Establishing a Contingency Plan to Improve Patient Comfort During Peripherally Inserted Central Catheter Insertions: A Quality Improvement EffortCE
Highlights
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The authors built a contingency plan to improve patient comfort during PICC placements.
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Patient comfort during PICC insertions was increased.
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The authors met their goals using quality improvement methodology.
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Prioritizing patient comfort may require an institutional culture change.
Abstract
Background: Negative outcomes can occur when painful experiences related to needle procedures are not addressed. Patients at the institution in this study were not demonstrating sufficient levels of comfort during peripherally inserted central catheters (PICC) placements, so formal assessment of discomfort or distress began via the Pediatric Sedation State Scale (PSSS), and an enhanced approach to comfort planning, built around the Comfort Promise, was implemented. Over 1 year, we aimed to increase the percent of patients meeting sufficient comfort during PICC insertions by our Vascular Access Team (VAT) from 54% to 65%.
Methods: Initially, VAT staff were educated on use of the PSSS and began routinely charting the highest score obtained during each PICC placement. Interventions were delivered concurrently and included (1) changing the VAT culture, (2) process development, (3) consensus building and scale up, and (4) information system modifications. Results: During the project period, 421 PICC insertions were completed. From baseline to the last 8 months, the percent of patients rated as experiencing sufficient comfort (PSSS = 2–3) during PICC placement increased from 54% to 74%, with the percent of patients experiencing significant discomfort or distress (PSSS = 4–5) decreasing from 45% to under 7%.
Conclusions: Success in this project required a culture change. Building consensus by engaging others and integrating with the processes, preferences, and priorities of each area was key. Future work will focus on increasing use of all Comfort Promise bundle elements, identifying patients at risk for escalation, and taking a long-term view to comfort planning, as well as applying lessons learned to other needle procedures.
Decision-making algorithm for comfort planning during peripherally inserted central catheter (PICC) insertions. Note: The Vascular Access Team may discuss with the primary team whether the patient will be sedated for another reason within 24 hours in which PICC placement could occur, request anxiolytic medication from the ordering provider, and/or consult with the Sedation Team.
Pediatric sedation state scale comfort ratings. (a) Percent of peripherally inserted central catheter (PICC) placements with rating of 2–3 on the Pediatric Sedation State Scale (PSSS). (b) Percent of PICC placements with rating of 0–1 on PSSS. (c) Percent of PICC placements with rating of 4–5 on PSSS.
Use of Comfort Promise bundle elements.
Use of other medications for comfort. Note: All other medications used in less than 5% of cases.
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