Most of you probably don't see many pediatric patients unless you do lots of ENT procedures. So when you've got a couple myringotomies or tonsillectomy and adenoidectomies on the schedule, the change might be a source of stress for you and your staff. Since it's unlikely you'll be able to hire a certified child life specialist for the day, we talked to a few at some of the top children's hospitals in the nation for their tips on handling pediatric patients like a pro.
Here are 10 books relating to separation you can have on hand for younger pediatric patients (pre-school age range), or that you can recommend to parents, courtesy of Tonya Shell, a Child Life Specialist in outpatient surgery at Children's Hospital of Pittsburgh. Title, author and theme are listed.
1. Offer a tour
Some centers offer tours on Sundays, while others do it the morning of surgery - but everyone we talked to lets pediatric patients familiarize themselves with the surgical environment. The key here, says Mary Tietjens, a child life specialist dedicated to surgery at Texas Children's Hospital in Houston, is to fully explain all the sensory experiences. At TCH, children get a full walking tour, during which they get to see and touch, among other things, EKG leads, the IV, the anesthesia mask and an OR.
"We let them choose the flavor of anesthesia they want," says Ms. Tietjens. "They are flavored oils - bubblegum, cherry, peppermint - that you wipe on the mask to help with the smell of the anesthesia during induction."
2. Talk to the child
"Address the child directly," says Ms. Tietjens. "Kneel down, shake her hand, introduce yourself and ask her, 'Whom did you bring with you today?' Let her introduce her parents. Send the cue to the child that she is important."
Helping the child feel as though she has some level of control will help her relax. When you educate, though, do it in an age-appropriate way and at an age-appropriate time.
"For older children, farther in advance is better," says Gloriane Kabat, the director of the child life department at Arkansas Children's Hospital. "A teen can handle talking about it a month or so in advance, but for a 4-year-old, it might be one or two days. That's when you can really tell them what they'll be seeing, provide the opportunity for medical play, and teach them with books and pictures." See "Recommended Reading" for more.
3. Keep parents informed and involved
Often, the parents are just as stressed, if not more so, than the child, and that will cause the child stress. A good way to prevent anxiety transfer is to keep the parents informed. Even better is parent-present induction for children aged 2 years to about 12 years, says Timothy W. Martin, MD, MBA, the chief of pediatric anesthesia at ACH.
"We have one induction room for every two ORs that physically opens into the OR proper," says Dr. Martin. "You can let the parent accompany the child in there and wear street clothes, which lets the parent still appear normal to the child, because you're not doing anything sterile or overly infection prone in the induction room."
If the parent needs to be in the OR - to coax the child there or because the induction room won't be used - she must dress in disposable overalls. Some keys: Give the parent a step-by-step of what will happen, ensure she understands the child will go limp during induction and use parent-present in-duction only if the child is without airway problems.
4. Let the parents inform you
Bring parents back to recovery within about 20 minutes of the child's arrival from the OR. There are several advantages to this.
"That makes a huge difference in recovery - if children see Mom or Dad right away, they are much more calm, and I think it helps them recover faster," says Ms. Tietjens. "We go over the pain scale with children before surgery, but we also rely on parents to help us. They know the difference between their child in pain and their child simply upset."
5. Eliminate fear of needles
Jet injectors, which may resemble a toy gun and be as small as a pencil, deliver medications parenterally, without a needle, before the IV catheter touches the skin. Modern jet injectors blast compressed carbon dioxide to eject medication through a micro orifice at the injection site.
Technology proponents insist the devices eliminate much of the anxiety felt by needle-phobic patients, virtually eliminate the pain associated with an injection or placement of the IV (reports on whether the devices are painless vary) and greatly aid infection control programs.
"There's a little pressure when it forces the medicine under the skin, but there's no poke with a needle. It's particularly good for children who shouldn't be swallowing a pre-med or who shouldn't take anything in their stomachs," says Dr. Martin.
6. Ride to the OR
You might want to buy a powered Barbie car and GI Joe jeep so children can drive themselves from pre-op to the OR. "If we let them drive, we don't premedicate or sedate them. It works great for kids 3 years to about 7 years - they get so excited about the car, they forget they're actually going to the OR," says Dr. Martin.
7. Strive for normalcy
"It's good to let children have familiar objects around them," says Hayley Bray, a child life specialist in the pre-op clinic at Children's Hospital Boston. "Let them bring a stuffed animal or blanket. We have a lot of play toys, too."
8. Electronic entertainment can also be a big help.
"Especially with younger children, TV can be hypnotic," says Suzanne Graca, a child life specialist who works with Ms. Bray. "If the 'Dora the Explorer' movie is going to do the trick, tell parents to bring it along."
At ACH's outpatient surgery unit, children can pick from a cart full of video games and hospital-supplied Gameboys, says Ms. Kabat.
9. Use the power of music
Music can be great for soothing, distracting and maintaining normalcy. Debbie Benkovitz, LSW, MT-BC, a music therapist at Children's Hospital of Pittsburgh, recommends you or a parent sing to the child before a procedure, making it interactive (for example, asking the child to invent lyrics) to relieve anxiety. She also suggests you have CDs or tapes and personal players on hand or that you let the child bring her own. Ms. Benkovitz recommends Raffi or Sesame Street for younger children; guide older children to choose music that's not overly emotional, or with fast tempos or heavy beats.
"As long as it's the right music, it's definitely a good idea," she says. "I had surgery a couple years ago and planned my music for before, during and after. I picked a kind of yoga music to come out of anesthesia. When my uncle had surgery, he was going to use a CD of an opera he loves, but it was something that would excite him and get his blood pressure up, so I didn't let him."
To avoid infection control issues in the OR, you can clean the player, cords and headphones with a disinfectant wipe, and bag it so only the cords are exposed, she says.
Another tool for keeping hands clean
While Sani-Dex ALC Antimicrobial Gel Hand Wipes aren't a replacement for a thorough manual wash of soiled hands, they kill bacteria and can help remove soil, so they may replace or augment your alcohol-based hand gel routine in pre- and post-op areas. The hand wipes, which are composed of non-woven cloth saturated with an ethyl alcohol gel solution, effectively kill 99.99 percent of harmful bacteria, according to Sani-Dex, the manufacturer. In addition to being fragrance and dye-free, Sani-Dex ALC contains emollients such as aloe, glycerin and Vitamin E to help minimize the drying effects of alcohol. The wipes are available in pocket packets or quick-pull canisters, and pricing ranges from $32 to $56 per case, depending on quantity. Call (800) 999-6423, visit www.pdipdi.com or Circle 166 on your Reader Service Card for more information.
Voice-driven electronic medical records
Designed specifically for orthopedic surgeons and their practices, ChartLogic's comprehensive Electronic Medical Office integrates voice-recognition technology and an orthopedic-specific voice vocabulary to create standardized charts and operative reports, the company says. Precision Voice is highly accurate, according to the manufacturer, and takes about a half-hour to set up for each physician. Price varies, because the system is sold on a per-user license fee basis, and larger practices might have more hardware requirements; office staff receive free system access. The company provides free on-site training and local support for the first year and will calculate your expected return on investment before you implement the system. Call (888) 337-4441, visit www.chartlogic.com or Circle 167 on your Reader Service Card for more information.
Help for transferring and transporting patients
The PL1000E Power Transport Lift from NK Medical Products might be able to reduce personnel costs, save time and help eliminate personnel back strain and injury, the company says. Here's how it works: Place the sheet under the patient, pull the eight straps through the buckles and lift the patient. One person can raise and lower the Power Transport Lift frame with a handset. The wheelbase is adjustable to fit a variety of stretchers or beds. The lift runs on low-voltage 24 VDC power with a charging system that plugs into any standard outlet. The mechanical compartment is fully enclosed; the exterior is durable and provides easy cleaning, the company says. It's rated for up to 400 pounds (bariatric model also available) and is waranteed for five years. The company would not give a price. Call (800) 274-2742, visit www.nkmedicalproducts.com or Circle 168 on your Reader Service Card for more information.
An advanced digital cystonephroscope?
If you want a better image in a cystonephroscope, the Invisio Flexible CystoNephroscope from ACMI Corporation might be a good choice. The fully integrated digital flexible endoscope requires one cable and one connection, which resists damage and enhances the image, the manufacturer says. The ICN is the smallest flexible cystonephroscope available, according to ACMI, and eliminates the light source, light cable and camera by putting the microcamera on the scope's distal end. It uses LED technology, resulting in less heat and greater durability than conventional light sources. The site-upgradeable software built into the system automates operation to make this digital flexible endoscope easy to use and highly durable, ACMI says. The company would not give a price. Call (888) 524-7266, visit www.acmicorp.com or Circle 169 on your Reader Service Card for more information.