Cozzi G, Valerio P, Kennedy R A narrative review with practical advice on how to decrease pain and distress during venepuncture and peripheral intravenous cannulation. Acta Paediatrica. 2021; 110:(2)

Cravero JP, Askins N, Sriswasdi P, Tsze D, Zurakowski D, Sinnott S Validation of the Pedatric Sedation State Scale. Pediatrics. 2017; 139:(5)

Friedrichsdorf SJ, Eull D, Weidner C, Postier A A hospital-wide initiative to eliminate or reduce needle pain in children using lean methodology. Pain Rep. 2018; 3

Ultrasound-guided intravenous access. 2023. http// (Accessed September 26, 2023)

Centers for Disease Control and Prevention. Strengthening clinical laboratories. 2018. https// (Accessed February 7, 2023)

Walther-Larsen S, Pedersen MT, Friis S Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals. ACTA Anaesth Scand. 2017; 61:(3)328-337

Postier AC, Eull D, Schulz C Pain experience in a US children's hospital: a point prevalence survey undertaken after the implementation of a system-wide protocol to eliminate or decrease pain caused by needles. Hosp Pediatr. 2018; 8:(9)515-523

Sorensen K, Skirbekk H, Kvarstein G, Woien H I don't want to think about it: a qualitative study of children (6-18 years) with rheumatic diseases and parents' experiences with regular needle injections at home. Pediatr Rheumatol Online J. 2021; 8:(19)

Ferraz-Torres M, Escalada-Hernandez P, San Martin-Rodriguez L, Delarosa R, Saenz R, Soto-Ruiz M Predictive factors for anxiety during blood sampling and insertion of peripheral intravenous catheters in paediatric patients in Spain. J Pediatr Nurs. 2021; 61:e35-e41

Friedrichsdorf SJ, Postier A, Eull D Pain outcomes in a US children's hospital: a prospective cross-sectional survey. Hosp Pediatr. 2015; 5:(1)18-26

Shomaker K, Dutton S, Mark M Pain prevalence and treatment patterns in a US children's hospital. Hosp Pediatr. 2015; 5:(7)363-370

Friedrichsdorf SJ, Goubert L Pediatric pain treatment and prevention for hospitalized children. Pain Rep. 2020; 5:(1)

Jacobse J, Ten Voorde W, Rissmann R, Burggraff J, Ten Cate R, Schrier L The effect of repeated methotrexate injections on the quality of life of children with rheumatic diseases. Eur J Pediatr. 2018; 178:(1)17-20

Martin H The power of topical anesthetics and distraction for peripheral intravenous catheter placement in the pediatric perianesthesia area. J PeriAnesth Nurs. 2018; 33:(6)880-886

Khadij S, Reszel J, Wilding J, Harrison D Children's fear and distress during a hospital-based family flu vaccine clinic: a parent survey. J Child Health Care. 2022; 26:(1)18-30

McCollum NL, Kamat PP, Stockwell JA Improving stakeholder satisfaction: nitrous oxide for peripheral intravenous cannulation for pediatric procedural sedation. J Radiol Nurs. 2017; 36:(4)238-241

Wagoner ST, Lorenc J, Edmunson E, Schurman JV Establishing a contingency plan to improve patient comfort during peripherally inserted central catheter insertions: a quality improvement effort. J Assoc Vasc Access. 2021; 26:(4)18-27

Zhouwen Y, Shou Y, Xu X, Lin L, Le Q, Gu Y Pharmacological and non-pharmacological interventions in management of peripheral venipuncture-related pain: a randomized clinical trial. BMC Pediatr. 2023; 23:(1)

Establishing a plan to improve pediatric patient comfort during PIV insertions and blood specimen collection: a quality improvement effort

04 April 2024
Volume 33 · Issue 7



Patient comfort during peripheral intravenous (PIV) insertion and specimen collection was increased.

The authors extended the contingency plan implemented for PICC insertion to include PIV insertion and specimen collection.

The authors met their goals by using quality improvement methodology.

Prioritizing patient comfort often requires institutional culture change.


Needle procedures can cause pain and distress, especially in pediatric patients.1 Retrospective data collected at a freestanding pediatric facility revealed that approximately 30% of pediatric patients were not demonstrating sufficient levels of comfort during peripheral intravenous (PIV) catheter insertion and specimen collection (lab draws) even after successful implementation of comfort measures by the vascular access team (VAT) in an adjacent procedure (eg peripherally inserted central catheter placement). The current quality improvement project was implemented to support adaptation and expansion of previous lessons learned to PIVs and lab draws specifically.

Design and Methods:

The VAT used the Pediatric Sedation State Scale,2 a standardized assessment tool integrated into the electronic medical record, to assess procedural comfort during PIVs and lab draws from February 2021 through April 2023. A total of 24 134 patients aged 0 to 18 years were included in the data collection. Interventions were delivered concurrently and included (1) reeducation/ongoing support for implementation of the Comfort Promise3 measures, (2) the creation and implementation of advanced comfort options, and (3) culture change.

Aims and Objectives:

The goal of the interventions was to improve the percentage of pediatric patients achieving adequate levels of comfort beginning at 68% in year 1 to 90% in year 2.


From February 2021 to April 2023, the VAT team was able to improve procedural comfort scores from 68% to 90% of pediatric patients with adequate comfort for lab draws and/or PIV insertions.


While standard comfort measures are a good first step in pain management during needle procedures, they are not sufficient for every pediatric patient. Nitrous, sedation, and the use of anxiolytics and analgesics can play an important role in reducing pain and anxiety during needle procedures and should be considered for patients not achieving adequate levels of comfort with standard comfort measures.

Approximately 150 to 200 million peripheral intravenous (PIV) catheters are placed each year in the United States, and 80% of inpatients receive one during their hospital stay.4 In addition, 14 billion laboratory tests are ordered in the United States annually.5 Children have rated needle procedure–related pain as the worst pain experienced when in the hospital.6 If these painful experiences are left unaddressed, patients are at risk for increased needle phobia, which can, in turn, increase pain and distress during future needlesticks and ultimately to greater rates of vaccine hesitancy and health care avoidance in adulthood.7,8

Given the negative experiences associated with needle procedures, there has been increased attention to pain management and comfort techniques to help decrease pain and distress during needlestick procedures.6,7,911 Generally, evidence-based pain management and comfort techniques can be categorized into pharmacologic and nonpharmacologic interventions.10 The Comfort Promise3 is a hospital initiative that combines both pharmacologic and nonpharmacologic pain management interventions as a bundle of 4 evidence-based pain management and comfort strategies to reduce or eliminate pain caused by needlesticks and to help prevent long-term negative psychological effects of trauma during these painful needle procedures. These 4 bundle elements include numbing the skin with pharmacologic agents,3 distraction (including, but not limited to, the use of child-life12), comfort holds,3 and sucrose or breastfeeding.7 This pediatric hospital offers these strategies as a standard of care for all pediatric patients requiring routine needlestick procedures, including but not limited to PIV insertion, blood specimen collection, midline placement, peripherally inserted central catheter (PICC)/central line placement, intramuscular injections, and subcutaneous injections.

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