Best Abstract from the Annual Meeting

Project J-Tip: Northland Urgent Care

Best Abstract Winner

Peg Orcutt-Tuddenham, DO with Megan Fraker, MD, winner of the Best Abstract Award at the SPUC Annual Meeting in September.

Dilts J, Fraker M, Jain S, Couch K, Hilton E, Wisdom K, Geier T, Hayes S, DeLurgio S
Children's Mercy Hospital, Kansas City, MO, USA

Purpose
Venipuncture, including peripheral intravenous catheter (IV) placement, is a leading cause of procedural pain in pediatric hospitals and EDs. Needle-free Jet Injection of Lidocaine Device (NJILD; J-Tip) has been found to be superior to other topical anesthetics in controlling IV pain1. Its rapid action and cost make it suitable for ED and urgent care center (UCC) use2. However, in our pediatric UCC, J-Tip was used with only 5% of IVs. Our objectives were: 1) use a quality improvement (QI) intervention to increase J-Tip utilization to 50% of IVs within 12 months, and 2) assess if J-Tip use was associated with decreased IV success rates.

Methods
After IRB approval, we initiated the project at our large mid-western pediatric UCC in October 2014. A multidisciplinary team defined key drivers and planned our intervention. To help identify barriers to J-Tip use before intervention design, we surveyed urgent care physicians, NPs, and RNs. Key barriers included few physicians ordering J-Tip, RN discomfort and lack of education with J-Tip, and the belief that J-Tip use made IV placement more difficult. The intervention included five serial experiences: (1) Reminder placards on workstations to encourage J-Tip orders; (2) Education at physician and RN meetings including an educational video made by QI team members; (3) Grand rounds video on pain myths and why pain control is important including encouragement to attend via a raffle; (4) Workshops with hands-on experience and trouble-shooting mentored by experienced J-Tip users; and (5) Ongoing incentives to RNs to share positive J-Tip experiences with colleagues via a “Warm Fuzzy Jar,” as well as qualifying for prize drawings each time they used a J-Tip. We evaluated monthly data on J-Tip utilization in the UCC for 7 months before, 6 months during, and 2 months after the intervention. Level 1 emergency severity index (ESI) triage patients were excluded from analysis.

Results
J-Tip use with IVs increased from 5% to 54% in 6 months. J-Tip use with IVs had a trend of a +2.4% per month throughout the 15 months (p=0.018). However, as shown in Figure 1, the J-Tip intervention resulted in a 22.5% permanent increase in J-Tip utilization for IVs starting in Oct. 2014. Additionally, the J-Tip IVs had a 71.5% success rate on the first attempt, compared to only 60.3% of those without J-Tip (p<0.05).

Conclusion
By applying QI methods, we achieved our target of increasing J-Tip utilization to >50% of IVs in non-critical UCC patients. Use of J-Tip was not associated with reduced IV placement success rates. We continue to monitor J-Tip utilization, and plan to initiate monthly raffles and ongoing education to ensure that J-Tip utilization remains high.

References

  1. Spangos S et al. Jet injection... Pediatr Emerg Care 2008. Aug;24(8):511-5.
  2. Pershad J, et al. Cost-effectiveness analysis... Arch Pediatr Adolesc Med 2008. Oct;162(10):952-61.

Fig 1

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