Creation and Assessment of a Pilot Program for Child Life Specialist-focused Voiding Cystogram
Diana K. Bowen, MD, Jennifer Puntillo, BS, CCLS, Ilina Rosoklija, MPH, Emilie K. Johnson, MD, MPH, Ellen C. Benya, MD, Martha Saker, MD, Cynthia Rigsby, MD, Earl Y. Cheng, MD.
Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA.
BACKGROUND: Cystography remains an anxiety-provoking test for both parents and children. Sedation is often used in complex cases, however, the ideal process has yet to be defined. This study aims to improve completion rates and patient/parent satisfaction with sedated cystography by redesigning the process to focus on child life specialist (CLS)-assessments for sedation and pre-procedural counseling.
METHODS: Stakeholder meetings were held to identify problems with sedated cystography at our institution (Figure 1), and process redesign was implemented. Indications for the new CLS-focused voiding cystogram (VCUG) or contrast-enhanced voiding urosonography (CeVUS) protocol included prior traumatic catheterization or cystography, anxiety of parent and/or child, or anticipated difficulty or discomfort with the test. All patients underwent pre-procedure phone screen with CLS who administered a validated risk questionnaire (PRAP) to assess patient coping skills, and educated parents regarding the procedure. On the day of cystogram, pre- and post-procedure parent survey was administered by the CLS, assessing the domains of coping, anxiety, understanding, and expectations. Domains were graded on 4-point scale with higher scores indicating a better understanding and ability to cope by the child. Open ended questions regarding the experience and potential for improvement were also included in the post-survey. Sedation with midazolam was utilized for patients as determined by CLS and pre-procedure assessment. A retrospective analysis was performed on all patients who underwent CLS-focused cystogram with or without midazolam. Data was analyzed using descriptive statistics, logistic regression, and paired T-test.RESULTS: 70 patients completed the new cystography protocol with pre-procedure PRAP assessment and of those, 63/70 (90%) parents completed pre- and post-procedure surveys. Median patient age was 5 years [interquartile range 3,7], and 71% were female. Forty percent had an indication of past traumatic VCUG or catheterization. All but one patient successfully completed testing. Overall, 44/70 (63%) patients received midazolam in addition to CLS support. Patients with a higher PRAP risk score were more likely to receive midazolam (OR 2.24 [95% CI 0.7-5.2]). There was a significant increase in survey score from pre-to post-procedure of 3.8 +/- 2.3 points (95% CI 3.1-4.4; p< 0.005). Parents identified the pre-procedure phone call and presence of CLS at the test as the most important factors for success. CONCLUSIONS: Process redesign for urography testing with a focus on CLS involvement and pre-procedural preparation has yielded encouraging results on interim analysis. Patients at high risk for failure nearly universally completed testing, including nearly 1 in 3 who did not require oral sedation. 
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