venipuncture is related to higher success in gaining venous access2.

6. How does EMLA Cream Work? The purpose of EMLA cream is to provide atraumatic care during minor procedures, such as venipunctures and intravenous catheterization, especially for pediatric patients. The usage of EMLA cream is currently not a part of a standard policy at the Medical University of South Carolina Children’s Hospital. Three research articles were examined to explore if the advantages of applying EMLA cream prior to certain procedures outweigh the disadvantages, therefore providing atraumatic care to pediatric patients.

7. Using EMLA cream before venipuncture • Reasons why nurses do not use/apply EMLA cream: • No prescription ordered • Length of time it takes to obtain EMLA cream once ordered • The supposed “white cloud” effect that makes it difficult to visualize a vein • Possibility that EMLA cream causes vasoconstriction of an available vein5 • Actions that can induce change: • Advocating for standing orders so nurses can have access to EMLA cream during appropriate situations • Educating staff nurses on proper use of EMLA cream as well as its contraindications • Instructing nurses that research shows EMLA cream can reduce pain during a venipuncture even if applied a mere five minutes before the procedure • Implementing the practice of applying heat after using EMLA cream to prevent vasoconstriction of the vein6

8. REVIEW OF THE LITERATURE

9. Study #1 RESULTS: The placebo slightly decreased the report of pain. EMLA cream had a distress reducing effect and a larger decrease in reported pain. 7

10. Study #1 Main Ideas: • Pain and distress associated with minor invasive procedures in children can be reduced by topical application of EMLA cream. • EMLA cream surpasses psychological interventions (such as distraction, music, breathing exercises, or watching a movie) as well as non-pharmacological interventions (procedural information and distraction). • A placebo cream was used for comparison and an identical scale for pain score was used for all participants in the study Conclusions: • There is a significant difference between the pain scores of those who received EMLA cream and those who did not. • Quantifiable advantage of EMLA cream in reducing the negative feelings • The explanation to the patient that EMLA cream reduces pain showed a decrease in patient distress • Placebo cream minimally diminished the report of pain, but overall EMLA cream was the most effective in reducing pain and distress8

11. Study #2 RESULTS: Advantages include ease of use and increased patient rapport. Having access to EMLA was the main barrier. 9

12. Study #2 Main Ideas: • Venipuncture is one of the most painful procedures that is frequently performed • EMLA cream can cause initial vasoconstriction that may hinder intravenous catheterization, however adding heat should encourage vasodilation • Wong-Baker FACES pain rating scale was used to report pain and the SonoSite iLook 25 was used to measure vein size Conclusions: • The application of heat counteracted the vasoconstriction effect of EMLA cream • The use of EMLA cream followed by heat increases peripheral intravenous catheterization success rate • Atraumatic care was established with an 80% first-attempt success rate10

13. Study #3 RESULTS: Advantages include ease of use and increased patient rapport. Having access to EMLA cream was the main barrier. 11

14. Study #3 Main ideas: • Analyzing the availability of EMLA cream for pediatric RNs • Identifying driving forces for EMLA cream usage • Understanding the barriers to EMLA cream usage Conclusions: • The practice of EMLA cream in pediatric RNs is inconsistent • When EMLA cream is not stocked on the floor and had to be obtained from pharmacy, it was not often used • Driving forces included the knowledge that venipuncture is painful for pediatric patients, and the fact that EMLA is easy to use • Restraining forces have a greater influence on a nurses perception than driving forces • Length of time needed to obtain EMLA cream = largest barrier • Another restraining force was the lack of in-depth training on EMLA12

15. BEST EVIDENCE BASED NURSING PRACTICE

16. Need for Change Vs. Barriers • Increased patient and guardian satisfaction with level of care • Increase in atraumatic care and decrease in patient discomfort levels • Nursing capability as advocates to implement new practice based on improving patient rapport • New practice will aid in decreasing the number of IV access attempts • Valid research/literature supports use of EMLA cream • Inservice will be provided to ensure proper and thorough instruction on EMLA cream • Cost of training nursing staff, physician staff, and pharmaceutical staff • Cost accrued by the patient as well as hospital cost of stocking EMLA • Necessary approval and agreement on protocol from multiple disciplines (pharmacy, medical, nursing) • Lack of patient knowledge of EMLA cream

17. Introducing Change

18. Strategies to Promote Change Evidence Based Education: • Provide the literature that supports the new protocol available to the staff and offer a comparison of the current situation without the new practice in place • Discuss with the staff the positive aspects of implementing the changes that will promote a higher level of atraumatic care while providing an inservice presentation. Communication: • Ensures that those implementing change will listen to any ideas from the staff on how to better implement the change Demonstration • Openly follow the new practice and encourage the clinical unit leaders on the floor to do the same.

19. Strategies to Achieve Outcomes Training: • Allow each discipline to train their staff before collectively training the staff • Create a multidisciplinary team that will instruct the training session for all the disciplines involved. This team will also be the resource team once the change takes place Documentation: • Provide routes of documentation for nursing, physician, and pharmacy staff in which they can properly record the implementation of the new practice

20. Decreasing/Eliminating Resistance • Offer a clear and concise statement of the goals of the new protocol • Eliminates any miscommunication or misunderstandings • Provide open discussion staff meetings about the new protocol: • Teach the nursing staff that this new practice gives them more input in patient care • Encourage questions and ask staff to voice feelings, either negative or positive, about change • Directly deal with controversy • Meet with those who oppose the new practice • Ask if they have ideas on ways to improve the implementation of the new practice • Assign them to a quality improvement team that focuses on the process of implementing the protocol

21. summary

22. References • Britt, R.B. (2005). Using EMLA cream before venipuncture. [Electronic Version]. Nursing 2005, 1, 17. • Hockenberry, M. J., & Wilson, D. (2007). Wong’s nursing care of infants and children (8th ed). St. Louis: Mosby. • Huff, L., Hamlin, A., Wolski, D., McClure, T., Eliades, A.B., Weaver, L., & Shelestak, D. (2009). Atraumatic care: EMLA cream and application of heat to facilitate peripheral venous cannulation in children. Issues in Comprehensive Pediatric Nursing, 32, 65-76. • May, K., Britt, R.B., & Newman, M. M. (1999). Pediatric registered nurse usage and perception of EMLA [Electronic Version]. Journal of the Society of Pediatric Nurses, 4(3), 105-112. • Rogers, T.L., & Ostrow, C.L. (2004). The use of EMLA cream to decrease venipuncture pain in children [Electronic Version]. Journal of Pediatric Nursing, 19(1), 33-39. • Tak, J.H., & van Bon., W.H.J. (2006). Pain- and distress-reducing interventions for venipuncture in children [Electronic Version]. Child Care Health Development, 32(3), 257-268.

23. Works Cited In Order • Hockenberry, M. J., & Wilson, D. (2007). Wong’s nursing care of infants and children(8th ed). St. Louis: Mosby. • May, K., Britt, R.B., & Newman, M. M. (1999). Pediatric registered nurse usage and perception of EMLA [Electronic Version]. Journal of the Society of Pediatric Nurses, 4(3), 105-112. • Britt, R.B. (2005). Using EMLA cream before venipuncture. [Electronic Version]. Nursing 2005, 1, 17. • Rogers, T.L., & Ostrow, C.L. (2004). The use of EMLA cream to decrease venipuncture pain in children [Electronic Version]. Journal of Pediatric Nursing, 19(1), 33-39. • Huff, L., Hamlin, A., Wolski, D., McClure, T., Eliades, A.B., Weaver, L., & Shelestak, D. (2009). Atraumatic care: EMLA cream and application of heat to facilitate peripheral venous cannulation in children. Issues in Comprehensive Pediatric Nursing, 32, 65-76. • Britt, R.B. (2005). Using EMLA cream before venipuncture. [Electronic Version]. Nursing 2005, 1, 17. • Tak, J.H., & van Bon., W.H.J. (2006). Pain- and distress-reducing interventions for venipuncture in children [Electronic Version]. Child Care Health Development, 32(3), 257-268.

24. Works Cited In Order • Tak, J.H., & van Bon., W.H.J. (2006). Pain- and distress-reducing interventions for venipuncture in children [Electronic Version]. Child Care Health Development, 32(3), 257-268. • Huff, L., Hamlin, A., Wolski, D., McClure, T., Eliades, A.B., Weaver, L., & Shelestak, D. (2009). Atraumatic care: EMLA cream and application of heat to facilitate peripheral venous cannulation in children. Issues in Comprehensive Pediatric Nursing, 32, 65-76. • Huff, L., Hamlin, A., Wolski, D., McClure, T., Eliades, A.B., Weaver, L., & Shelestak, D. (2009). Atraumatic care: EMLA cream and application of heat to facilitate peripheral venous cannulation in children. Issues in Comprehensive Pediatric Nursing, 32, 65-76. • May, K., Britt, R.B., & Newman, M. M. (1999). Pediatric registered nurse usage and perception of EMLA [Electronic Version]. Journal of the Society of Pediatric Nurses, 4(3), 105-112. • May, K., Britt, R.B., & Newman, M. M. (1999). Pediatric registered nurse usage and perception of EMLA [Electronic Version]. Journal of the Society of Pediatric Nurses, 4(3), 105-112.