SummaryAs part of a research study, a trained educator visited primary care practices affiliated with the Connecticut Children’s Medical Center to teach clinicians about proven strategies for reducing the pain and anxiety associated with childhood immunizations. After this 1-hour “academic detailing” session, the educator left behind various materials to support ongoing use of the strategies and then followed up with the practice by telephone over the next month to address any concerns. The program, which ended after the study concluded, significantly increased use of targeted strategies, leading to enhanced satisfaction with the immunization experience among clinicians.Moderate: The evidence consists of pre- and post-implementation comparisons of use of various strategies for reducing immunization-related pain and anxiety in children, as reported by parents and clinicians, along with similar comparisons of parent and clinician satisfaction with the immunization experience.
Developing OrganizationsConnecticut Children's Medical Center
Date First Implemented2007
A pilot test of the program took place in 2007, with a larger evaluation in 14 practices during 2008 and 2009.
Patient PopulationThe program served children in need of immunizations and their parents.Age > Child (6-12 years); Vulnerable Populations > Children; Age > Infant (1-23 months); Preschooler (2-5 years)
Problem AddressedImmunizations often cause pain and distress for children, parents, and providers, in some cases to the point that the procedure dominates the medical encounter and damages the relationship between provider and child/parent. Established techniques can reduce this pain and anxiety, but many providers fail to use them.
- Frequent source of pain and stress: Immunizations frequently cause pain and stress in children, parents, and providers,1 and this problem has gotten worse as the number of immunizations given during childhood has increased. Up to 10 percent of children develop an injection phobia that makes receiving an immunization a very frightening experience. In some cases the procedures dominate the medical encounter and undermine the patient–provider relationship.2
- Unrealized potential of mitigating strategies: Established strategies like distraction can reduce the pain and anxiety associated with immunizations.3,4 Yet many providers are unaware of or fail to routinely use such strategies.5,6
Description of the Innovative ActivityA trained educator visited primary care practices to teach clinicians about proven strategies for reducing the pain and anxiety associated with immunizations. At the end of these 1-hour “academic detailing” sessions, the educator left behind various materials to support ongoing use of the strategies. The educator then followed up one or more times with the practice over the next several weeks to address any concerns. Key program elements include the following:
- One-hour teaching session: A pediatric nurse with experience working in physician offices led a 1-hour session at participating practices that focused on various proven strategies for reducing pain and anxiety associated with immunizations. The sessions began with a 15-minute video, followed by informal conversation over snacks about the use of the various strategies, including how to overcome practical barriers to implementing them. For example, if clinicians resisted due to concerns about the additional time required, the educator demonstrated how use of the strategies takes very little time (and may even save time by keeping the child calm). Strategies covered during the session included the following:
- Preparing child and family: The educator emphasized the need to inform the child about the shot and discussed the best time to do so. Although the appropriate time varies based on the child’s temperament, it generally will be right before the shot for younger children and further in advance for older children, who often need time to process the information.
- Appropriate needle length: Many clinicians do not use a long enough needle, which can lead to increased pain. To address this issue, the educator reviewed the evidence supporting use of longer needles (usually more than 5/8ths of an inch).
- Distraction techniques: The educator reviewed various strategies for distracting infants and older children. Infant strategies included applying sucrose on the tongue, swaddling and/or holding the child in the appropriate position, and/or, if appropriate, having the mother breastfeed the infant during the shot. Strategies for older children included instructing the child to focus on his or her breathing, counting or telling stories during the shot, or having the child blow into a pinwheel.
- Pain-minimizing techniques: The educator reviewed various strategies for minimizing pain, including use of appropriate injection technique, applying pressure at the site during the injection, and selected use of topical anesthetics. During the initial part of the study, the educator discussed use of a commercial plastic device to create uniform pressure on the site; however, by the middle of the study, this product was no longer available.
- Materials to support ongoing use: At the end of the session, the educator left behind various materials to support ongoing use of the strategies, including the following:
- Video: A copy of the 15-minute video shown during the detailing session can be used with new staff or as a review for existing staff.
- Poster for clinicians: A poster provides office staff with user-friendly information on the best pain-reducing strategies and techniques by age of child (covering from infancy to school age).
- Parent brochure: An educational brochure clearly lays out a variety of strategies parents can use to minimize their child’s pain and anxiety.
- Supplies: The educator left behind a supply of sucrose, pinwheels, and other materials needed for specific strategies discussed during the session.
- Followup support: The educator contacted each practice one or more times by telephone during the first month following the training session to address any concerns and provide advice on how to customize strategies to fit practice needs.
Context of the InnovationConnecticut Children’s Medical Center serves as a teaching hospital and home of the University of Connecticut School of Medicine Department of Pediatrics and pediatric residency and fellowship programs. In 2010, the hospital handled more than 288,000 child care visits, 53,000 emergency department visits, and over 9,900 surgeries. The hospital’s approximately 30 affiliated primary care practices serve nearly 15,000 children a year. The impetus for the program came from a pediatrician with a longstanding interest in pain relief. This individual recognized that a variety of information existed on proven strategies for reducing immunization-related pain, but most of it appeared in pediatric psychology, nursing, anesthesia, and other journals that pediatric clinicians seldom read. Those that do read these journals, moreover, often fail to recall the information during their busy day. As a result, little actionable information existed at the point of care to reduce immunization-related pain, even as the number of immunizations given to children was increasing. To address this issue, the pediatrician decided to convene a consensus conference as a first step in developing a program to change clinician behavior. (See the Planning and Development Process section for more on this conference and the program’s evolution.)
ResultsThe program significantly increased use of the targeted pain- and anxiety-reducing strategies, leading to enhanced satisfaction with the immunization experience among clinicians.
Moderate: The evidence consists of pre- and post-implementation comparisons of use of various strategies for reducing immunization-related pain and anxiety in children, as reported by parents and clinicians, along with similar comparisons of parent and clinician satisfaction with the immunization experience.
- Increased use by providers: Providers reported increased use of various strategies, as outlined below1:
- Appropriate needle size: The proportion of providers using a needle longer than 5/8ths of an inch with infants rose from 15.2 percent at baseline to 34.1 percent after 6 months. A similar trend occurred with toddlers, where use rose from 17.0 to 51.2 percent.
- Pain-reducing techniques: Providers increased their use of specific techniques for reducing pain in infants, including sucrose (use of which rose from 3.9 percent at baseline to 29.3 percent after 6 months) and plastic devices for applying injection-site pressure (3.9 to 46.3 percent). For toddlers and school-age children, they increased use of topical anesthetics (15.7 to 24.4 percent).
- Distraction techniques: Providers increased use of various strategies for distracting toddlers and school-aged children, including pinwheels (with use rising from 11.8 percent at baseline to 53.7 percent after 6 months) and focused breathing (35.3 to 56.1 percent).
- More patients/parents receiving or using targeted strategies: Parents reported that either they or their children were more likely to receive or use specific strategies as a result of the program, with substantial increases common in the first month and the majority of these gains typically being sustained or increased over 6 months, as outlined below1:
- Provision of written information: The proportion of parents reporting having received written information from their provider rose from 28.1 percent at baseline to 35.1 percent 1 month after the provider participated in the program, with further increases to 39.4 percent after 6 months.
- Learning new techniques: Nearly half (45.6 percent) of parents reported having learned new techniques for reducing their child’s pain and anxiety from their provider 1 month after that provider participated in the program, up from 8.1 percent at baseline. After 6 months, the majority of this increase had been sustained, with 31.9 percent of parents reporting having learned new techniques.
- Use of any strategy or technique: More than two-thirds (70.9 percent) of parents reported that their provider used one or more strategies or techniques to reduce their child’s pain/anxiety during the immunization process, up from 57.7 percent at baseline (a statistically significant increase). After 6 months, this figure had slipped to 64.4 percent (a figure not statistically different than the baseline level).
- Strategies with infants: The proportion of parents reporting that they or their provider used a pacifier with sucrose increased significantly, from 0 percent at baseline to 37.3 percent after 1 month; use dropped to 8.2 percent after 6 months, but this level was still meaningfully above the baseline level. Use of breastfeeding and pacifiers without sucrose did not increase substantially as a result of the program.
- Strategies with toddlers: The proportion of parents reporting that their toddler used a pinwheel (provided by either parent or clinician) increased from 9.8 percent at baseline to 56.2 percent after 1 month; use fell to 28.4 percent after 6 months, still significantly above baseline levels. Use of injection-site pressure with plastic devices similarly increased, from 0.8 percent at baseline to 22.3 percent after 1 month, with a further increase to 33.3 percent after 6 months. Use of other distraction techniques did not change as a result of the program.
- Strategies with school-age children: The proportion of parents reporting that their school-age child used a pinwheel increased from 9.3 percent at baseline to 23.9 percent after 1 month, with the majority of these gains being sustained over 6 months (20.7 percent). As with toddlers, use of injection-site pressure increased substantially as well, from 1.9 percent at baseline to 54.3 percent after 1 month, with a slight dropoff at 6 months (43.1 percent). Unlike with toddlers, use of other distractions also increased with school-age children, from 57.4 percent at baseline to 68.9 percent after 6 months, a statistically significant change.
- Higher satisfaction with immunization experience: Both parents and providers reported increased satisfaction with the immunization experience, although only the increase seen among providers met the test of statistical significance.1
- Parents: Mean satisfaction scores among parents rose modestly, from 4.56 at baseline to 4.68 after 6 months. (Parents ranked satisfaction on a 5-point scale, with “1” indicating a “very dissatisfied” parent and “5” indicating a “very satisfied” parent.) This increase did not meet the test of statistical significance.
- Providers: Levels of provider satisfaction increased by a statistically significant amount, from 3.43 at baseline to 3.83 after 6 months.
Planning and Development ProcessKey steps included the following:
- Holding consensus conference: As noted, the program leader convened a conference attended by individuals representing multiple disciplines to review, discuss, and come to consensus on effective strategies for reducing the pain and anxiety associated with immunizations.
- Publishing results: Conference organizers wrote and published a journal article summarizing the evidence and providing recommendations related to strategies for reducing immunization-related pain and anxiety. The authors used standard rating systems to assess the strength of the evidence behind each strategy.
- Developing actionable materials for clinicians: Recognizing that clinicians often do not read or act on information in journals or even written guidelines, program developers created a set of actionable materials to assist clinicians in using these strategies on a daily basis. They worked with an outside company to produce the video and accompanying script, and with a separate graphic design company to develop the poster for clinicians and educational brochure for parents.
- Deciding on “academic detailing” approach: Aware of ample evidence that traditional, didactic education (e.g., grand rounds, lectures) often does not change clinicians' practice, program leaders decided to disseminate the materials using an academic detailing approach similar to that used successfully by pharmaceutical companies for many years.
- Identifying educator and developing session script: Program leaders identified a pediatric nurse within the hospital’s clinical research department to serve as the educator. This individual had ample experience working in physician offices (including having participated in an office-based pediatric asthma education program) and was familiar with the literature related to effective strategies for reducing immunization pain. (She had participated in the consensus conference.) Working with the program developer, she developed a script for the sessions, which were modified as necessary to meet a practice’s needs.
- Conducting pilot test and subsequent larger study: An initial pilot study tested the program in a handful of practices affiliated with the hospital. Based on its success, program developers initiated a larger study in 14 other affiliated practices in the suburbs of Hartford, CT, 13 of which completed the academic detailing and evaluation process. Participating sites included six small (one- to three-doctor) and seven larger (four- to nine-doctor) practices.
Resources Used and Skills Needed
- Staffing: The program requires one nurse educator to handle the academic detailing sessions and followup with each practice. The nurse typically spends a few hours on each practice for the initial session (including travel time to and from the office) and one or more followup calls. During the research study, the nurse also surveyed patients and clinicians by phone to collect data to evaluate the program’s impact.
- Costs: Ongoing program-related costs are minimal, consisting primarily of the nurse educator’s time and minor supply-related expenses (e.g., duplicating the video, copying the poster and brochures, purchasing pinwheels and other inexpensive supplies).
Funding SourcesKohl Family Foundation; Mayday Fund
The Mayday Fund supported the consensus conference and development of the subsequent article, video, poster, and brochure, while the Kohl Family Foundation supported the pilot test and subsequent research study.
Tools and Other ResourcesRecommendations that came out of the consensus conference can be found in: Schechter NL, Zempsky WL, Cohen LL, et al. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007;119(5). [PubMed] Available
Individuals interested in obtaining program-related materials can contact Nancy Bright, RN, at Connecticut Children's Medical Center at (860) 545-9997.
Getting Started with This Innovation
- Have credible person approach practices: The program leader (a pediatrician) had 30 years of experience and strong ties to the local community, making it relatively easy for him to convince practices to participate.
- Identify right person as educator: The most effective educators will have ample experience working with primary care office staff, familiarity with effective strategies for reducing immunization-related pain, and a sense of comfort, authority, and confidence in working with clinicians (who may initially be suspicious of the program’s value and of the educator).
- Use food to create right atmosphere: As pharmaceutical companies have learned, holding informal conversations over food can be highly effective in engaging clinicians in an informal, open dialogue.
- Establish credibility as neutral, helpful resource: Clinicians may be suspicious of organizations that try to “sell” them something. To avoid this perception, make it clear that the sponsoring organization is a neutral, unbiased party and that sessions will focus on sharing proven strategies, not selling a particular product or approach.
Sustaining This Innovation
- Periodically check in with practices: If resources allow, the educator should contact practices on a regular basis to address ongoing issues and challenges. Additional onsite sessions can be provided as needed.
- Consider integrating with other outreach: The program can be combined with other topics conducive to educational outreach, such as appropriate management of pediatric asthma or diabetes. This approach would allow the educator to conduct more frequent outreach (perhaps quarterly), with sessions rotating between topics.
- Weigh pros and cons of ongoing evaluation: Measuring the program’s impact can be a time-consuming, expensive endeavor, requiring regular surveys of patients and clinicians. Adopting organizations need to consider the pros and cons of such an investment and act accordingly. Some program leaders may feel that ongoing evaluation ensures continued momentum and helps to identify and address problems in a timely manner. Others may be convinced of the program’s merits based on previous studies and feel no need for ongoing evaluation of this low-cost, low-risk initiative.
Contact the InnovatorNeil L. Schechter, MD
Children’s Hospital Boston
Department of Anesthesia, Perioperative and Pain Medicine
300 Longwood Ave.
Boston, MA 02115
William Zempsky, MD
Connecticut Children's Medical Center
Innovator DisclosuresDr. Schechter and Dr. Zempsky have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesSchechter BL, Bernstein BA, Zempsky WT, et al. Educational outreach to reduce immunization pain in office settings. Pediatrics. 2010;126(6):e1514-21. Originally published online November 15, 2010. [PubMed]
Schechter NL, Zempsky WT, Cohen LL, et al. Pain reduction during pediatric immunizations: evidence based review and recommendations. Pediatrics 2007;119:e1184-98. [PubMed]
Schechter BL, Bernstein BA, Zempsky WT, et al. Educational outreach to reduce immunization pain in office settings. Pediatrics. 2010;126(6):e1514-21. Originally published online November 15, 2010. [PubMed]
Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract. 1995;41(2):169-175. [PubMed]
Taddio A. Conquering pain: the hidden cost of immunization. Clin Ther. 2009;31 suppl 2:S47–S167. [PubMed]
Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management during routine childhood immunizations: the nerve of it. Clin Ther. 2009;31 suppl 2:S152–S167. [PubMed]
MacLaren J, Kain ZN. Research to practice in pediatric pain: what are we missing? Pediatrics. 2008;122(2):443-444.[PubMed]
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Original publication: May 11, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 31, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.