"Less Ouch IV": Minimizing Pain for Non-critical IVs in a Pediatric ED

Background:Peripheral intravenous (IV) line insertion is a common pediatric procedure performed in the emergency department (ED).  At an early age, painful IV experiences can have a long-term impact, leading to needle phobia, decreased medical adherence, and negative nurse and physician satisfaction.  Fast-acting interventions to reduce IV insertion pain are available. We aimed to decrease pain associated with non-critical IVs without increasing time to IV insertion in our pediatric ED. Our primary aim was to increase the proportion of “less ouch” IVs from a baseline of 8% to 50% within 12 months. Methods:A multidisciplinary team of pediatric ED nurses, physicians, child life specialists, and pharmacists created an evidence-based pain reduction algorithm for IV insertions. The algorithm is age-based and prioritizes fast-acting interventions, such as oral sucrose for patients under 1 year old and Buzzy® (a vibratory device) for patients over 1 year old. All IVs placed in the pediatric ED were included in the initiative. The initiative excluded IVs ordered as a “critical IV” and IVs placed in patients with an Emergency Severity Index of 1. An IV was considered “less ouch” if an age-appropriate pain reducing intervention from the algorithm was documented.Initial interventions included the introduction of the algorithm at nursing and physician meetings. An IV order panel replaced the “insert IV” order on the ED preferred order list.  This order panel bundles the “insert IV” order with the recommended PRN pharmacologic orders and a nursing communication order recommending use of non-pharmacologic interventions.  “Buzzy® Hives” were implemented to house these devices in each nursing zone for easier visibility and use.Monthly PDSA cycles were performed with nursing and physician feedback incorporated.  Subsequent interventions included posters near IV insertion supplies, team reminders during meetings and in newsletters, and order set integration of the IV order panel. The balancing measure was the average time from IV order to insertion.  We used statistical process control to examine changes in measures over time. Results:From October 2022 to February 2023, the proportion of ED IV insertions using a “less ouch” intervention from 8% to 15%. The average time from IV order to insertion remained stable at 48 minutes. Conclusions:We increased the proportion of non-critical IVs placed using age-appropriate pain reducing interventions without increasing time to IV insertion through implementation of an age-based algorithm, IV order panel, and periodic education. Future efforts will focus on increasing and sustaining adherence.