Calming kids’ hospital anxieties

James M. Callahan, MD, an attending physician in the emergency department (ED) at Children’s Hospital of Philadelphia (CHOP), Pennsylvania, expresses in a nutshell why addressing his young patients’ hospital anxiety is of top concern.

“I’ve been doing this for more than 20 years, and when a child is calm and cooperative, you can get a much better physical exam,” he says. “It’s part of being a caring and compassionate physician to try and address their fears and anxieties.”

Beyond that, by addressing a child’s fears and anxiety, a physician is better able to build a trusting relationship with the patient and family, he adds. That’s especially important in the ED where there isn’t a lot of time for relationship building.

Going to the operating room is scary for adults and children alike, states Timothy Lee, MD, assistant professor of surgery and pediatrics at Texas Children’s Hospital, Houston. “Nobody wants [his or her] child to have an operation,” he says. “So, from that standpoint-and from being a parent myself-you try to make a surgical procedure as pleasant an experience as possible. I think if we’re able to address their anxiety early on in the preoperative area, the kids are able to have a better experience.”

‘How’ is the key

Children’s anxiety in the hospital setting affects care and safety-most critically, whether or not they need to be sedated for tests and procedures. Strategies to reduce their anxiety can have big impacts on children’s experiences, quality of care, and healthcare costs. The literature reflects that, to be successful, such strategies have to be implemented correctly.

Some researchers looking at age-appropriate play therapy to help children during hospitalization have found it reduces stress, psychological trauma, anxiety, and behavioral issues.^1,2

Conversely, in a systematic review of studies looking at how educating children who are about to undergo surgery improves anxiety and other emotions, nurse researchers found education effectively reduces anxiety in older children-but could actually make younger children more anxious.³

An evolving model

Initially, Children’s Hospital of Pittsburgh of UPMC, Pennsylvania, began its journey to distract patients in order to reduce the number of sedations and the hospital’s corresponding backlog for computed tomography (CT) scans in 2005, according to Kathleen Kapsin, RT (R) (M), MS, director of the pediatric radiology department.

“Our accessibility was terrible,” she recalls. “You might have to wait a week, 10 days, 2 weeks, or even longer to get onto the scanner. We thought, what if we didn’t need to sedate these children? Wouldn’t that help us to go faster?”

Kapsin and colleagues started off using simple distractions including a Snoezelen, a device that projects images. “A child could pick if they wanted to watch a scuba diver, or a ballerina dancing, or butterflies,” Kapsin says.

The staff also introduced music, softened the lights in the room, and even secured a disco ball for the ceiling. “The disco ball made these lights go around the room, which was very entertaining for some of these kids,” she relates.

Next, the hospital swapped its white walls for a mural with an underwater scene, so kids could experience entering the CT scanner as if they were embarking on a voyage under the sea.

The staff also realized that children’s anxiety about hospital testing started before they even left their homes. In response, the staff developed educational materials that they mailed to parents prior to the test date. The parents could read the kid-friendly information (now web-based) to prepare children for the hospital journey to come.

In addition, the staff developed better skills to sense angst when patients arrived at the hospital for testing. They learned to talk with the child literally at the child’s level, by kneeling if needed, and in language children understood. The staff began to encourage parents to accompany and hold their children, and better recognized the importance of giving children choices so they felt more control.

Children's Hospital of Pittsburgh of UPMC's "distraction rooms" for treating children include the Jungle Adventure room with a SPECT/CT nuclear camera.

The interventions worked. In fiscal year 2005, Children’s Hospital of Pittsburgh was performing 351 sedations for CT scans. By fiscal year 2006, the sedations had been reduced to 45. From fiscal year 2006 to 2007, only 9 sedations were necessary. “We reduced sedations almost 97%-from 5% of our kids to 0.1%,” Kapsin states.

The results were so impressive that Children’s Hospital of Pittsburgh expanded the concept of distraction rooms throughout the hospital when the institution built its new facility in 2009. They took the concept to a new level, Kapsin relates, adding multisensory input by which children undergoing imaging, including CT, magnetic resonance imaging (MRI), and nuclear medicine procedures, would enter an adventure of sights, smells, sounds, and more.

Children can now watch and listen to movies during their tests. In one CT room, they enter Parrot Island, in which they’ll smell a hint of coconut aromatherapy and have to “swim over” water (blue floors) in order to reach a treasure chest of prizes for a scan well done.

Children's Hospital of Pittsburgh of UPMC's colorful Camp Cozy imaging room eases children's fears of the PET/CT camera.

“In the MRI room, we have a space theme. We put these fabulous MRI cinema goggles on the children, so [it’s as if] they’re going to watch a movie in space,” Kapsin enthuses. “They have headphones, so they can’t hear that sound of the MRI so much. We also have an MRI simulator. A child up to about age 10 can get onto the simulation scanner. We can move them into the fake magnet. We can let them hear the fake sounds. We can put the fake headsets on. So, they are desensitized by this so, by the time they get in the scanner, they’re ready.”

The result? Sedation rates continued to decrease, while utilization rates on the devices increased. From fiscal year 2009 to 2010, there had been a 22% decrease in sedations for CT, MRI, and nuclear medicine procedures despite a 7% increase in the number of such procedures being conducted.

“In fiscal year 2013, we [performed] a total number of 51,476 such procedures; we sedated [in] 6.5%, meaning we only sedated about 3000 of those patients,” Kapsin reports.

The ‘child whisperers’

Some children’s hospitals are adding child life specialists to their staffs with the specific mission to relieve children’s fears and anxiety using play and psychological preparation. The child life experts at the hospitals in this article play many roles. They not only consult on hospital initiatives to reduce children’s anxiety, but also help prepare children for tests, procedures, and treatments, as well as spend time with patients in the acute care setting, to make sure those patients are as distracted and happy as possible.

Callahan calls the child life specialists in CHOP’s ED allies and advocates. (Child Life Council, a national organization that represents child life specialists, offers valuable information about these specialists, including a section on evidence-based practice statements, at www.childlife.org.)

Art and music as stress busters

In addition to these “kid distraction experts,” CHOP engages art and music therapists who often work with the hospital’s occupational and physical therapists. The art and music provide children with escapes and, in the case of art, self-expression, states Elana Brewer, MS, CCLS, child life director at CHOP.

Children’s Hospital of Philadelphia also employs pet therapy with volunteer canines that, Brewer says, provide both distraction and comfort. “We had a dog go back with a patient during an ultrasound,” Brewer recalls. “It was a young child who didn’t want to go. The animal provided that comfort level and stress relief to where [we were] successful in getting the ultrasound study.”

Research is lacking on how pet therapy specifically impacts children’s anxiety about things such as pain, according to Brewer. However, a new study now under way at CHOP might change that. Researchers there are conducting a trial in which children with cerebral palsy receive pet therapy before, during, and after Botox injections to relax their spasms, which reduces pain related to muscle rigidity.

“Every indication seems to be the patients are more compliant,” Brewer reports. “They’re more comfortable and at ease, and often request pet therapy for future visits.”

Big-ticket items

Interventions to reduce stress come in many shapes, sizes, and costs. Some are simple communication and play techniques, including blowing bubbles to distract a child. Others are elaborate multisensory attractions. Relieving kids’ anxiety, normalizing the experience-even making hospital experiences fun-can be an expensive commitment, as evidenced by Children’s Hospital of Pittsburgh’s distraction rooms, where the movie goggles alone cost about $40,000 each.

There are other big ways in which children’s hospitals are wowing patients and families. Children’s Hospital of Philadelphia was among the nation’s first children’s hospitals to build the Seacrest Studio, as a result of a grant from the Ryan Seacrest Foundation (yes, the American Idol host). The foundation is dedicated to enhancing the quality of life for seriously ill and injured children through unique programs that utilize multimedia and interactive platforms, according to ryanseacrestfoundation.org.

The hospital’s Seacrest Studio is a TV and radio studio that offers children the chance to participate in live programming, whether they physically come to the studio or call in from their hospital rooms, according to Brewer.

“We have games every day,” Brewer relates. “We have a radio program every day for 2 hours, during which they can request songs. They can come to do karaoke. We’ve used that studio in conjunction with our music therapists and have had groups-some of our outpatient groups that are undergoing the same treatments-do performances in there.”

Patients can make also video diaries. For special life occasions that the children’s hospitalization will cause them to miss, hospital staffers go to patients’ bedsides to facilitate memory-making opportunities for these important milestones.

“If patients are graduating from high school, but can’t be there because they’re in the hospital, we will try to create a situation in which we can connect them as much as possible to make them feel like they are participating in graduation,” Brewer explains.

Angels among us

Eric Hess, vice president of operations, Children’s Hospital of Pittsburgh of UPMC, says that programs to keep kids as stress free as possible with onsite child life specialists and other initiatives has since been made a part of the hospital’s budget, but such initiatives are also a focus of philanthropists.

Fueled by the success of the distraction rooms in drastically reducing both sedations and the length of device waiting lists, Children’s Hospital of Pittsburgh has expanded the concept to 28 more rooms in the last year, Hess reports.

“All of those rooms [have been made possible through] philanthropy,” he notes.

These sorts of calming, creative, and kid-centric environments not only attract patients, but also pediatricians, says Andrew Urbach, MD, associate chief medical officer, Children’s Hospital Pittsburgh of UPMC, and professor of pediatrics, University of Pittsburgh School of Medicine.

“Most pediatricians and people who choose to work with kids want an environment that allows them to perform maximally in the care of children,” Urbach says. “So, having a facility that supports patient and family-centered care, having programs that support it, and having people behave and act in a way that supports that culture is exciting to people as an opportunity,”

Most importantly, Urbach says, not being frightened makes a big difference to a child. “They come back to their patient room feeling very different than if they cry for an hour,” he states.

Of course, Urback says, enhanced safety is at the core of all these initiatives. “[Children] don’t need to receive sedation. So, from my point of view, I’m providing a safer level of care because I’m not risking respiratory depression.”

The stress-relieving programs at the hospital help patients and families feel important and respected, he adds, and the environment helps to foster strong relationships among clinicians and patients alike.

Home-grown ‘hospital-ity’

Urbach remembers attending a meeting about 15 years ago during which experts talked about creating a family-resource center. It’s there that he got great advice, he recalls. “They said, even if it’s a filing cabinet in a closet, start it and let it evolve and let it build and let people get excited about it.”

Urbach recommends that his pediatrician colleagues who want to start similar initiatives for reducing children’s anxiety at their local hospitals begin with a vision.

“Match that vision to your mission and find a way,” Urbach urges. “Find a way by advocating either personally or for your patients and their families. I think it has to do with mission and passion and how you tell your story. Donors want to see excitement. They want to see great things happen with the resources they provide doing things for patients and families in a very tangible way.”

Harkening back to that first meeting 15 years ago, he notes, “Our family resource center right now is actually 20,000 square feet. I would say we do it on a fairly grand scale as many of the larger children’s hospitals do,” he says, “but that doesn’t mean you can’t start on the path. Speak about this to anyone who will listen. Eventually, you can accomplish more than you thought you could on your scale.”

REFERENCES

1. Lerwick JL. Psychosocial implications of pediatric surgical hospitalization. Semin Pediatr Surg. 2013;22(3):129-133.

2 .Potasz C, De Varela MJ, De Carvalho LC, Do Prado LF, Do Prado GF. Effect of play activities on hospitalized children’s stress: a randomized clinical trial. Scand J Occup Ther. 2013;20(1): 71-79.

3. Copanitsanou P, Valkeapää K. Effects of education of paediatric patients undergoing elective surgical procedures on their anxiety-a systematic review. J Clin Nurs. 2014; 23(7-8):940-954.

For further reading, Kaulen recommends these 2 books on the topic:

Rollins JA, Bolig R, Mahan C. Meeting Children's Psychosocial Needs Across the Health-Care Continuum. Austin, TX: ProEd; 2005.

Thompson RH. The Handbook of Child Life: A Guide for Pediatric Psychosocial Care. Springfield, IL: Charles C. Thomas Publisher LTD; 2009.

Ms Hilton is a medical writer in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.