Cultivating CALM for better care

Aim

CALM Care supports healthcare providers to reduce medical distress, through engaging consumers  and carers, supporting education and training, and mobilising person-centred care.

Outcomes

• Cannula insertions (54%), followed by blood tests (36%) were the most observed medical  procedures.
• Mean (SD) length of procedures (staff) was 6,06 mins (5,08 mins), range 2 - 18 mins.
• Mean (SD) length of procedure (child self-regulated) was 7,59 mins (6,53 mins), range 2 to 25 mins.
• Mean FLACC score for pre, peak and post-procedure before implementation of CALM Care was 1.00, 3.20, 0.88 and following implementation was 1.71, 2.57, 0.43 (p=0.0018). Note, a score above 3 indicates an adverse event.
• Caregivers reported high satisfaction (8.5/10).
• Children >8 years reported moderate to high satisfaction (7.7/10).
• CHQ staff reported CALM Promise is highly acceptable (9.6/10). The program is aligned with NSQHS Standard 2 and Standard 5, CHQ Planetree and 'Better Services'.

Background

Procedural pain is pain that occurs with an episode of medical care. Painful or distressing medical procedures are common in health care settings across age groups. For children and young people, interventions such as insertion of intravenous cannulas or nasogastric tubes, dressing changes and intramuscular injections can cause significant distress and pain, and if not managed well can lead to anticipatory anxiety and subsequent challenges when engaging with the health care system.

These challenges include (but are not limited to) treatment delay, missed appointments or medication doses which incur a cost, increased staff requirements for procedural support, and vaccine hesitancy. A tiered approach (universal, targeted, specialist) to all procedural care has demonstrated a reduction in both short and long-term impacts of poorly managed procedural pain and distress.

At the Queensland Children’s Hospital (QCH), there has been an increase in procedural care requirements, with more investigations, treatment options and complexity of care alongside more patients with neurodiversity and increased generalised anxiety. Patient reported experiences such as ‘Mother unhappy patient was forced down on the bed (...) causing bruises’ (PREM report,2024) highlight that organisational and/or professional norms may override the distress of our patients having procedures and this can become an accepted, or even expected, part of practice. Many clinical procedures are brief and performed frequently. It has been suggested that this creates the context whereby the completion of the procedure is paramount despite the distress of the child.

A coordinated and standardised approach to the management of pain and pain-related distress associated with medical procedures for children, young people and their families’ receiving services at QCH was not in place. This resulted in avoidable trauma for patients and their families and staff; increasing number of referrals to support children using additional measures to receive routine medical treatment; subsequent health economic impact on efficiency and additional intervention requirements (therapeutic and pharmacological); and long-term health impacts for individuals resulting from avoidance of health care.

To address this problem, the CALM Care project team (with funding from the 2024 Chief Executive Imagination Fund) formalised the CALM Care Framework
with five principles to guide practice:

• C - Comfort: Provide care that is as positive and comfortable as possible.
• A - Analgesia: Ensure children and young people have access to simple pain relief for every procedure.
• L - Language: Staff and caregivers communicate in a way that helps to create a positive experience.
• M - Mindfulness: Empower children, young people and their caregivers to engage with non-pharmacological strategies.
• M – Memory: Focus on positive aspects of their experience to form positive memories.

Previous implementation strategies, including educational meetings/materials, and identifying clinical champions had failed to lead to wide-spread or sustained adoption of CALM Care.

Discussion

Implementation has involved 0.6FTE (CNC) and 0.1FTE (SMO) CALM Facilitators working  directly with local workgroups to plan, implement and embed CALM Care within workflows.

Customisation of CALM Care for local workflows, and delivery of staff training (online and in-person) is a core requirement. A further 0.1FTE (HP6) and up to 0.5FTE in-kind  contributions (CNC, SMO, HP) have supported collaborations with mid- to high-level leaders to investigate sustainable onboarding practices using existing platforms. Online resources are accessible for staff training in conjunction with consumer-facing resources  available from Children's Health Queensland - About Us - CALM Care.

Online interactive courses for staff are now available on Teach Q/iLearn, with almost 300 staff enrolled since November 2024. Findings have highlighted the prevalent impact on sustainability  of new initiatives due to high-frequency staff movement patterns (staff rotation/separation, business case for changes e.g., ward reconfiguration) and clinical areas with high volume/high complexity throughput (e.g., Emergency). The value of allocated staffing  resources to work flexibly with front-line clinicians and mid- to high-level leaders is critical to the success of CALM Care adoption in workflows.

Implementation strategies that had the greatest impact on implementation success were: accessing new funding;  audit and provide feedback; change physical structure and equipment (e.g., digitalisation of My CALM Plan for integration into the medical record); conduct local needs assessment; conduct ongoing training; develop educational materials; facilitation; identify  and prepare champions; involve consumers; and the use of a clinical advisory group (with diverse, multi-level representation). The i-PARIHS framework was a good fit, from project design to analysis and interpretation of data. The most requested additional  training by healthcare workers was for the ‘language’ principle of CALM Care.

There was overwhelming positive feedback from the clinical champions when demonstrating CALM Care resources in person, but less engagement and follow-up using email. A broad network  of existing staff across nursing, medical and allied health education have been consulted regarding requisite training requirements for incoming staff, supported by user feedback such as: Very informative information on techniques for procedural anxiety Highlighted  how important language is with regard to procedures Useful session that provided tools to implement in the group's future work Gained insight into different positioning techniques to reduce anxiety in children Learnings have included work on top-down governance  and alignment of common language (e.g., procedural care, trauma-informed care) for psychosocial initiatives. The 15 inter-dependencies for project delivery required high level project management skills.

Ongoing funding is currently being sought to support  a CALM Facilitator role in FY25/26, to complete the implementation of CALM Care across QCH. There is a perceived high risk of failure to maintain and/or continue to embed CALM Care practice into workflows without the facilitation role, due to inconsistent  approaches and experiences across wards and outpatient clinics for both patients and staff. Other paediatric hospital’s experiences suggest that a whole-of-organisation culture change is likely at least three years in the making. CALM Care as a system-wide  initiative aligns CHQ with national and international paediatric hospital settings focused on improving patient experiences.

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