Poke Plan: An Initiative to Improve Distraction and Pain Mitigation With Venous Access in Hospitalized Children.

BACKGROUND: Adequate pain control and anxiety relief during peripheral intravenous cannula (PIV) placement improves patient, parental, and staff satisfaction and reduces health care-induced stress in children. We noted a low rate of analgesic/anxiolysis use (<20%) and child life utilization (3%) in our institution. This quality improvement project was initiated to increase pain mitigation strategies in hospitalized children requiring PIV access. METHODS: From November 2020 to March 2021, we created a key driver diagram and summarized possible interventions with the aim to increase our use of pain control strategies to >40% and child life utilization to 25%. For 12 months, 8 Plan-Do-Study-Act cycles were conducted focusing on nursing education and training, improved documentation, electronic medical record optimization, easy access to analgesics and anxiolytics, family involvement, and weekly huddles. Our primary measure was the percentage use of pain medications for PIV access. The utilization of PIV experts from the ICU (advanced practice registered nurses and physicians) served as the balancing measure. RESULTS: A total of 883 patient charts were reviewed. The use of topical anesthetics and anxiolytics increased from 16.2% at baseline to 78.9% after the implementation of the quality improvement project. Eighty percent of parents reported their child was kept comfortable during the procedure using pain mitigation and comfort measures. A slight increase from 2% to 5.8% was noted in the utilization of advanced practice registered nurses and intensivists. CONCLUSIONS: Implementation of a standardized approach for PIV placement improved team communication and provided better preparation for pain control before needle insertions in hospitalized children.

Interactions in Sociotechnical Systems: Achieving Balance in the Use of an Augmented Reality Mobile Application.

OBJECTIVE: We explore relationships between barriers and facilitators experienced by users to understand dynamic interactions in sociotechnical systems and improve a mobile phone-based augmented reality application that teaches users about the contents of a standardized pediatric code cart. BACKGROUND: Understanding interactions between performance obstacles and facilitators can provide guidance to (re)designing sociotechnical systems to improve system outcomes. Clinicians should know about contents and organization of code carts, and an augmented reality mobile application may improve that knowledge but changes the sociotechnical system in which they learn. Prior work identified barriers and facilitators impacting the use of this application-participants described dimensions together, indicating interactions that are explored in the current study. METHOD: We conducted four focus groups (number of clinicians = 18) and two interviews with clinicians who used the application. We performed a secondary analysis of focus group data exploring interactions between previously identified barriers and facilitators to application use. We used epistemic network analysis to visualize these interactions. RESULTS: Work system barriers interacted with barriers and facilitators interacted with facilitators to amplify cumulative negative or positive impact, respectively. Facilitators balanced barriers, mitigating negative impact. Facilitators also exacerbated barriers, worsening negative impact. CONCLUSION: Barriers and facilitators interact and can amplify, balance, and exacerbate each other-notably, positives are not always positive. To obtain desired outcomes, interactions must be further considered in sociotechnical system design, for example, the potential improvements to the application we identified.

Walking the line: balancing performance barriers and facilitators in an augmented reality mobile application for paediatric code cart training.

An augmented reality (AR) mobile smartphone application was developed for clinicians to improve their knowledge about the contents and organisation of a standardised paediatric code cart, an important tool in safe, effective paediatric resuscitations. This study used focus groups and interviews with 22 clinicians to identify work system barriers and facilitators to use of the application. We identified twelve dimensions of barriers and facilitators: convenience, device ownership, device size and type, gamification, interface design, movement/physical space, perception of others, spatial presence, technological experience, technological glitches, workload, and the perception and attitude towards code cart and resuscitation. These dimensions can guide improvement efforts, e.g. redesigning the interface, providing non-AR modes, improving the tutorial. We propose nine principles to guide the design of other digital health technologies incorporating AR. In particular, the workload demands created by using AR must be considered and accounted for in the design and implementation of such technologies. Practitioner summary: Augmented reality (AR) may prepare workers for situations that do not occur frequently. This study investigates barriers and facilitators to using an AR mobile smartphone application developed to improve clinician knowledge about code carts, leading to improvements to the application and principles to guide the design of other AR-based technologies.

Acute lymphoblastic leukemia presenting as cholestatic jaundice in a 7-year-old boy.

This is a case of a 7-year-old boy with acute lymphoblastic leukemia presenting with cholestasis and elevated transaminase levels. Acute lymphoblastic leukemia is the most common malignancy in children and can have variable presenting clinical manifestations. However, cholestasis is less commonly encountered in the pediatric population and can be a diagnostic challenge. We present a case of a 7-year-old boy discovered to have elevated transaminase levels while undergoing an evaluation for motor tics, which subsequently progressed to cholestasis and acute liver failure secondary to acute lymphoblastic leukemia. He demonstrated marked improvement after induction therapy and is in clinical remission. Clinicians should be ever mindful of the potentially unique presentations of childhood leukemia.