Little Journey: using virtual reality to prepare children for surgery Dr Chris Evans UCL PhD Student (Supervisor: Dr Ramani Moonesinghe) Bloomsbury Innovation group Fellow NHS England Clinical Entrepreneur Fellow Founder of Little Sparks
Aims 1 Peri-operative anxiety 2 Issues with information 3 Little Journey app 2
1 Peri-operative anxiety 2 Issues with information 3 Little Journey app 3
Paediatric Peri-operative anxiety 500,000 elective day-cases per annum in UK Sury MR, Palmer JH, Cook TM, Pandit JJ. The state of UK anaesthesia: a survey of National Health Service activity in 2013. Br J Anaesth 2014; 113: 575-84. Post-hospital behavioural symptoms Recent audit at UCLH found this to be 67% (Significant anxiety as deemed by gold standard observational tool) 50-75% experience anxiety 18% agitation Poor wound healing Increased painkiller requirements Delayed recovery Kain Z, Mayes L, O'connor T, Cicchetti D Preoperative anxiety in children. Archives of Paediatric & Adolescent medicine 1996; 150: 1238-45. Short-term effects Long-term effects Bed wetting Nightmares Separation anxiety Poor appetite Poor focus/attention 50% at 2 weeks 20% at 6 months 8% at 1 year 4
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Anxiety response YOU THREAT Psychology 6
Negative Behaviour 7
1 Peri-operative anxiety 2 Issues with information 3 Little Journey app 8
Issues with information: Peri-operative Information Aim to change behaviour Volume of information Timing of information Format Patient choice Evidence based information Family involvement 9
What are trying to achieve? 10
Anxiety What are we trying to achieve? Induction of anaesthesia Preparation (trait anxiety) Distraction (state anxiety) Time 11
Coping Emotion-focused coping Distraction Disengagement Coping Mental imagery/rehearsal Problem-focused coping Modelling Peer-observation Desensitisation 12
Anxiety What information to give? Pediatric Anesthesia 2010 20: 318 322 doi:10.1111/ j.1460-9592.2010.03263.x Perioperative anxiety in children M I CH EL L E A. FORTI ER Ph D *, A N TON I O M. D EL ROSA RI O BS, SA RA H R. M A RTI N MA*AN D Z EEV N. K A I N MD, MBA * *Department of Anesthesiology and Perioperative Care, University of California-Irvi ne, Department of Pediatric Psychology, Children s Hospital of Orange County, Indiana University School of Medicine and Department of Pediatrics, Children s Hospital of Orange County, Orange, CA, USA Section Editor: Per-Arne Lonnqvist Arrival Summary Objectives & Aim: The purpose of this investigation w as to examine children s anxiety across the perioperative setting. Background: A lthough several studies have examined preoperative anxiety in children, few researchers have illustrat ed perioperative anxiety; that is, anxiety in children throughout the pre and postoperative continuum. M ethods: Participants w ere 261 children ages 2 12. Anxiety w as rated prior to surgery, immediately after surgery, and for 2 w eeks at home Induction follow ing surgery. Results: Low child sociabil ity and high parent anxiety predicted perioperative anxiety. Perioperative anxiety w as related to postoperative pain and negative postoperative behavioral change. Conclusions: Identifi cation and prevention of anxiety in children can help prevent negativ e outcomes follow ing surgery. Time Recovery 13
How to give it? 14
Behaviour change B= behaviour P= person E= environment 15
Peri-operative information Pre-operative information Intra-operative information Post-operative information 16
Timing of information 17
Prepare the Family unit Advance Program 18
EBP Evidence Based Practice Patient values and preferences 19
RCT vs Co-design 20
Patient Choice/Control Weeks Written Text Subjective Patient values and preferences Information Monitor Information Blunter Objective Pictures/video Days 21
1 Peri-operative anxiety 2 Issues with information 3 Little Journey app 22
Virtual Reality A computer generated three dimensional environment with which a user can interact Author Study Type Country of origin Numbers Intervention Bekelis et al RCT (single-site) US 127 VR preparation tool Mosso et al RCT (single-site) Mexico 21 VR intraoperatively Robertson et al RCT (single-site) Australia 60 VR in holding bay Vazquez et al Case series Mexico 22 VR post-operatively in ITU 24
Little Journey 27
Proposed randomised controlled trial Hypothesis: The use of a virtual reality pre-hospital preparatory tool in children aged 3-12 years of age, can reduce peri-operative anxiety in ambulatory surgery. Population Intervention Comparison Outcomes Children aged 3-12 years of age undergoing ambulatory surgery. Requiring general anaesthetic for dental surgery 1 st GA ASA I-III Little Journey app provided at pre-assessment clinic with virtual reality headset to use at home personalised to each participating centre Standard care (including use of play specialists) Primary Outcome: Modified Yale Peri-operative Anxiety Scale Secondary Outcomes: Parental anxiety, Compliance with induction, Emergence delirium, In app analytics and post-hospital behavioural changes. 28
Key features Preparation through play Easily scalable Sustainable Simple content management system Tailored to patients & hospitals Done in own home/time Low-cost 29
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Summary Co-design Provide patient choice Collaborate Information issues Engage family 31
Acknowledgements: UCLH Charity Bloomsbury Innovation Group Laura Henry Studios Entopia NHS Digital Victoria Kelly (Behavioural Psychologist) Sophie Copley Thank you Any questions? chris@littlespark s hospital.com @Little_hospital @dr_chrisevans