title: Using quality improvement methods to increase use of pain prevention strategies for childhood vaccination.
abstract: OBJECTIVE
  To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology.
  
  
  METHODS
  Specific intervention strategies (i.e., comfort positioning, nonnutritive sucking and sucrose analgesia, distraction) were identified, selected and introduced in three waves, using a Plan-Do-Study-Act framework. System-wide change was measured from baseline to post-intervention by: (1) percent of vaccination visits during which an evidence-based pain prevention strategy was reported as being used; and (2) caregiver satisfaction ratings following the visit. Additionally, self-reported staff and caregiver attitudes and beliefs about pain prevention were measured at baseline and 1-year post-intervention to assess for possible long-term cultural shifts.
  
  
  RESULTS
  Significant improvements were noted post-intervention. Use of at least one pain prevention strategy was documented at 99% of patient visits and 94% of caregivers were satisfied or very satisfied with the pain prevention care received. Parents/caregivers reported greater satisfaction with the specific pain prevention strategy used [t(143) = 2.50,P≤ 0.05], as well as greater agreement that the pain prevention strategies used helped their children's pain [t(180) = 2.17,P≤ 0.05] and that they would be willing to use the same strategy again in the future [t(179) = 3.26,P≤ 0.001] as compared to baseline. Staff and caregivers also demonstrated a shift in attitudes from baseline to 1-year post-intervention. Specifically, staff reported greater agreement that the pain felt from vaccinations can result in harmful effects [2.47vs3.10;t(70) = -2.11,P≤ 0.05], less agreement that pain from vaccinations is "just part of the process" [3.94vs3.23;t(70) = 2.61,P≤ 0.05], and less agreement that parents expect their children to experience pain during vaccinations [4.81vs4.38;t(69) = 2.24,P≤ 0.05]. Parents/caregivers reported more favorable attitudes about pain prevention strategies for vaccinations across a variety of areas, including safety, cost, time, and effectiveness, as well as less concern about the pain their children experience with vaccination [4.08vs3.26;t(557) = 6.38,P≤ 0.001], less need for additional pain prevention strategies [3.33vs2.81;t(476) = 4.51,P≤ 0.001], and greater agreement that their doctors' office currently offers pain prevention for vaccinations [3.40vs3.75;t(433) = -2.39,P≤ 0.05].
  
  
  CONCLUSIONS
  Quality improvement methodology can be used to help close the gap in implementing pain prevention strategies during routine vaccination procedures for children.
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Jennifer Verrill
authors.initials: JV
authors.lastname: Schurman
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Amanda D
authors.initials: AD
authors.lastname: Deacy
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Johnson
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Jolynn
authors.initials: J
authors.lastname: Parker
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Kristi
authors.initials: K
authors.lastname: Williams
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Dustin
authors.initials: D
authors.lastname: Wallace
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Mark
authors.initials: M
authors.lastname: Connelly
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Lynn
authors.initials: L
authors.lastname: Anson
authors.affiliation: Jennifer Verrill Schurman, Amanda D Deacy, Rebecca J Johnson, Dustin Wallace, Mark Connelly, Division of Developmental and Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, United States.
authors.forename: Kevin
authors.initials: K
authors.lastname: Mroczka
keywords: Comfort positioning; Distraction; Immunization; Non-nutritive sucking; Pain management; Pain prevention; Pediatrics; Primary care; Quality improvement; Sucrose analgesia; Vaccination