Running head: QUALITY ASSURANCE PROJECT

Quality Assurance Project to Implement
Audiovisual Distraction in Pediatric Radiation Oncology
Amy S. Mabry
Arizona State University

1

QUALITY ASSURANCE PROJECT

2
Abstract

Approximately 15,270 children were diagnosed with cancer last year and a common
treatment includes daily radiation therapy. Children must remain immobilized for the planning
and treatment to ensure the radiation beam precisely delivers radiation to the tumor and reduces
exposure to the normal surrounding tissue. Radiation therapy may last several weeks, which
requires children to be put under daily anesthesia for an extended length of time to ensure
immobilization. The risks for anesthesia include airway obstruction, broncho/laryngospasm,
oxygen desaturation, apnea, nausea/vomiting, hypothermia, hypotension, hypoxia, cardiac arrest,
sepsis due to central line access, and death. The relationship between daily anesthesia
administration and neurotoxicity is currently unclear. The purpose of audiovisual distraction
(AVD) during radiation therapy was to decrease anesthesia exposure, improve quality of life, and
decrease anxiety of patients and families. A plan to implement an AVD device at the time of
radiation planning and during daily treatments was conducted in a large pediatric radiation
oncology practice in Arizona. Inclusion criteria were children needing radiation, between the
ages of 5 and 15, who do not have history or complaint of visual impairment, who have the
ability to follow directions for AVD, and were deemed candidates by the Radiation Oncologist
and Child Life Specialist through physical and mental assessment. Data collection included
anesthesia requirements, heart rate, PedsQL Tool, and time in treatment room gathered at the
planning session and at the end of treatment. Microsoft SPSS was used for data analysis.
Descriptive statistics were used to describe the sample and outcome variables. The aggregated
data was analyzed to ascertain if the number of children in the inclusion age range had a
decreased need for anesthesia, decreased anxiety, and increased quality of life. The primary
outcome for the AVD was: all four children who participated were able to undergo radiation

QUALITY ASSURANCE PROJECT
therapy without the need for anesthesia . The children were able to remain awake for treatment
could attend school, as permissible, eat before treatment, and spend significantly less time at the
treatment facility. The concern of repetitive anesthesia and neurotoxicity will not be a factor in
the child’s long term late effects of treatment. The reduction of need on anesthesia staff and
nursing staff was estimated to save over 500,000 dollars for the 89 treatments the four children
underwent with the AVD. The benefits of the intervention not only provided a better treatment
experience for all children, but it allowed the facility to utilize the treatment machine more
efficiently, providing radiation therapy as an option to even more patients.

3

QUALITY ASSURANCE PROJECT

4

Quality Assurance Project to Implement
Audiovisual Distraction in Pediatric Radiation Oncology
In 2017 roughly 15,270 children, between the ages of zero to 19, were diagnosed with
cancer in the United States; of those children, 1,790 children will die of their disease (National
Institute of Health [NIH], 2017). Globally 300,000 children are diagnosed with cancer each year.
Approximately one in 285 children in the United Sates will be diagnosed with cancer before their
20th birthday (American Childhood Cancer Organization, 2017). A cancer diagnosis is
overwhelming, frightening, and difficult for not only the patient but the family as well. The
medical care for a child with cancer includes a large multidisciplinary team and the treatment
course for pediatric oncology patients can involve chemotherapy, surgery, radiation therapy,
stem cell transplant, and immunotherapy (NIH, 2017). Each treatment modality presents its own
obstacles, limitations and complications. Radiation therapy introduces new obstacles for patients,
family, and medical team. Children as young as infants are treated with radiation therapy.
Radiation therapy requires patient immobilization to ensure the radiation beam precisely delivers
radiation to the tumor and reduce exposure to the normal surrounding tissue (Verma, et al.,
2016). The immobilization of the patient allows for daily reproducibility, which is key in treating
the correct area of the body. If a child is unable to maintain immobilization on their own,
anesthesia is necessary for treatment planning and daily treatment.
Background & Significance
The risks for anesthesia include airway obstruction, broncho/laryngospasm, oxygen
desaturation, apnea, nausea/vomiting, hypothermia, hypotension, hypoxia, cardiac arrest, sepsis
due to central line access, and death (Mizumoto et al., 2015; Tucker, Jain, & Mahesh, 2017).
Children with cancer are at increased risks secondary to body systems that are often depleted due

QUALITY ASSURANCE PROJECT

5

to the comorbidities of cancer treatment. The usual risks of anesthesia are compounded by the
fact that overall the body systems are not operating at the highest potential due to the treatment
they are receiving. Children with cancer pose a potential for clinically significant deterioration
under general anesthesia (Latham & Greenberg, 2010). Children receiving concurrent radiation
therapy with chemotherapy are at increased risk for complications. The impact of daily
anesthesia has long reaching effects, not only on the patient and family, but also within the
healthcare system, potentially causing increased healthcare costs secondary to complications.
Pediatric sedation has increased over the years with the advancement of medications
available to provide safe and effective sedation that impairs health outcomes. In Uffman, et al.
(2017) a study of MRI utilization and associated use of anesthesia and sedation (A/S), the need
for anesthesia increased from 21% to 28% from 2009 to 2014. With the advancements in
sedation, the American Academy of Pediatrics and American Society of Anesthesia mandated
guidelines and criteria to maintain procedural safety (Sterni, Beck, Cole, Carlson, & Turmelle,
2008). The most recent Guidelines of the American Academy of Pediatrics for anesthesia were
published in 1992, which focus on single procedures. The medical community has an increasing
interest and concern between the link of anesthesia and neurotoxicity caused by repetitive
anesthesia. The Mayo Clinic conducted a study of 5,000 children and found that there is an
increased risk in learning disabilities in children exposed to two or more anesthesia episodes
before the age of four (Barton, Nickerson, Higgins, & Williams, 2017). Verma, et al. (2016)
conclude that though radiation A/S is safe comparatively to the A/S of an operating room setting,
there is still concern about the neurocognitive consequences of multiple anesthetics in pediatric
patients. McMullen, Hanson, Bratton and Johnstone (2015) conducted a retrospective study to
determine the safety parameters of A/S in children receiving radiotherapy. A/S needs vary with

QUALITY ASSURANCE PROJECT

6

each individual causing for case by case assessment. Gardling, Tornqvist, Mansson, and
Hallstrom (2017) conducted a controlled clinical trial testing the development,
feasibility/piloting, evaluation, and implementation of general anesthesia (GA). The study stated
that GA for radiotherapy involves risk, sleep disruption, and suboptimal nutrition which leads to
additional discomfort. The study showed that children who underwent GA for radiotherapy,
displayed more negative emotional behavior through vocalization, activity, interaction, and level
of cooperation. Most proton radiation centers are free standing and away from specialized
pediatric care (Buchsbaum et al., 2013). During Buchsbaum et al. (2013) study, of the 138
patients treated with A/S, there were three events, one child fell off of a gurney and two other
children had aspiration episodes, leading to intubation and hospital stay for both. The use of A/S
during a study conducted by Mizumoto et al. (2014) identified the average time of a patient
undergoing A/S was 50 minutes, and treatment started roughly seven minutes after induction of
anesthesia. Scott et al. (2016) estimates the annual reduction of anesthesia with the use of a Child
Life Specialist (CLS) for 100 patients to exceed $775,000. Patients are required to be fasting for
the radiation procedure with anesthesia. The fasting can be a challenge for both patients and
families and cause increased compromised nutritional status in a patient population that is
already at risk for nutritional deficit.
In a radiation department in the southwest United States, providers are currently
anticipating the need for anesthesia on their interaction with the patient at the consultation. The
provider in conjunction with the CLS decided if the child is developmentally and physically
capable of receiving radiation therapy without anesthesia. The CLS is vital in the day to day
treatment of children, especially in the radiation therapy setting. They are capable of walking
children through treatment with reduced anxiety, assisting them with going under anesthesia

QUALITY ASSURANCE PROJECT

7

calmly or staying awake during treatment. The CLS is consulted to assess the child and
determine if the child is developmentally able to attempt radiation therapy without anesthesia. In
2016 there were over 75 children, between the ages of four months old and 22 years old treated
with radiation therapy in this facility. Radiation therapy treatment spanned between one week to
eight weeks of Monday through Friday treatment. The number of pediatric and adult patients
being treated every day continues to rise, and the time on the machine is coveted. The proton
radiation beam can only treat for eleven hours a day due to daily maintenance. The time it takes
to administer anesthesia and radiation therapy is longer than treatment of a child tolerating
treatment safely without anesthesia, which in turns reduces the number of patients treated per
day. In addition to having benefits for the patient, safely decreasing the use of anesthesia, when
appropriate, would allow this facility to provide more sessions of treatment per day, which could
possibly save additional lives.
Problem Statement/ PICO Statement
The standard of care for safe and effective radiation therapy for children who are likely to
move during radiation therapy is to place the child under general anesthesia. Children between
the ages of five and fifteen may be able to complete radiation therapy without anesthesia, with
the help of an AVD device. In pediatric patients, how does an audiovisual distraction
intervention compared to standard distraction reduce anesthesia exposure in children?
Search Strategy
An exhaustive literature search was performed to obtain research studies pertinent to the
PICO question. The literature search was conducted in three scientific databases PubMed,
CINHAL and Scopus. PubMed was utilized first, as it has a large selection of peer reviewed
articles. CINHAL and Scopus were the second and third database used in the literature search.

QUALITY ASSURANCE PROJECT

8

A grey literature search was also conducted to discover any material not published and used for
the background and significance. A hand search of articles was conducted in the reference list of
two studies to obtain relevant research articles not found within the three database searches. An
hour was spent with the a librarian to review search strategies to ensure exhaustive search was
achieved. A literature review was conducted again in 2019 with no further research uncovered.
PubMed
The following keywords were included in the initial search: “anesthesia”, “pediatric” and
“procedures”. This search yielded 9016 articles. The search was then limited to articles
published in the last five years (2013-2018), English language, and the age range of birth to 18
years. The search results were reduced to 1982. The key word radiation therapy was added to
the search criteria, 30 articles were generated through the search. Five studies were selected
from the search results through examination of the title and abstract related to the content and
relation to the problem statement. The previous search criteria were again entered into the
search bar and “outpatient” was added to the keywords, this produced two studies, one in which
was chosen for supporting research on pediatric anesthesia. In all, six research articles met the
criteria to be selected to be analyzed for the purpose of supporting the PICO question.
CINHAL
The search started with the keywords “anesthesia”, “pediatrics” and “procedures”. The
results of the search were 572 articles. The limit of full text was added to the exclusion criteria,
reducing the results to 137. A time limit of articles published in the last five years was added,
yielding 70 results. The keyword “radiation therapy” was added. The final search resulted in
nine articles. Using preselected criteria, one of the nine was used in the evidence to support the
PICO question.

QUALITY ASSURANCE PROJECT

9

Scopus
Scopus data base was searched for articles and studies related to the PICO question. The
first two key words searched were “anesthesia and pediatrics”. The search produced 20, 818
articles. The limitations added next were English language and last five years which reduced the
results to 4721. The keywords “procedures and radiation therapy” were added to the search
parameters. This search yielded 80 results. The review of the 80 articles produced nine studies
that met the criteria used for the purpose of supporting the PICO question. The nine studies
found in Scopus were previously found in the PubMed and CINHAL database searches and
ancestry search. No new studies were selected for literature review.
Grey Literature
The search for grey literature began with a search of clinical trials using the keywords,
“anesthesia, pediatric, and radiation oncology” with limitations of birth to 17 years old. Four
clinical trials resulted in the search. One clinical trial titled, Ketamine Tolerance in Children
after Repeated Administration During Radiotherapy Sessions, was applicable to research
question. The clinical trial was completed in 2014. Background and significance information
related to pediatric cancer was obtained through American Childhood Cancer Organization and
National Institute of Health websites.
Ancestry Research
Ancestry searching was conducted on two research articles obtained during the database
search. Through the hand search of Khurmi, Patel, Koushik, Daniels, and Kraus (2017) reference
list, two research articles, written within five years, which were relevant to the PICO topic.
Owusu-Agyemang (2014) reference list was also reviewed. One article from the reference list
was used in the literature review. All three articles were ultimately later found in Scopus

QUALITY ASSURANCE PROJECT

10

database when the same keywords were used. The synthesis table with the selected studies can
be seen in Appendix A.
Evidence Synthesis
There are several randomized control trials (RCT) that provide conclusive evidence that
audiovisual distraction is beneficial in pediatric treatment. Burns-Nader (2017), Hua (2015),
Jeffs (2014), and Khadra (2018) used audiovisual visual distraction in the treatment of children
with burns during wound management care. The RCTs treated children between the ages two
months and 17 years of age. All the studies concluded that children with the AV distraction
reported less pain and anxiety with wound care compared to the children with pharmaceutical
intervention and standard distractions.
Hinker (2017) conducted a pilot study of 23 pediatric patients undergoing radiation
therapy treatment between the ages of three and 12 years, using an audiovisual-assisted
therapeutic ambience during radiation treatment. The goal of the pilot study was to assess the
AV system developed and the reduction of daily anesthesia. Hinker (2017) reported that 23 of
the 25 (92%) of the patients were able to complete the prescribed radiation therapy treatments
using the AV intervention without anesthesia. The median age of the pediatric patient was six.
Seven of the 23 pediatric patients were originally treated with daily anesthesia, but effectively
transitioned to the AV intervention and finished treatment without daily anesthesia. The
synthesis of the evidence can be seen in table format in Appendix A.
The evidence gathered showed significant success of AVD in children who are
undergoing painful medical procedures. The evidence can be applied to the use of AVD devices
in children between the ages of five to fifteen. There is statistical significance of the articles

QUALITY ASSURANCE PROJECT

11

listed in Appendix A that AVD is a safe and effective method to distract and entertain children
during medical procedures.
Purpose Statement
The purpose of this quality assurance project is to use an audiovisual device to decrease
the need for general anesthesia, decrease anxiety, and increase patient and family quality of life
for children between the ages of five to fifteen who are undergoing radiation therapy in a
radiation oncology center in the southwest United States.
Contribution of Theory to Utility of the Evidence
Erickson’s Modeling and Role Modeling Theory can be used to help the healthcare
providers understand that each child is uniquely different and will have their own sets of needs
(Butts & Rich, 2015), see Appendix B. The theory allowed the facility to understand that each
child comes into the facility at a different stage of development, psychological development and
physical and mental disabilities secondary to their cancer diagnosis. The staff can use the
uniqueness of each patient and family to come up with appropriate preparation for radiation
therapy. The child life therapist and staff used role modeling to help the child reduce anxiety
with radiation therapy by show them how the AVD devices work and allow them to use the
device before actual planning or treatment occur.
Evidence Based Practice Model
The Rosswurm and Larabee’s Model for Evidence Based Practice Change was used to
implement proposed project on reducing pediatric anesthesia. The model worked well in the
hospital setting where the project was conducted. The hospital culture has a high regard for
utilizing an organized and defined processes for change. The Model for Evidence Based Practice
has organized and thoroughly defined steps. The model is a six step process to implement the

QUALITY ASSURANCE PROJECT

12

change in an organization (Appendix C). The steps include assess the need for change in
practice, locate the best evidence, critically analyze the evidence, design practice change,
implement and evaluate change in practice, and integrate and maintain change in practice
(Melnyk & Fineout-Overholt, 2015).
Project Methods
International Review Board (IRB) at Arizona State University (ASU) approval was
obtained for the quality assurance project. The institution where the project was conducted used
a IRB wizard that provided an exempt status for the quality assurance project. All staff
participating in the AVD project completed a human subjects protection module required by the
institution where the project was conducted. Education on the AVD devices implemented was
provided to the Radiation Oncology staff at a staff meeting to include: Radiation Oncologist,
Nursing staff, Child Life Specialist, and Radiation Therapists. The Radiation Oncologist and the
Child Life Specialist evaluated the child at the time of consult to assess the inclusion criteria for
the AVD.
The candidacy was determined through physical exam and evaluation in a collaborative
effort with both the Radiation Oncologist and the CLS in order to assess if a patient was socially
and age appropriate. The CLS assessed the patient through developmental milestones of age,
maturity level, history of school performance, ability to follow simple commands during consult,
parental support and interaction, and history obtained from medical record as part of the standard
of care.
Inclusion Criteria
All children needing radiation therapy between the ages of five and fifteen, who did not
have a history or complaint of visual impairment who could view audiovisual media through an

QUALITY ASSURANCE PROJECT

13

iPad or iTV goggles were considered eligible. The candidate was able to follow the directions
for AVD and are deemed candidates by the Radiation Oncologist and Child Life Specialist
(CLS) through clinical judgment at time of consult. The Radiation Oncologist determined if
AVD device was a reasonable option for the patient through physical and mental assessment at
the time of consult. The CLS was introduced and the CLS determined if the patient was a
candidate. All eligible patients were be offered the AVD device.
Exclusion Criteria
A history or complaint of visual impairment was determined through visual assessment at
consult, evaluation of medical records as this is part of standard of care. Children who do not
meet the screening of the radiation Oncologist and CLS will not meet candidacy for the AVD
distraction tool.
Children who were deemed to be candidates for the AVD were given a participation letter
at the time of radiation planning in either Spanish or English, and given the opportunity to ask
questions. They were allowed to trial the AVD and decide if they want to be included in the
project by the Doctorate of Nursing (DNP) student. A waiver of consent was obtained through
ASU’s IRB. The DNP student was available for guidance at the planning session and the child’s
first radiation treatment.
Budget
The AVD project budget was limited in the financial needs. The iTV Goggles were
purchased by the Radiation Oncologist; the iPad was purchased by the Child Life Specialist
department; and the movies were donated or were already owned by the Child Life Specialist
department.
Data Collection

QUALITY ASSURANCE PROJECT

14

The demographics collected were the child’s age, sex, cancer diagnosis, number of
treatments, and the AVD device used. The PedsQL survey was assigned by the project team to
be given to the child and parent at the time of simulation and at the end of treatment. The
PedsQL survey tool was validated and reliable per previous research and is the standard of care
at the facility. The treatment time in the room was assessed at first treatment and last treatment.
The patient’s heart rate was obtained at simulation and last treatment management visit. A
descriptive analysis was conducted on the data collected.
Outcomes/Project Results/Impact
Results
Four children needing radiation therapy between the ages of five to fifteen years old
participated. The average age of the children participating was ten (Sd=2.36) years and three
months. The children’s ages ranged from seven to twelve years of age. Half of the children
were male (50%). The children’s diagnoses were all different (Appendix D) The average
number of treatment days were 22 (Sd=9.22), with a range of 12 to 31 treatment days. The
average first treatment time was 43 (Sd=17.54) minutes, with a range of 22 to 64 minutes. The
average first treatment heart was 102 (Sd=19.67) beats per minute, with a range of 73 to 116
beats per minute (Appendix D). The average baseline anxiety score for n=2 was 7.5 (Sd=6.36)
points, with a range of three to twelve points. The baseline worry score was the exact same as
the anxiety score.
The average last treatment time was 32.75 (Sd=6.99) minutes, with a range of 25 to 42
minutes. Three of the four children had a decreased in treatment time from the beginning of
treatment to the end of treatment. Patient number four’s treatment time is graphed, see appendix
E. The average last treatment heart was 101 (Sd=11.90) beats per minute, with a range of 83 to

QUALITY ASSURANCE PROJECT

15

108 beats per minute. The end of treatment anxiety score and worry score were not observed due
to all children being lost to follow up.
Impact
The time the children were able complete radiation treatment was decreased compared to
the time needed to treat a child under anesthesia. The average cost of daily anesthesia is roughly
six to seven thousand dollars per treatment. The 89 treatments the children were able to remain
awake during, saved the patient and hospital an estimated $534,000 on anesthesia cost alone.
The reduced treatment time used by children not utilizing daily anesthesia, allows the department
to treat more patients during the day.
Discussion
Limitations
The number of children who were able to participate in the AVD quality assurance
project is a limitation. The limited number of children, four, limited the ability to establish
statistical significance. Only descriptive analysis could be completed. Future research should
enroll more patients with a longer time frame to enable more children to participate.
Three out of the four children were lost to follow up in regards to the PedsQL survey.
The PedsQL was only collected at baseline and at the completion of treatment for one patient.
Child number two completed a baseline, but did not complete a final survey. Child number one
and four had a language listed as Spanish, although both patients spoke English. The language
selection caused the PedsQL survey to not be triggered in the research department. The end of
treatment visit with the Radiation Oncologist for child number two was canceled, thus canceling
the PedsQL survey.

QUALITY ASSURANCE PROJECT

16

The children were capable of maintaining their nutritional status due to the ability to eat
before treatment. The fall risk related to daily anesthesia is reduced and the child is capable of
sustaining their school attendance as permitted. The condensed time spent at the hospital allows
for an increased quality of life.
In the future, the children who are beginning treatment will be reviewed with the research
department for the evaluation of need for the PedsQL survey. Going forward, if the child speaks
English, the research coordinator will manually order the survey. The research coordinator has
now attempted to obtain a Spanish version of the survey to reduce the number of children from
being excluded based on language selected. The scheduling department was educated on the
need to reschedule the PedsQL portion of an end of treatment management in the future.
Future Practice
The facility will continue to utilize the AVD devices in radiation therapy to reduce the
anesthesia exposure to pediatric patients. The use of AVD can be evaluated in different
healthcare settings to reduce anesthesia exposure. Magnetic resonance imaging (MRI) utilizes
anesthesia in order to successfully obtain imaging in children. The AVD could be implemented
in this setting to give children the ability to remain awake during scans. The adult Radiation
Oncologist are discussing the implementation of the AVD for adult patients who have long
treatment times or high anxiety. Further research should be conducted to examine a larger
sample size to do further statistical analysis on this specific patient population.
The child’s ability to remain awake for daily radiation therapy treatment not only
improves the patient and family’s quality of life it reduced the possible risk of complications.
Reducing the number of children undergoing daily anesthesia will move up the treatment start
time for all patients, thus reducing the time children under daily anesthesia must remain without

QUALITY ASSURANCE PROJECT
food or water. The benefits of the intervention will not only provide a better treatment
experience for all children, but it will allow the facility to utilize the treatment machine more
efficiently, providing radiation therapy as an option to even more patients.

17

QUALITY ASSURANCE PROJECT

18
References

American Childhood Cancer Association. (2017). Childhood Cancer Statistics
[website]. Retrieved from: https://www.acco.org/childhood-cancer-statistics/
Bagattoni, S., D'Alessandro, G., Sadotti, A., Alkhamis, N., & Piana, G. (2018). Effects of
audiovisual distraction in children with special healthcare needs during dental
restorations: A randomized crossover clinical trial. International Journal of Paediatric
Dentistry, 28(1), 111-120. doi: 10.1111/ipd.12304
Barton, K., Nickerson, J., Higgins, T., & Williams, R. (2018). Pediatric anesthesia and
neurotoxicity: What the radiologist needs to know. Pediatric Radiology, 48(1), 31-36.
doi: 10.1007/s00247-017-3871-4
Burns-Nader, S., Joe, L., & Pinion, K. (2017). Computer tablet distraction reduces pain and
anxiety in pediatric burn patients undergoing hydrotherapy: A randomized trial. Burns
43(6), 1203-1211. doi:10.1016/j.burns.2017.02.015
Buchsbaum, J., McMullen, K., Douglas, J., Jackson, J., Simoneaux, R., Hines, M., . . . Johnstone,
P. (2013). Repetitive pediatric anesthesia in a non-hospital setting. International Journal
of Radiation Oncology, Biology, and Physics, 85(5), 1296-1300.
doi: 10.1016/j.ijrobp.2012.10.006
Chad, R., Emaan, S., & Jillian, O. (2018). Effect of virtual reality headset for pediatric fear and
pain distraction during immunization. Pain Management, 8(3), 175-179. doi:
10.2217/pmt2017-0040
Gårdling, J., Törnqvist, E., Månsson, M., & Hallström, I. (2017). Age-appropriate preparations
for children with cancer undergoing radiotherapy: A feasibility study. Journal of Child
Health Care, 21(4), 370-380. doi: 10.1177/1367493517727070

QUALITY ASSURANCE PROJECT

19

Garrocho-Rangel, A., Ibarra-Gutiérrez, E., Rosales-Bérber, M., Esquivel-Hernández, R.,
Esparza-Villalpando, V., & Pozos-Guillén, A. (2018). A video eyeglasses/earphones
system as distracting method during dental treatment in children: A crossover
randomized and controlled clinical trial. European Journal of Paediatric Dentistry, 19(1),
74-79. doi: 10.23804/ejpd.2018.19.01.14
Hiniker, S., Bush, K., Fowler, T., White, E., Rodriguez, S., Maxim, P., . . . Loo, B. (2017). Initial
clinical outcomes of audiovisual-assisted therapeutic ambience in radiation therapy
(AVATAR). Practical Radiation Oncology, 7(5), 311-318.
http://dx.doi.org/10.1016/j.prro.2017.01.007
Hua, Y., Qiu, R., Yao, W., Zhang, Q., & Chen, X. (2015). The Effect of Virtual Reality
Distraction on Pain Relief During Dressing Changes in Children with Chronic Wounds
on Lower Limbs. Pain Management Nursing., 16(5), 685-691.
doi:10.1016/j.pmn.2015.03.001.
Jeffs, D., Dorman, D., Brown, S., Files, A., Graves, T., Kirk, E., . . . Swearingen, C. (2014).
Effect of virtual reality on adolescent pain during burn wound care. Journal of Burn Care
& Research: Official Journal of the American Burn Association., 35(5), 395-408.
doi:10.1097/BCR.0000000000000019
Khadra, C., Ballard, A., Déry, J., Paquin, D., Fortin, J., Perreault, I., . . . LeMay, S. (2018).
Projector-based virtual reality dome environment for procedural pain and anxiety in
young children with burn injuries: A pilot study. Journal of Pain Research, 11, 343-353.
doi: 10.2147/JPR.S151084
Koller, D., & Goldman, R. (2012). Distraction techniques for children undergoing procedures: A

QUALITY ASSURANCE PROJECT

20

critical review of pediatric research. Journal of Pediatric Nursing., 27(6), 652-681.
doi:10.1016/j.pedn.2011.08.001
Latham, G., & Greenberg, R. (2010). Anesthetic considerations for the pediatric oncology
patient--part 3: Pain, cognitive dysfunction, and preoperative evaluation. Paediatric
Anaesthesia., 20(6), 479-489.
McMullen, K., Hanson, T., Bratton, J., & Johnstone, P. (2015). Parameters of anesthesia/sedation
in children receiving radiotherapy. Radiation Oncology 10(65). doi:10.1186/s13014-0150363-2
Melnyk, B.M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and
healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Mizumoto, M., Oshiro, Y., Ayuzawa, K., Miyamoto, T., Okumura, T., Fukushima, T., . . .
Sakurai, Hideyuki. (2015). Preparation of pediatric patients for treatment with proton
beam therapy. Radiotherapy and Oncology., 114(2), 245-248.
http://dx.doi.org/10.1016/j.radonc.2015.01.007
Sterni, L., Beck, S., Cole, J., Carlson, D., & Turmelle. M. (2008). A Model for Pediatric
Sedation Centers Using Pharmacologic Sedation for Successful Completion of
Radiologic and Procedural Studies. Journal of Radiology Nursing, 27(2), 46-60. doi:
10.1016/j.jradnu.2008.01.004
National Institute of Health. (2017). Childhood Cancer Facts [website]. Retrieved from:
https://www.cancer.gov/types/childhood-cancers/child-adolescent-cancers-fact-sheet#q1
Uffman, J., Tumin, D., Raman, V., Thung, A., Adler, B., & Tobias, J. (2017). MRI Utilization
and the Associated Use of Sedation and Anesthesia in a Pediatric ACO. Journal of the
American College of Radiology, 14(7), 924-930.

QUALITY ASSURANCE PROJECT

21

http://dx.doi.org/10.1016/j.jacr.2017.01.025
Verma, V., Beethe, A., LeRiger, M., Kulkarni, R., Zhang, M., & Lin, C. (2016). Anesthesia
complications of pediatric radiation therapy. Practical Radiation Oncology, 6(3), 143154. http://dx.doi.org/10.1016/j.prro.2015.10.018

Appendix A

QUALITY ASSURANCE PROJECT

22
Synthesis Table

Studies

LOE

Bagattoni Burns- Chad
Nader
2017
2017
2018
RCT
RCT
Pilot
Study
II
II
III

Age

5-10 y

4-12y

Gender
Number of
Participants
Virtual Reality
Distraction
Intervention
Audiovisual
distraction
Intervention
Pharmacological
Intervention
Wound
Dressing
Changes/ Burn
Treatment
Radiation
Treatment
Dental
Procedures
Length of
treatment
Heart Rate
Anxiety
Modified Smith
Scale
Procedure
Behavior Check
List
McMurtry
children’s fear
scale
Frankl

x
48

x
30

Year
Design

Garrocho- Hiniker Hua Jeffs
Rangel
2018
2017
2015 2014
RCT
Pilot
RCS RCT
Study
II
III
II
II

6-17y 5-8y
17

x
40

3-12y
x
23

x
x

x

x

x

x

416y

1017y

65

30

x

x

Khadra Koller
2018
Pilot
Study
III

2012
SCR

2mo10y

0mo19y
x
1632

x

x

x

x

I

x

x

x

x

x

x

x
x

x

x

x

x

x

x
x

x

x
x
x

x
x

x

QUALITY ASSURANCE PROJECT
Behavioural
rating Scale
Spielberger’s
State-Trait
Anxiety
Inventory for
Children
Pain
Wong Baker
Faces Scale
FLACC
Adolescent
Pediatric Pain
Tool
Visual Analogue
Scale
Nurse’s Reports
Children’s
Emotional
Manifestation
Scale (CEMS)
Pulse
Rate/Oxygen
Saturation
CCLS

23

x

x

x
x

x

x
x

x
x
x

x

x
x

x
x

x
x

x

x

x

QUALITY ASSURANCE PROJECT

24

Appendix B
Erickson’s Modeling and Role Modeling Theory

QUALITY ASSURANCE PROJECT

25
Appendix C

Evidence Based Practice Change

Running head: QUALITY ASSURANCE PROJECT

26

Appendix D
Descriptive Analysis Table

Baseline

End of Tx

Tx Time (x̅)

43 (s.d.=17.54) minutes

32.75 (s.d=6.99) minutes

Tx Time (range)

22-64 minutes

25 – 42 minutes

Heart
Rate (x̅)

102 (s.d+19.67) bpm

101 (s.d.= 11.90) bpm

Heart Rate (range)

73-116 bpm

83-108 bpm

Anxiety (n=2) Scores (x̅)

7.5 (s.d.= 6.36) points

Lost to follow up

Anxiety
(n=2) Score (range)

3 – 12 points

Lost to follow up

Worry (n=2)
Scores (x̅)

7.5 (s.d.= 6.36) points

Lost to follow up

QUALITY ASSURANCE PROJECT
Worry (n=2)
Scores (range)

27
3 – 12 points

Lost to follow up

QUALITY ASSURANCE PROJECT

28
Appendix E

Treatment Time of Patient Number 4 from Beginning to End

Appointment Duration (min) Over Time Patient 4
90
80

Appointment Duration (min)

70
60
50
Series4

40

Linear (Series4)

30
R² = 0.1637

20
10
0

0

5

10

15

20

Fraction Number

25

30

35