Case Study #3: Comfort Zone Program--Pediatric Stress Management

Figure 1. MADdy the Blowfish pediatric mucosal atomization deviceEMERGENCY DEPARTMENT SETTING:

  • Dedicated pediatric facility in large Texas city
  • Level I Trauma Center
  • Over 75,000 annual ED visits
  • 45 ED rooms


  • Children find ED visits very stressful
  • Pain does not build character, but creates fear of doctors and hospitals
  • 69% of children experience painful events that meet DSM criteria for emotional trauma while hospitalized, and 22% meet DSM criteria for PTSD
  • Create a team approach to address pain, anxiety, and discomfort associated with the treatment of pediatric patients in the emergency setting
  • Provide comforting interventions that minimize children’s fear and discomfort
  • Increase pain management awareness via education, protocols, and attitude changes
  • Although there were many new approaches being used across the U.S. to provide this type of care in a pediatric setting, no single site had yet assimilated all such approaches and technology into one program


  • Commitment to Family Centered Care (FCC)
  • Utilization of Child Life Specialists (distraction toys and tools to help alleviate anxiety and stress)
  • Non-Pharmacologic Therapies
  • Cognitive-behavioral
  • Physical
  • Pain education materials for the ED staff, centered on pain perception, recognition and treatment for children
  • Pain scoring systems implemented at triage, and a formal pain treatment protocol
  • Multiple types of topical anesthetics for wound care and IV starts
  • Comfort Positioning
    • Allow child to sit up instead of lie down
    • Involve family member to enhance support for the child
    • Prepare child and parent for procedure
    • Identify “coach” to help relax/distract and validate child’s feelings
    • Encourage a “one-voice” approach to minimize over-stimulation
    • Provide encouragement, positive reinforcement, and choices
    • Use available resources, such as Child Life Specialist and “comfort kits”
  • Non-threatening nasal sprays to provide potent pain relief and mild sedation without the need for an IV
  • For the first time in the hospital’s area, the administration of nitrous oxide (laughing gas) outside of the operating room
  • Use of moderate sedation in the ED for the most uncomfortable procedures:
    • Intranasal Fentanyl
    • Intranasal Versed
    • Combination


  • Implementation of the Comfort Zone pain management protocol significantly reduced pediatric patients’ memory of pain during the ED visit, as measured at discharge (Table 1).
  • Although not statistically significant, results trended positively for parents’ recollection of their child’s pain being reduced during the ED visit, and for both patients’ and parents’ assessment of pain at discharge
  • The Comfort Zone created a more compassionate way to treat children in the ED, and can improve patient perceptions and simplify care.
  • Findings published in American Journal of Emergency Medicine.
  • Patient satisfaction scores for pain control improved dramatically, reaching as high as the 97th percentile (among more than 300 hospitals nationwide).

Table 1. Pediatric Pain Management with Comfort Zone

Pediatric self-report
face scales
Without Comfort Zone
Mean (CI)
With Comfort Zone
Mean (CI)
Before Visit 6.77 (6.46-7.09) 6.47 (6.01-6.94) .414
During Visit 5.07 (4.76-5.39) 4.01 (3.64-4.39) <.001
After Visit 1.99 (1.74-2.24) 1.56 (1.29-1.83) .092