Background

The number of MRI requests is constantly increasing, especially for paediatrics. This can be a challenging patient group, frequently with additional needs. Younger children are often scanned under general anaesthetic (GA), which comes with associated risks and additional costs. Attending hospital can be traumatic for not only the patient, but also for the parents/carers due to the unfamiliar environment, equipment, and new people. We are developing and implementing alternative methods to reduce the need for a GA in MRI, in turn, saving money and improving the patient experience.

Play Therapy

Play therapy uses a mixed method approach to make hospital appointments fun. Play Specialists build a rapport with the patient whilst explaining the scanning process and the importance of cooperation. Each session is tailored to the patient, different patients require varying amounts of support and reassurance. A simple explanation is given, including the need to lie down, stay still, noise levels and time frame. They can see a screen/DVD through a mirror and hear audio through headphones.
Play therapy has previously been used to prepare some children for their GA-MRI. With enough time, preparation and support, it is possible for children to have MRI scans awake. After reviewing the Paediatric MRI pathway and liaising with the children’s hospital, a successful bid was made to a local hospital charity to fund a full-time play specialist for 12-months.
A pilot of eight children was successfully performed with seven completing their scan with diagnostic images. One had to return for a GA-MRI due to noise sensitivity. After this positive outcome, we began booking one Play Therapy List (6-8 patients) per week.
Initially, children aged 3-12years were selected for non-contrast scans, which was then expanded slightly for older children with additional needs, and for certain younger well-behaved children. We now also scan those who require contrast, thus including a significantly larger proportion of those on the waiting list.
When suitable patients are identified, the parents/carers are called to explain this new service and to discuss whether their child may be able to have an awake scan. Each appointment has additional time for preparation with the play specialists and bookings are overlapped so one can be scanned whilst another is being prepped.
Protocols are adapted, minimising the number of sequences; the most important scanned first, and the noisiest last. Motion controlled sequences are used where possible.
Additionally, we have a child-friendly colourful, fun waiting-area, a Kitten Scanner and a screen with DVD-player in the scan room. All are invaluable resources for the Play Specialists.

Analysis

The first seven months were analysed for success, out of 181 children, 10 had to return for a GA-MRI due to movement, noise sensitivity or not tolerating the scanner/coils. An additional three did not attend. The majority were between 3-13yrs old, and one 2yr old and a 1yr-8month old. The two youngest patients were both successful.
The acquired images were assessed for diagnostic quality and scan reports reviewed for comments on motion artefact. 2% were undiagnostic, 5% were heavily degraded-but still diagnostic, 4% moderate and 17% mild. 72% had no noteworthy motion artefact showing the success of this new pathway.
Future work will include analysing the data in more depth to include more detailed feedback from children/parents/carers, reduction levels of waiting lists, and any difficulties the play specialists have.
Difficulties included limited scanner capacity and a lack of both Play Specialists and Radiographers, leading to only one list per week. Additionally, children noticing parents’ anxieties was observed requiring additional preparation time for some parents. Delays due to difficult cannulations and waiting for clinicians to attend to give contrast.

Teaching Point

Play Therapy is not a new concept within healthcare, but with funding from charities and support through the play specialist team, setting up this new service has been extremely beneficial within the MRI department. Focussing on not only the patient experience, but also the experience of the parent/carer has led to increased attendance rates and a more positive overall outcome for all involved.
With no relative risk when compared to a GA-MRI, less trauma/stress for the children, and 98% of successful scans being diagnostic, this new service is highly advantageous. The Trust also benefitted from fewer GA 's; money is saved due to specialist equipment and staff not being needed, and waiting lists being reduced faster.
Whilst the role of the Radiographer during these scans has not changed significantly, involvement with play specialists has helped to develop our own practice through improved communication and interpersonal skills. Observing and assisting the play specialists has highlighted alternative techniques which can be adopted when scanning paediatrics at other times. The ability to adapt our approach to each individual patient is essential for providing the best care possible.

Conclusion

Play Therapy has been an excellent addition to the options available for paediatric patients needing an MRI scan. Not only is it safer for the child, less traumatic and occasionally enjoyable, it is a more pleasant and less stressful time for the parents. A relatively simple service to implement, it is cheaper and has helped to reduce the paediatric waiting-list considerably; allowing those who need a GA-MRI to have this sooner.

Acknowledgements

With thanks to the Trust Play Specialist Team, local hospital's charities, and Working to Achieve value and Excellence Team for their help and support.

References

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