Procedural Distraction in the Paediatric ED: Time for Virtual Reality? (info/references from talk at CSG meeting)

During my six months working in the paediatric emergency department, I’ve noticed that the vast majority of young children are petrified of needles.

A huge amount is at stake when a child requires an intravenous cannula. If the procedure is unsuccessful:

  • It increases the time prior to administration of treatment (like IV antibiotics).
  • It means subjecting the child to another dose of pain during the second attempt. That prospect could make them agitated and even more difficult to cannulate the second time. Repeated failures could mean a procedural sedation or intraossesous access is required. Potentially risky stuff.
  • It’s time-consuming for staff. This is expensive and potentially dangerous as staff are unable to be elsewhere in a busy department.
  • Particularly harrowing experiences might lead to crippling needle phobia or PTSD. This could be problematic for future hospital visits, particularly if the child turns out to have a chronic illness like diabetes..

During intravenous cannulation (or any other painful procedure in the ED), the gold standard includes the services of a play specialist working together with a parent +/- an iPad/handheld electronic device. However, if the child catches a glimpse of the needle, it doesn’t matter how expertly the child is being distracted – it tends to be game over and brute force is usually required. Experiencing this happen on repeat for 6 months has led me to my lightbulb moment: Virtual reality as a means of procedural distraction in the paediatric ED.

Here is my idea for a small RCT…

PICO

Population
Patients in the paediatric ED requiring IV cannulation between the ages of 6-16

Intervention
Interactive virtual reality experience delivered via Samsung Gear VR head-mounted-display and earphones.

Comparison
Standard of care. This would include the presence of a parent, play specialist, and iPad.

Outcomes
Self-reported pain scoring (primary outcome)

Parent-reported pain scoring
play specialist-reported pain scoring
Length of procedure
Number of procedural attempts
Patient/parent/operator satisfaction

We are also considering a concurrent qualitative study of patient experiences of IV cannulation with and without VR.

PonderMed Podcast with Dr. Grimes, “The VR Doctor”

Evidence for procedural distraction

Uman, L. S., Chambers, C. T., McGrath, P. J., & Kisely, S. (2008). A systematic review of randomized controlled trials examining psychological interventions for needle-related procedural pain and distress in children and adolescents: An abbreviated Cochrane review. Journal of Pediatric Psychology, 33, 842–854.

Oliveira NCAC, Gaspardo CM, Linhares MBM. Pain and distress outcomes in infants and children: a systematic review. Braz J Med Biol Res. 2017 Jul 3;50(7):e5984.

Miller K, Tan X, Hobson AD, Khan A, Ziviani J, OʼBrien E, Barua K, McBride CA, Kimble RM. A Prospective Randomized Controlled Trial of Nonpharmacological Pain Management During Intravenous Cannulation in a Pediatric Emergency Department: Pediatric Emergency Care. July 2016 – Volume 32 – Issue 7 – p 444–451.

Moadad N, Kozman K, Shahine R, Ohanian S, Badr LK.Distraction Using the BUZZY for Children During an IV Insertion. J Pediatr Nurs. 2016 Jan-Feb;31(1):64-72.

Evidence for VR and procedural distraction

Gold J. I., Mahrer N. E. Is Virtual Reality Ready for Prime Time in the Medical Space? A Randomized Control Trial of Pediatric Virtual Reality for Acute Procedural Pain Management. J Pediatr Psychol. 2017 Oct 19. (See video above for more info on this study)

Gold, J. I., Kim, S. H., Kant, A. J., Joseph, M. H., & Rizzo, A. S. (2006). Effectiveness of virtual reality for paediatric pain distraction during IV placement. CyberPsychology and Behavior, 9, 207–212.

Gold J. I., Reger G., & Rizzo A. A., et al. Virtual reality in outpatient phlebotomy: evaluating pediatric pain distraction during blood draw. Presented at the 10th Annual Poster Session of the Saban Research Institute. Los Angeles: Children’s Hospital Los Angeles; The Journal of Pain 6(3), Supplement, Page S57, March 2005.

Hua, Y., Qiu, R., Yao, W. Y., Zhang, Q., & Chen, X. L. (2015). The effect of virtual reality distraction on pain relief during dressing changes in children with chronic wounds on lower limbs. Pain Management Nursing, 16, 685–691.

Hoffman, H. G., Patterson, D. R., Seibel, E., Soltani, M., Jewett-Leahy, L., & Sharar, S. R. (2008). Virtual reality pain control during burn wound debridement in the hydrotank. The Clinical Journal of Pain, 24, 299–304.

Das, D. A., Grimmer, K. A., Sparnon, A. L., McRae, S. E., & Thomas, B. H. (2005). The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries: a randomized controlled trial [ISRCTN87413556]. BMC Pediatrics, 5, 1.

Project Team (so far)

Dr. Robert Lloyd (@PonderingEM)
Dr. Keith Grimes (@keithgrimes)
Dr. Graham Johnson
Dr. Andrew Tabner (@andrewtabner)

Please don’t hesitate to get in contact for more information about the project. Email me at ponderingem@gmail.com.

Best,
Robert Lloyd
@PonderingEM

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PonderMed #2: Professor Tony Young, NHS innovator-in-chief


Want more of Professor Young?

Twitter – @DrTonyYoung

LinkedIn – linkedin.com/in/drtonyyoung

The MedTech Campus

The Clinical Entrepreneur Programme

Links to key talking points from the podcast

Professor Simon Carley’s blog explaining the ‘learning choreographer’ concept

The new Anglia Ruskin Medical School

Black Box Thinking by Matthew Syed

Healthcare Safety Investigation Branch

FutureNova

Proximie

NHS Innovation Accelerator

Academic Health Science Networks

DigitalHealth.London

‘The Man in the Arena’ by Theodore Roosevelt

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

Until next time.

Robert Lloyd
@PonderingEM

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PonderMed #1: Keith Grimes “The VR Doctor”


Want more of Dr. Grimes?

Find him on twitter – @keithgrimes

Read his blog

Listen to his ‘Curistica’ podcast

Join his VR Facebook community – ‘VR Doctors’

The ‘5 ways’ of using VR in healthcare

  1. Procedural distraction
  2. Novel therapeutic modality
    An evidence-base is building in chronic pain management, and watch this space for Keith’s ‘PREVENT ITU DELIRIUM‘ research.
  3. Novel diagnostic modality
    A great example is Vitae VR – dementia screening in the form of a virtual trip to the supermarket.
  4. Education and training
    The Medical Realities Platform, founded by Shafi Ahmed (@ShafiAhmed5), is providing 360° video VR training to surgeons all over the world.
  5. Breaking down barriers and delivering new perspectives
    Nick Peres (@MoorOfALife), creator of patientvr.co.uk, is pioneering the use of VR to deliver immersive patient perspective in healthcare education.

Here is a Curistica podcast where Keith describes the ‘5 ways’ in detail, and another where he interviews Nick Peres.

Important links

The #DigitalHealth conversation

Tiko’s GP Group

Google Glass. Keith has blogged about how he has experimented with it in clinical practice.

Skip Rizzo’s work on VR as a therapy for PTSD

Howard Rose’s work on VR as a therapy for pain

Types of VR headsets – Samsung Gear VR, Google Cardboard, Oculus Rift 

The Clinical Entrepreneur Programme, led by NHS England Clinical Innovation Lead Tony Young (@TonyYoung)

The NHS Innovation Accelerator

Podcasts mentioned at the beginning of the show (as promised)

Clinical:

Non-clinical:

I hope you enjoyed Episode 1! Until next time.

Robert Lloyd
@PonderingEM

*credit to Ben Lloyd for podcast music, Alan Howard for podcast image, and Emilie Snaith for logo design

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