Charmaine Kleiber

Effects of distraction on children's pain and distress during medical procedures: a meta-analysis

BACKGROUND It is difficult to determine the usefulness of distraction to decrease childrens distress behavior and pain during medical procedures because many studies use very small samples and report inconsistent findings. OBJECTIVES To investigate the mean effect sizes across studies for the effects of distraction on young childrens distress behavior and self-reported pain during medical procedures. METHOD Hunter and Schmidts (1990) procedures were used to analyze 16 studies (total n = 491) on childrens distress behavior and 10 studies (total n = 535) on childrens pain. RESULTS For distress behavior, the mean effect size was 0.33 (+/-0.17), with 74% of the variance accounted for by sampling and measurement error. For pain, the mean effect size was 0.62 (+/-0.42) with 35% of the variance accounted for. Analysis of studies on pain that limited the sample to children 7 years of age or younger (total n = 286) increased the amount of explained variance to 60%. CONCLUSIONS Distraction had a positive effect on childrens distress behavior across the populations represented in this study. The effect of distraction on childrens self-reported pain is influenced by moderator variables. Controlling for age and type of painful procedure significantly increased the amount of explained variance, but there are other unidentified moderators at work.

Infusing research into practice to promote quality care

This article describes the Iowa Model of Research in Practice, a heuristic model used at the University of Iowa Hospitals and Clinics for infusing research into practice to improve the quality of care. The components of the model are presented with examples. The impact of the model on patient, staff, and fiscal outcomes is delineated.

A meta-analysis of effects of heparin flush and saline flush: quality and cost implications.

The purpose of this meta-analysis was to estimate the effects of heparin flush and saline flush solutions on maintaining patency, preventing phlebitis, and increasing duration in peripheral heparin locks. The average effect size (value) across 15 studies with a total sample size of 3,490 was 0573 for patency (clotting). The 95% credibility interval ranged from-.2267 to .3413. The average effect size across 13 studies with a total sample size of 2,356 was -.0757 for phlebittis. The 95% credibility interval ranged from -.2497 to .0983. The average effect size for duration across six samples with a total sample size of 1,960 was -.0550. The 95% credibility interval ranged from -.2424 to .1324. It can be concluded that saline is as effective as heparin in maintaining patency, preventing phlebitis, and increasing duration in peripheral intravenous locks. Quality of care can be enhanced by using saline as the flush solution, thereby eliminating problems associated with anticoagulant effects and drug incompatibilities. In addition, an estimated yearly savings of

Normative salivary cortisol values and responsivity in children

109,100,000 to

Impact of parent-provided distraction on child responses to an IV insertion

218,200,000 U.S. health care dollars could be attained.

Saline for peripheral intravenous locks in neonates: evaluating a change in practice

This was a descriptive study on normative salivary cortisol values and responsivity to a hospital clinic visit and an intravenous (IV) procedure in children. The study presented was a subproject of a primary research study that examined parents coaching their children requiring an IV placement in the use of distraction. One measure of child response in the primary study, salivary cortisol, was included to further our understanding of childrens physiologic response to stressful and painful stimuli. Salivary cortisol samples were obtained from 384 children aged between 4 and 10 years upon arrival to the clinic and 20 minutes after their IV insertion. Baseline samples were collected at home on a typical day for the children. Data from baseline samples were used to establish normative values between 8:00 a.m. and 3:00 p.m. on a nonprocedural day. Results demonstrate that normative cortisol levels in children follow a pattern similar to the circadian pattern in adults, decreasing from early morning to mid afternoon. Matched samples from control group children were used to evaluate group responsivity. Salivary cortisol levels on the baseline day were lower than those obtained during the day of the procedure and tapered over time as expected (-8.7% +/- 6.7%, p = .431). Cortisol levels on the clinic day increased from baseline and increased further in response to IV placement (15.7% +/- 6.7%, p = .023). A Location x Time interaction was significant (p = .019). Findings demonstrate that salivary cortisol is a useful measure of stress response that can be used to evaluate intervention effectiveness.

Salivary Cortisol Responsivity to an Intravenous Catheter Insertion in Children with Attention-Deficit/Hyperactivity Disorder

This study evaluates the impact of parent-provided distraction on childrens responses (behavioral, physiological, parent, and self-report) during an IV insertion. Participants were 542 children, 4 to 10 years old, randomized to an experimental group that received a parent distraction coaching intervention or to routine care. Experimental group children had significantly less cortisol responsivity (p = .026). Children that received the highest level of distraction coaching had the lowest distress on behavioral, parent report, and cortisol measures. When parents provide a higher frequency and quality of distraction, children have lower distress responses on most measures.

Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial.

Purpose: To evaluate the efficacy of saline versus 10 units/ml heparin for peripheral IV flushes in neonates. Design: A nonexperimental group design was used to compare the longevity of heparin and saline IV locks. A research utilization method was chosen to increase the study power while simultaneously implementing a practice change and evaluating the outcomes. Power analysis showed that a sample size of approximately 120 per group was needed to decrease the risk of beta error to 0.1. Sample: Subjects included neonates in the Special Care Nurseries at a Level III large midwestern university teaching hospital. Data were collected from a convenience sample of 123 neonates receiving 10 units/ml heparin flush into a peripheral IV. Practice was then changed to preservative- free normal saline, and data collection continued for 117 neonates. Main Outcome Variable: IV catheter longevity. Results: There was no significant statistical difference in IV catheter longevity between IV locks flushed with 10 units/ml heparin and those flushed with normal saline. Patient weight accounted for a significant proportion of the variance in IV catheter life.

Group Functioning of a Collaborative Family Research Team

OBJECTIVE To compare salivary cortisol baseline levels and responsivity as well as behavioral distress to intravenous (IV) catheter insertions in 4- to 10-year-old children with (n = 29) and without (n = 339) attention-deficit/hyperactivity disorder (ADHD). METHODS This is a secondary data analysis from a sample of 542 children who participated in a multisite study on distraction. Data included were demographic variables, Pediatric Behavior Scale-30, Observational Scale of Behavioral Distress-Revised, and four salivary cortisol samples. RESULTS Home samples from the ADHD group revealed nonsignificant but higher cortisol levels than the non-ADHD group. However, on the clinic day, the ADHD group had significantly lower cortisol levels before (0.184 vs. 0.261, p = .040) and 20-30 min after IV insertion (0.186 vs. 0.299, p = .014) compared with the non-ADHD group. CONCLUSIONS Cortisol levels in children with and without ADHD differ in response to the stress of an IV insertion.

Relaxation Training and Postoperative Music Therapy for Adolescents Undergoing Spinal Fusion Surgery

BackgroundParents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training. ObjectiveThe aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress. MethodsChildren undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress. ResultsA total of 574 children, ages 4–10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels. DiscussionSome parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.