MUSC Best PracticesUse of EMLA Cream for Atraumatic CareNEW GRADUATE RESIDENCY PROGRAM, MUSCShelley Grosso, RN BSNJenny Breeden, RN BSN

INTRODUCTION

MUSC ExcellenceMUSC 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

Atraumatic CareDonna 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

Use of EMLA Cream as a form Atraumatic CareThe 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.

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.

Using EMLA cream before venipunctureo 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 vein5o 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

REVIEW OF THE LITERATURE

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

Study #1Main Ideas: o Pain and distress associated with minor invasive procedures in children can be reduced by topical application of EMLA cream.o 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).o A placebo cream was used for comparison and an identical scale for pain score was used for all participants in the studyConclusions:o There is a significant difference between the pain scores of those who received EMLA cream and those who did not.o Quantifiable advantage of EMLA cream in reducing the negative feelingso The explanation to the patient that EMLA cream reduces pain showed a decrease in patient distresso Placebo cream minimally diminished the report of pain, but overall EMLA cream was the most effective in reducing pain and distress8

Study #2

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

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

Study #3

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

Study #3Main ideas:o Analyzing the availability of EMLA cream for pediatric RNso Identifying driving forces for EMLA cream usageo Understanding the barriers to EMLA cream usageConclusions:o The practice of EMLA cream in pediatric RNs is inconsistento When EMLA cream is not stocked on the floor and had to be obtained from pharmacy, it was not often usedo Driving forces included the knowledge that venipuncture is painful for pediatric patients, and the fact that EMLA is easy to useo Restraining forces have a greater influence on a nurses perception than driving forceso Length of time needed to obtain EMLA cream = largest barriero Another restraining force was the lack of in-depth training on EMLA12

BEST EVIDENCE BASED NURSING PRACTICE

Need for Change Vs. Barrierso Increased patient and guardian satisfaction with level of careo Increase in atraumatic care and decrease in patient discomfort levelso Nursing capability as advocates to implement new practice based on improving patient rapporto New practice will aid in decreasing the number of IV access attemptso Valid research/literature supports use of EMLA creamo Inservice will be provided to ensure proper and thorough instruction on EMLA cream

o Cost of training nursing staff, physician staff, and pharmaceutical staffo Cost accrued by the patient as well as hospital cost of stocking EMLAo Necessary approval and agreement on protocol from multiple disciplines (pharmacy, medical, nursing)o Lack of patient knowledge of EMLA cream

INTRODUCING CHANGE

Strategies to Promote ChangeEvidence 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 changeDemonstration• Openly follow the new practice and encourage the clinical unit leaders on the floor to do the same.

Strategies to Achieve OutcomesTraining:• 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 placeDocumentation:• Provide routes of documentation for nursing, physician, and pharmacy staff in which they can properly record the implementation of the new practice

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

SUMMARY

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.

Works Cited In Order1. Hockenberry, M. J., & Wilson, D. (2007). Wong’s nursing care of infants and children(8th ed). St. Louis: Mosby.2. 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), 105-112.3. Britt, R.B. (2005). Using EMLA cream before venipuncture. [Electronic Version]. Nursing 2005, 1, 17. 4. 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), 33-39.5. 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. 6. Britt, R.B. (2005). Using EMLA cream before venipuncture. [Electronic Version]. Nursing 2005, 1, 17. 7. 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.

Works Cited In Order8. 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), 257-268.9. 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. 10.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. 11.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), 105-112.12.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.