LEAPP-ING to childrens’ defense

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Several years ago, before our children’s hospital was built, I remember spending time chatting with one of our child-life specialists about various incidents in the hospital. And by “chatting” I mean rants about procedures or events that involved some degree of non-patient-centered care.

This wasn’t just your every-day “I didn’t ask them what they thought of the plan” kind of failing, this was the “we do this procedure on adults all the time in the office, so we’re not going to use pain meds on your 3 year old” kind of failing.

There were various kinds of issues. The “treating kids like small adults” was just one, others included the “sneak attack” where doctors (usually surgeons) would rush into a patient’s room, and perform some kind of invasive procedure – whether it be a dressing change, a drain removal, or some other kind of “quick” thing – that would often degrade into a messy charade of “we’re nearly done” and “this doesn’t hurt” while the nurses are stat-paging child-life to come sort out the screaming child. Sometimes even a relatively well planned attempt would fall flat due to missing items or drugs wearing off. Some procedures, which I shan’t reveal here for risk of HIPAA violation and upsetting my readers too much, were nothing less than torture.

As it happens, she and I were far from the only ones thinking about this. One of the pediatric Attendings who was working on a project grant for child advocacy, one of my co-residents (now an Attending in her own right) who helped teach my Communication Skills course, and a couple of nurses were also keen to fix things. Several brain-storming sessions later we came up with the core idea, and our residency director (grabbing coffee outside the meeting room and overhearing us) coined the acronym – LEAPP.

Listen – Evaluate – Anticipate – Plan – Proceed.

Listen – to the concerns of the parents, the nurses, and the patient. Does this child have a specific fear or pattern of behavior, or coping strategy? What worked well, or didn’t, in the past?

Evaluate – the current situation. Has this child already gone through a traumatic event, such as a burn, amputation or other situation that puts them at high risk for Medical Traumatic Stress? What is their current pain level? How anxious are they?

Anticipate – what could go wrong? What if the child acts out? Should we have a plan B? What kinds of non-pharmacological and pharmacological interventions can we use to reduce pain and anxiety?

Plan – get your stuff together, get the treatment room ready (patient beds are NOT the place to do procedures – they should be the one safe haven a kid has in the hospital), get the people ready: doctors, nurses, child life. Who is going to be “the voice” for the child during the procedure? How long will this take? Have enough meds ready to hand without needing more from pharmacy.

Proceed – only when everyone, including the patient, is ready. This means waiting for meds to take effect!

This grand ideology, invented in a small conference room by half a dozen disparate people of entirely different roles, got itself some legs. We did research, surveys of the parents, doctors and staff as they performed procedures on the floor. We drew up plans to teach these principles, created quizzes and slides, and somehow convinced the Graduate Medical Education Office to put it online for us. We scripted, acted and filmed an educational video to illustrate the points, with interviews from the best patient-advocates we knew – the big-time surgical and ER pediatric faculty who could lead by example to teach their residents what was REALLY important in medicine: caring for patients.

At some point an email came my way with a hospital policy on it. And I blinked.

Hospital policy. An institutional policy for pediatric procedural pain management. And I looked at what we had done.

It had taken us two years, but we had created a mandatory educational initiative for EVERY resident (not just pediatric residents) at our hospital. We had made it hospital policy to LEAPP for every pediatric procedure – meaning that if a resident or attending didn’t follow it, they were in breach of an OFFICIAL policy. This wasn’t touchy-feely stuff any more – this was serious.

I was stunned. I had heard the phrase – “Never doubt that a small group of determined individuals can change the world – indeed, it is the only thing that ever has” – but until that moment I had never really seen it in action.

Now you can walk about our shiny, roomy, children’s hospital and see our green froggy sticker on patient rooms who are due to have a procedure. The LEAPP manual is at the nursing station. Child Life is no longer performing damage limitation, but instead is preventing the damage from occurring in the first places. Nurses and doctors are working together to best plan how things should be done.

At least, they should be. There have been hiccups. We’d like to think things are better.

But you know what….we’re doing a survey about that.

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