SummaryTo reduce the need to sedate young patients and improve the patient/family care experience, the radiology department at Children’s Hospital of Pittsburgh of UPMC introduced the Adventure Series program, which uses child-friendly, engaging, theme-based room designs; multisensory distractions (e.g., music, videos, aromatherapy); and staff who go out of their way to engage with patients and use age-appropriate techniques to distract and calm them. The program has significantly reduced use of sedation, nearly eliminated lengthy waits to schedule computed tomography scans, enhanced throughput, and increased parent and staff satisfaction.Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of pediatric patients requiring sedation, required lead times for scheduling a computed tomography scan, volume of scans performed, and satisfaction with various aspects of radiology department services among parents and staff who had experience with the department before and after program implementation.
Developing OrganizationsChildren's Hospital of Pittsburgh of UPMC
Use By Other OrganizationsAnn and Robert H. Lurie Children’s Hospital of Chicago (formerly Children’s Memorial Hospital) implemented this program as part of its move to a new facility, while Children’s National Medical Center in Washington, DC, has implemented it in its X-ray rooms.
Date First Implemented2005
The program commenced in September 2005 in one room—the computed tomography room at the hospital's old inpatient facility. The program began in nine radiology rooms within the hospital’s new facility when it opened in May 2009.
Vulnerable Populations > Children
Problem AddressedYoung children often are anxious about receiving radiology imaging procedures, making it difficult for them to stay perfectly still and thus preventing staff from getting the high-quality image needed. As a result, many pediatric radiology departments routinely sedate children. Sedation, however, creates additional risks and burdens for the patient and family, and increases the amount of time needed for each procedure, which reduces throughput and creates the potential for backlogs. Techniques to distract young patients can help manage their distress without sedation, yet relatively few hospitals use them.
- High anxiety: Not surprisingly, young children often get nervous and anxious in the hospital, particularly in radiology departments where large equipment and sterile rooms are generally seen as intimidating. Many children lack the cognitive reasoning skills to understand what is happening to them and why, and as a result experience fear, anxiety, and hopelessness.1
- Inability to remain still, leading to cancellations and backlogs: Young children who feel anxious often find it difficult if not impossible to lie still during imaging procedures and radiology treatments, including magnetic resonance imaging (MRI) and computed tomography (CT) procedures that require complete stillness to ensure a high-quality image.2 If children do not remain still, the scan generally cannot be completed, forcing technologists to reschedule it as a sedation procedure. At Children’s Hospital of Pittsburgh of UPMC, such cancellations occurred frequently, creating backlogs, since the hospital had only one dedicated CT scanner for pediatric patients (along with shared use of a second scanner in the adult wing of the facility).
- Frequent use of sedation, which has multiple drawbacks: To avoid the potential for cancellations and delays, many pediatric radiology departments routinely sedate children undergoing imaging procedures, including CTs, MRIs, radiation treatments, and positive emission tomography (PET) scans. Sedation, however, has multiple drawbacks, as outlined below:
- Greater burden for patient/family, including longer visits: Use of sedation requires the patient to fast for between 4 and 8 hours before the procedure. It also increases the amount of time required to complete the visit (from 35 to 45 minutes to roughly 4 hours), due primarily to the time needed to administer the sedation and allow for post-procedure recovery.2
- Potential for backlogs: The additional time also creates the need for more staff attention and limits the hospital’s imaging capacity, creating the potential for backlogs and long scheduling lead times. For example, before implementation of this program, patients had to wait 16 to 18 days to schedule an outpatient CT scan at the Children’s Hospital of Pittsburgh of UPMC. In addition to the cancellation problem highlighted above, the hospital’s routine use of sedation for these procedures was a major contributing factor to the backlog.2
- Small increase in risk: Use of sedation marginally increases the risk of complications; one study found that 0.4 percent of pediatric patients sedated for a radiology imaging test experienced a respiratory adverse event.3
- Unrealized potential of distraction techniques: While a variety of techniques designed to engage and distract patients during procedures has been shown to help manage pain and distress in children undergoing medical procedures,2 few radiology departments routinely use them.
Description of the Innovative ActivityTo reduce the need to sedate young patients and improve the patient and family experience, the radiology department at Children’s Hospital of Pittsburgh of UPMC introduced the Adventure Series program, which uses child-friendly, engaging, theme-based room designs; multisensory distractions (e.g., music, videos, aromatherapy); and staff who go out of their way to engage with patients and use age-appropriate techniques to calm and distract them. Key program elements are outlined below:
- Child-friendly, engaging, theme-based room designs: The design of each of the nine rooms within the department reflects a specific theme that caters to young children. For example, the radiation oncology room has been designed as Adventure Beach, including a boardwalk and beach designs on the walls, an oxygen tank that looks like a scuba tank, a linear accelerator disguised as a sandcastle, and a moving board that looks like a surfboard. Other themes include Outer Space (used in three rooms for MRI procedures), Camp Cozy (PET and CT), Pirate Island (also CT), Coral City (emergency CT), and Jungle Safari Adventure (used in two rooms for nuclear medicine procedures). Rooms are painted and designed to reflect the theme, typically featuring decals, murals, three-dimensional decorations, lighting, and other design features consistent with the theme. Each room incorporates a set of four animal characters that appear in various places. Portrayed differently in each room to reflect the theme, these characters are used by staff as part of their efforts to distract and engage patients (see below for more details.) The monkey character is interactive in nature, with the child able to push it so the animal swings on a rope. The goal is to help each child feel like he/she is going through an “adventure” with the characters.
- Multisensory distractions: Most rooms have a compact disc (CD) player that plays relaxing music consistent with the theme (which helps reduce the patient’s heart and breathing rates). Children can also bring their own favorite music to play during the procedure. All rooms have a digital video disc (DVD) player or other equipment to allow children to watch a video. Patients can either bring their own videos or choose from a collection available in the department. Because the MRI room cannot have metal objects (which interfere with the scan), this room features 2 pairs of plastic virtual reality glasses that allow patients to watch videos during scans, which sometimes take up to 90 minutes. In addition to the audio and video distractions, aromatherapy permeates each room, with smells consistent with the theme. For example, Camp Cozy smells woodsy, while the Pirate Room smells like pina colada.
- Staff who interact with and distract patients in age-appropriate manner: Department staff routinely dress and act in a manner consistent with the theme, communicate and interact with patients in an age-appropriate manner, and use age-appropriate techniques to distract and engage patients, all with the goal of keeping them calm and relaxed and hence avoiding the need for sedation. More details on how staff do this appear below; in addition, several anecdotes appear in the Back Story section that demonstrate how staff routinely go out of their way to make patients feel comfortable.
- Dressing and acting the part: Schedulers, registrars, nurses, technologists, transporters, and physicians go out of their way to make the fantasy seem real to the child. For example, one male nurse routinely wears custom-made scrubs that have a pirate theme, and regularly plays the part of a pirate while seeing patients. Staff in the Outer Space room talk with the children about how they will go into space with the other “astronauts” in the room. Staff in other rooms play up the water and beach themes—for example, one CT technologist pretended to be part-mermaid and “swam” with a young female patient (also part-mermaid) to pick up her prize from the treasure chest after she finished her procedure. (See below for more on prizes.)
- Child-friendly, age-appropriate interactions throughout process: Staff interactions are designed to gain the trust of—and build a relationship with—the child. Staff constantly observe the child’s behavior and try to react accordingly, often playing up the theme experience (e.g., asking the patient to get into the “pirate ship,” “log jammer,” “tent,” or “space capsule” rather than the “scanner”). Staff involve family members whenever possible, and generally avoid use of terms that can cause anxiety, such as “shot,” “dye,” or “flush your IV.” They routinely bend down or kneel so as to be at the child’s level when interacting, often hold his/her hand, and try as much as possible to offer the child a “voice and a choice.” For example, staff allow children to remain in their parent’s lap while being examined if they so desire and such an arrangement is technically possible. If not, staff phrase things in a manner that gives the child a feeling of control. For instance, rather than asking if he or she wants to get up on the table (to which most children will answer “no”), staff give the child a choice—to get up on the table on his/her own or with the parent’s help. Other choices routinely given to patients relate to which movie or music to play during the procedure, and where to place the blood pressure cuff—on the arm or leg.
- Age-appropriate distraction techniques: Before, during, and after the procedure, staff engage in age-appropriate distraction techniques. For infants, these include rocking, patting, massage, and use of a disco ball. For toddlers, staff generally avoid holding them down (which they tend to dislike), and often encourage them to sing and/or play with something, such as pinwheels, bubbles (which facilitate deep breathing and relaxation), interactive toys, and light wands. School-age children often prefer games, books, party blowers, bubbles, television, and/or videos, whereas teenagers often like to use stress balls, watch videos, and/or listen to music. All of these materials are available to patients in the rooms.
- Staff-administered rewards after procedure: After the child completes the procedure, staff offer high praise and help him/her pick out a theme-appropriate prize as a reward for lying still and being brave. Some rooms have specially designed rewards—for example, children in Camp Cozy receive a themed postcard signed by the staff.
- Child-friendly policies and procedures: Department policies and procedures seek to educate the child and family in advance of the procedure, and to make them as comfortable and relaxed as possible before, during, and after it. A letter sent to all parents instructs them to access the department Web site to read about the department’s child-friendly policies and procedures, which are outlined below:
- Engaging educational materials to prepare for visit: Before the procedure, each child can read a themed coloring book that explains the process in a child-friendly manner, laying out what the boy or girl should expect and do at each step of the journey. Each page also includes a tip for parents about how they can help their child through this part of the process. (A separate education sheet targeted specifically to parents can also be accessed online.) Different booklets exist for each type of procedure, with the drawings incorporating themes and characters from the relevant room design. Each booklet features two versions—one for boys and one for girls. The aforementioned letter reminds parents to print the booklet out from the Web site and read it with their child before the procedure. Those who do not can pick up a printed copy in the waiting room.
- Reminder to bring comforting objects: The Web site reminds parents that their child can bring in an object, such as a blanket, favorite toy, music, or movie, that comforts him or her.
- Allowing parents to remain in room: Parents can generally remain in the room with the child during the scan. If possible and desired by the child, parents can lie on the examination table and hold the child during the scan (while wearing appropriate protection against radiation).
- Scheduling infants close to meal times: Staff work with the parents of very young children to schedule scans close to feeding times and encourage them to feed the child right beforehand so as to promote drowsiness and sleep. Scans can often be performed quite easily when a child is sleeping.
Context of the InnovationChildren’s Hospital of Pittsburgh of UPMC is a full-service children’s hospital located in Pittsburgh, PA. In fiscal year 2012, the hospital handled 13,804 inpatient stays, more than a million outpatient visits, and roughly 77,000 emergency department visits. The hospital’s radiology department offers a full array of inpatient and outpatient services to children of all ages.
The impetus for this program began in the fall of 2005. Though radiology staff had historically used informal distraction techniques such as singing, telling stories, and using massage techniques to help children relax when undergoing a CT scan, the department still frequently relied on sedation, experienced frequent cancellations due to children not being able to stay still, and faced long backlogs in scheduling. With demand for services increasing and little opportunity to purchase additional capacity (the hospital’s planned move to a new facility was still years away), department leaders began looking for ways to reduce the backlog. They quickly identified sedation as a key driver of delays, and decided to intensify their efforts to engage and distract patients undergoing CT scans.
ResultsThe program has significantly reduced use of sedation, nearly eliminated lengthy waits to schedule a CT scan, enhanced throughput, and increased parent and staff satisfaction.
Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of pediatric patients requiring sedation, required lead times for scheduling a computed tomography scan, volume of scans performed, and satisfaction with various aspects of radiology department services among parents and staff who had experience with the department before and after program implementation.
- Less use of sedation: In the CT room at the old facility, the number of sedations for pediatric CT procedures fell by 99 percent—from 354 cases to just 4—between fiscal year 2005 (before the program began) and fiscal year 2007, even as patient volumes grew.2 After the new facility opened in May 2009 (with 9 rooms having implemented the approach), department-wide use of sedation dropped by nearly 20 percent from the previous year. Since that time, use of sedation has continued to fall, with the department achieving a total sedation reduction of 25.2 percent despite a volume increase of 66 percent between fiscal years 2009 to 2011.
- Higher throughput, elimination of backlog: Staff productivity and CT room throughput increased after introduction of the program at the old facility. The 99-percent decline in use of sedation described above helped to free up additional capacity, enabling the capacity-constrained department to increase CT scan volumes by 15 percent between 2005 and 2007. As a result, the 16- to 18-day backlog was eliminated, with outpatient CT scans routinely being scheduled for the same or next day.2 At the new facility, the radiology department as a whole experienced a 66-percent jump in patient volume between 2009 and 2011; this increase was due in part to the freed-up capacity created by the reduction in sedation use.
- Higher parent, staff satisfaction: Both parents and staff report higher levels of satisfaction with the program than with the traditional approach used in the old facility.
- Parents: In surveys of parents of children who received scans at both the old hospital (without use of distraction techniques) and the new facility, the vast majority expressed high or very high levels of satisfaction with the distraction techniques, and indicated they would come back to the hospital should their child need another scan because of these techniques.
- Staff: Surveys of staff members who have worked in both settings found that they were much more satisfied with the new approach, believing it had a positive impact on their ability to do their jobs and on patients and families. The staff reported that the approach engaged patients, improved their coping skills, and reduced their anxiety levels, leading to much better cooperation during the procedure.
Planning and Development ProcessThe program evolved over time, beginning in the CT room in the old facility, expanding to a second room (MRI) in that facility, and later being adopted by nine radiology rooms in the new facility. Key steps in this evolution are outlined below:
- Introducing approach on small scale in CT room: As a first step, department leaders installed a solar projector (called Snoozelyn) in the CT room of the old facility that projected serene images on the walls. They also began to give patients a “voice and choice” by letting them decide what to watch on the walls. These small changes alone led to a meaningful decline in the use of sedation.2
- Making additional, staff-led changes to CT room: The initial success convinced staff of the merits of the approach, and they began to suggest additional small steps, such as toning down the lights (so the projections would look better), aromatherapy, and placing pictures on the wall. Staff also decided to purchase a low-cost mural to disguise the scanner as a castle. Over time, staff made other design changes to the room.
- Redesigning CT room more substantially: Department leaders decided to use the installation of a new 64-slice CT scanner as an opportunity to redesign the CT room more substantially. A nurse on the unit with degrees in education and television production led the effort, choosing an underwater fantasy motif and using images of coral reefs and life-size mermaid dolls as part of the design. He also designed a removable, washable vinyl cover for the scanner painted with a seascape. Other features included a light box installed on the ceiling that projected the Milky Way and also held a flat-screen television monitor and DVD player.
- Expanding to MRI room: The MRI area at the old facility adopted some of the same techniques used in the CT room. For example, one of the MRI rooms was painted in an underwater theme, whereas the walls of a second room were decorated with jungle murals. In August 2007, the department purchased a pair of plastic virtual reality goggles to allow children to watch a movie during an MRI scan without interfering with the equipment. These measures relatively quickly produced a 35-percent decline in use of sedation for MRI procedures.2
- Expanding significantly with move to new facility: Department leaders decided to use the move to a new inpatient facility as an opportunity to start with a “clean slate” and incorporate the program throughout the department. The goal was not only to design the right physical space, but also re-engineer the department’s approach to the entire patient/family experience. Key steps in that process are outlined below:
- Collaborating on research, creation of new patient/family experience: In collaboration with in-house child life experts and GE Healthcare (which makes the radiology equipment used at the hospital), department staff conducted observational research, including focus groups with children and adults and site visits to other children’s hospitals. The goal was to better understand how children and parents see imaging equipment and visits to the hospital, and to identify practices to improve that experience. Results suggested strong enthusiasm for the new approach and a desire to revamp the look and feel of traditional radiology equipment and rooms.
- Creating designs and story lines: An in-house design team that included nurses, technologists, child life specialists, and a music therapist visited GE to meet with its creative design team. Over a year-long period, the GE and in-house teams developed themes and story lines for each room, along with a plan to guide the physical design. The goal was to create culturally sensitive, gender-neutral designs appropriate and engaging for pediatric patients of all ages. The teams held weekly conference calls to exchange ideas and review sketches, with staff providing regular input on the design.
- Creating themed music and educational materials: A former music therapy extern composed themed music for each room. A child life specialist and the music therapist took the lead in developing the educational materials, in collaboration with specialists who provided the clinical and other information to be included. GE Healthcare provided the art work, with the music therapist and child life specialist adding the parental tips and rewriting the language to engage and educate the child.
- Ongoing training throughout process: The hospital has not developed a formal education or training curriculum for staff. However, since the beginning of the initiative, child life specialists and nurse educators have provided periodic education and training on age-appropriate interactions, language, and distraction techniques. At every staff meeting, the child life specialist emphasizes the importance of the issue and provides concrete examples of how best to communicate and interact with young patients. The department also incorporates this type of education into regularly scheduled workshops and events. For example, a recent workshop focused on appropriate language to use with children.
- Planning expansion: The success of the program has convinced department leaders to expand the approach to the fluoroscopy and ultrasound rooms in fiscal year 2013, assuming that adequate funding can be found.
Resources Used and Skills Needed
- Staffing: The hospital hired no new staff for this initiative. Existing staff volunteered their time to develop and implement the program, and they routinely incorporate program-related activities (e.g., dressing up in accordance with the theme, using distraction techniques) into their regular duties.
- Costs: The cost of room design or redesign varies considerably, depending on room size and the comprehensiveness of the design. For a few hundred dollars, small changes can be made that can produce meaningful results, such as purchasing a disco ball, projector, CD player, DVD player, and stickers and prizes. At Children’s Hospital of Pittsburgh of UPMC, the relatively modest redesign of the CT room at the old facility cost roughly $5,700,2 although the materials purchased for this room were not designed to be durable, environmentally friendly, or easy to clean. The more extensive designs incorporated into the new hospital made use of higher-end, more durable, “green” materials, with total costs averaging $35,000 to $45,000 per room. Program leaders believe these costs can be more than recouped over time through reduced use of sedation and the increase in throughput generated by fewer cancellations and shorter scan times.
Funding SourcesChildren's Hospital of Pittsburgh of UPMC
The hospital funded the majority of costs associated with the designs; a few private donors provided financial support for several of the rooms.
Tools and Other ResourcesInformation on additional resources and tools related to this program can be obtained from the innovators.
Getting Started with This Innovation
- Plan for initial staff resistance: CT staff initially resisted this approach, believing it would take more time to engage in distraction techniques and preferring instead to continue the practice of sedation. The child life specialist and other program champions countered this resistance by teaching staff to better understand how a child sees the process and environment, and sharing information on the benefits of age-appropriate communication, interactions, and distraction techniques.
- Start small, expand over time: By starting with just a few minor changes in one room, department leaders were able to demonstrate the benefits of this approach quickly and at low cost. Early successes won over initially resistant staff in a short period of time, with most staff quickly becoming supportive and engaged after seeing the program’s benefits firsthand.
- Consider low-cost alternatives: If a complete overhaul of one or more rooms is not possible, consider small, inexpensive steps, such as introducing child-friendly aromatherapy, music, and lighting; painting the room to make it less intimidating; purchasing inexpensive toys and stickers to use as rewards; purchasing a DVD and/or CD player along with music and videos; and/or creating child-friendly educational materials to help the patient understand what he or she will be experiencing and why.
Sustaining This Innovation
- Regularly elicit and act on staff input: Since the program’s inception, many of the best suggestions for improvements have come from staff.
- Share results and stories: Both administrators and frontline staff will remain supportive of and engaged in the program if they see tangible evidence of its positive benefits, not just in terms of statistics (e.g., the impact on sedations and procedure volume), but also the real-life stories of patients, parents, and staff who have benefited. Children’s Hospital of Pittsburgh of UPMC has developed a book that details some of these stories. (A few brief examples are provided in the Back Story section that follows.)
- Conduct regular training: Staff may need regular reminders about how to interact with and distract young patients. Regular training sessions provide an opportunity to learn from experts about specific language and approaches to use and/or avoid, while also giving frontline workers a chance to share lessons, stories, and best practices with each other.
Contact the InnovatorKathleen Kapsin, RT, MS
Director of Radiology
Children's Hospital of Pittsburgh of UPMC
4401 Penn Avenue
Pittsburgh, PA 15224
Natalie Sten, MS, CCLS
Department of Radiology
Children's Hospital of Pittsburgh of UPMC
4401 Penn Avenue
Pittsburgh, PA 15224
Innovator DisclosuresMs. Kapsin reported receiving an honorarium for a speaking engagement related to this program, and that General Electric collaborated with the hospital on program design. Ms. Sten reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesEtzel-Hardman D, Kapsin K, Jones S, et al. Sedation reduction in a pediatric radiology department. J Healthc Qual. 2009;31(4):34-9. [PubMed]
Smith P. ‘Adventure Series’ rooms help distract nervous youngsters at Children’s Hospital. Pittsburgh Post-Gazette 2012 May 28.
McGee K. The role of a child life specialist in a pediatric radiology department. Pediatr Radiol. 2003;33(7):467-74. [PubMed]
Etzel-Hardman D, Kapsin K, Jones S, et al. Sedation reduction in a pediatric radiology department. J Healthc Qual. 2009;31(4):34-9. [PubMed]
Sanborn PA, Michna E, Durakowski D, et al. Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology. 2005;237:288-94. [PubMed]
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Original publication: January 16, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 16, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.