Transcript Evidence Based Nursing Practice: Using Emla Cream in

MUSC Best Practices
Use of EMLA Cream for Atraumatic Care
NEW GRADUATE RESIDENCY PROGRAM, MUSC
Shelley Grosso, RN BSN
Jenny Breeden, RN BSN
INTRODUCTION
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
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
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.
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 venipuncture
o 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
o 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
DESIGN:
Randomized
Group Study
RESULTS: The
placebo slightly
decreased the report
of pain. EMLA cream
had a distress
reducing effect and a
larger decrease in
reported pain.
A study comparing the use
of EMLA cream and a
placebo cream along with
other non-pharmacological
interventions to aid with
reported and observed
distress associated with
venipuncture.
SAMPLE:
73 boys and
63 girls,
ages 3-12
years old
SAMPLING
METHODS:
Subjects separated
into five
experimental
groups and one
control group
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Study #1
Main 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 study
Conclusions:
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 feelings
o The explanation to the patient that EMLA cream reduces pain showed a decrease in
patient distress
o Placebo cream minimally diminished the report of pain, but overall EMLA cream was
the most effective in reducing pain and distress8
Study #2
DESIGN:
Descriptive
Quantitative
Design
RESULTS:
Advantages include
ease of use and
increased patient
rapport. Having
access to EMLA was
the main barrier.
A study investigating
whether heat after
application of EMLA
cream will ultimately
promote atraumatic
care in pediatric
patients.
SAMPLE:
16 female
and 14 male
children. 8 12 years old
SAMPLE METHODS: A
Convenience sample
was selected including
children with medical
surgical diagnoses
who needed vascular
access but excluding
children with mental
disability.
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Study #2
Main Ideas:
o Venipuncture is one of the most painful procedures that is frequently
performed
o EMLA cream can cause initial vasoconstriction that may hinder intravenous
catheterization, however adding heat should encourage vasodilation
o Wong-Baker FACES pain rating scale was used to report pain and the
SonoSite iLook 25 was used to measure vein size
Conclusions:
o The application of heat counteracted the vasoconstriction effect of EMLA
cream
o The use of EMLA cream followed by heat increases peripheral intravenous
catheterization success rate
o Atraumatic care was established with an 80% first-attempt success rate10
Study #3
DESIGN:
Descriptive
Study
RESULTS: Advantages
include ease of use
and increased patient
rapport. Having
access to EMLA cream
was the main barrier.
A study on the
availability, use, and
the perception of
pediatric nurses on
EMLA cream for
venipuncture and
intravenous
catheterization.
SAMPLING
METHODS:
Pediatric nurses
surveyed with
20-item
questionnaire
SAMPLE:
211 responses
out of 400
surveys
distributed
across 36 states
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Study #3
Main ideas:
o Analyzing the availability of EMLA cream for pediatric RNs
o Identifying driving forces for EMLA cream usage
o Understanding the barriers to EMLA cream usage
Conclusions:
o The practice of EMLA cream in pediatric RNs is inconsistent
o When EMLA cream is not stocked on the floor and had to be
obtained from pharmacy, it was not often used
o Driving forces included the knowledge that venipuncture is painful
for pediatric patients, and the fact that EMLA is easy to use
o Restraining forces have a greater influence on a nurses perception
than driving forces
o Length of time needed to obtain EMLA cream = largest barrier
o Another restraining force was the lack of in-depth training on
EMLA12
BEST EVIDENCE BASED
NURSING PRACTICE
Need for Change Vs. Barriers
o Increased patient and guardian
satisfaction with level of care
o Increase in atraumatic care and
decrease in patient discomfort levels
o Nursing capability as advocates to
implement new practice based on
improving patient rapport
o New practice will aid in decreasing
the number of IV access attempts
o Valid research/literature supports
use of EMLA cream
o Inservice will be provided to ensure
proper and thorough instruction on
EMLA cream
o Cost of training nursing staff,
physician staff, and
pharmaceutical staff
o Cost accrued by the patient as
well as hospital cost of stocking
EMLA
o 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 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.
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
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
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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 Order
1. 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
Works Cited In Order
8. 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.