P2.276: Implementing atraumatic needles for LPs: Enhancing pediatric patient safety and practice compliance, a quality improvement initiative

Purpose/Objectives: Lumbar punctures (LPs) are routine in pediatrics, with post-dural puncture headache (PDPH) the most common complication. Evidence strongly supports atraumatic needles in reducing PDPH and other post-dural complications. However, hospitalists at a large academic quaternary children’s hospital historically did not use atraumatic needles and had higher-than-anticipated PDPH rates (17.6%). This Quality Improvement Project (QIP) aimed to increase atraumatic needle utilization for pediatric hospital medicine patients to reduce PDPH incidence.

Design/Methods: A structured, multi-disciplinary QI initiative used evidence-based interventions, iterative Plan-Do-Study-Act cycles, and stakeholder engagement. A retrospective chart review assessed needle type and complication rates, including required treatment, before QIP implementation. Run charts tracked outcome, process, and balancing measures in twice-monthly increments. Special cause variation was assessed using IHI rules. A pre-posttest design evaluated changes in outcome and balancing measures. Measures were selected based on current evidence to provide real-time data supporting practice change.

Results: Between April 16, 2023, and October 15, 2023, hospitalists performed 68 LPs, with only 1 (1.5%) using an atraumatic needle. PDPH incidence was 17.6%. During the same period in 2024, 65 LPs were performed, with 25 (38.5%) using an atraumatic needle, reducing PDPH to 9.2% (Figures 1 & 2).
The project exceeded its PDPH reduction aim, but special cause variation was not met per IHI guidelines. Pre-post QIP PDPH comparison was not statistically significant X2 (1, N = 133) = 2.01, p = .156, with post-hoc power at 32.5%. However, Fisher’s exact test confirmed a significant association between atraumatic needle use and PDPH reduction (p = .015).
Complications requiring treatment declined modestly from 23.5% to 21.5%, though not statistically significant. Self-perceived competence and confidence could not be evaluated due to low survey response (1/97 pre-surveys, 5 post; no matched pairs).
Atraumatic needle use significantly increased from 1.5% to 38.5% post-QIP, X2 (1, N = 133) = 28.91, p < .001. Provider education goals were exceeded, with 99% of hospitalists and 100% of pediatric residents receiving instruction.
Balancing measures—including mean attempts, failed LPs, and traumatic LPs—remained unchanged, with no special cause variation.

Conclusion/Discussion: Targeted education, streamlined ordering, and improved access significantly increased atraumatic needle adoption. An internal instructional video from an early adopter appeared more effective than external resources. While survey fatigue limited formal assessment of confidence, behavioral data indicated sustained practice change.
Treatment types shifted, suggesting reduced severity of complications. Pre-QIP treatments included fluid boluses, Toradol, blood patches, opioids, caffeine, and NSAIDs; post-QIP, only Toradol and NSAIDs were used.
No negative effects were observed in balancing measures, reinforcing atraumatic needle use as a safe and effective intervention. The significant association between atraumatic needle use and PDPH reduction supports broader implementation across service lines.