Needle fear and pain are primary concerns for children during hospital visits. The CARD system (Comfort, Ask, Relax, Distract) was demonstrated to reduce fear and pain in children when integrated into routine vaccinations. To date, it has not been implemented for needle procedures undertaken in hospitals. In this Quality improvement (QI) study, CARD was integrated into needle procedures undertaken in the nuclear medicine department of a large academic hospital. We aimed to increase the percentage of children reporting a better experience compared to their last needle by 15%. The implementation tackled implementation of strategies from each of the 4 domains of CARD in a stepwise fashion, informed by staff preferences. 

 

            Before and after QI study guided by the Model for Improvement. Project development began with building a comprehensive team. “Before” level data were collected from children’s visits before CARD implementation. Staff were asked for areas for improvement during the “before” phase. Children and caregivers reported on areas for improvement via feedback surveys. Feedback collected during the “before” phase determined the approach to CARD implementation. During CARD, feedback continued to be collected which informed Plan, Do, Study, Act (PDSA) cycles to refine implementation. Staff were additionally asked about attitudes towards CARD interventions and the PDSA changes using open-ended debrief forms throughout implementation. 

 

            The project team consisted of CARD implementation experts, medical technologists, managers, booking staff, physicians, child life specialists, and clinical educators. Changes to practice utilized the CARD 4E model (Education, Environment, Engagement and Evaluation). “Before” feedback determined that CARD implementation would be completed using a stepwise approach. Interventions under 4E model were introduced independently over time. Feedback guided refining PDSAs which included (1) trialling different room orientations to hide fear cues, (2) increasing communication with staff about child and caregiver feedback, (3) updating CARD resources for communication, (4) developing case scenarios for staff education, and (5) refining the process for CARD checklist administration. Staff liked CARD and tested interventions were feasible and acceptable to practice. 

 

           This work outlines a stepwise approach to CARD implementation designed in collaboration with staff for a hospital nuclear medicine department undertaking needle procedures in children. Staff involvement in implementation makes it more likely that changes will be sustained over time.