Ed – At the SMACC conference our good friend and simulation guru Jesse Spurr 1 talked about virtual reality as a future technique for education and for therapy. It’s an area that we’ve not really seen in practice (yet) and so it was really interesting to see this paper published so soon after the conference.
That takes us back to this week and thinking about children in the ED. Procedures in children – particularly venepuncture and cannulation – are tricky. It’s very easy to get into a spiral of paediatric distress, parental anxiety and personal stress that seems to predict procedural failure. Much of this occurs because children are scared, they’re irrational (at least by most adult standards), and the fact that they are even in the Emergency Department has been preceded by an illness or injury – a stressful event in itself.
That said, it is in our interests to make things as smooth as possible, particularly when it comes to procedures. Having a bad procedural experience tends to predict future difficulties, so that investment of time in preparation to make things go as smoothly as possible is not time wasted. This is one of my favourite rants – you can read more in this earlier blog post 2 about procedures and this one 3 about paediatric pain.
So, when I spotted this paper on the use of Virtual Reality (VR) for distraction during painful procedures 4, I was very interested. As always, please take the time to read the paper yourself – it’s open access so there’s no excuse!
What is this paper about?
This is a paper from Melbourne, in Victoria, Australia. The authors wanted to see if VR could provide better distraction than standard distraction techniques employed during needle-based painful procedures. To answer this question, they recruited paediatric patients requiring venepuncture or IV cannulation from two settings (the ED and pathology) and randomised them to either VR or standard of care.
In this case, standard of care still involved some distraction techniques – which is fair, as the study is not looking at distraction as a single entity but specifically the benefits of interactive VR. Use of electronic screens, toys and/or books was classed as standard of care. The interactive VR in question was an aquatic environment in which the child could elicit a “visual effect” by looking directly at virtual fish.
What did they do?
Subjects were “opportunistically identified”, which I took to mean a convenience sample. They included children aged 4-11 years, with a requirement for venepuncture or cannulation, with sufficient English language skills to be able to provide comments and feedback. Exclusions included critical illness or deteriorating state, along with medical conditions precluding VR use (presumably epilepsy falls into this group).
Parents/carers gave consent while all participating children gave assent – a nice touch not often seen in paediatric papers but vital in giving children agency over what happens to them – powerlessness being a significant distress factor.
Computerised random-number generation was used for randomisation in a 1:1 ratio, with the ED and pathology populations handled entirely separately. Again, this seems appropriate as they are potentially quite different settings with differing urgency and perceptions surrounding them.
The authors state that “blinding was not feasible” – I suppose to be completely fair, they could have used VR headsets without the VR displaying, however this wouldn’t really have been standard of care as other methods of distraction could not have been concurrently employed – so it’s hard to see how else they could have explored the effectiveness of VR separately in a blinded fashion.
For outcomes, they powered the study around a primary outcome of change in baseline pain between VR and standard of care using the Faces Pain Scale-Revised (FPS-R) 5. This is similar to the Wong-Baker Faces Scale but rather than 0-5 (Wong-Baker) it runs from 0-10. It is a validated tool, which is important, but I’m always a little wary of such subjective tools as a primary outcome. Of course, pain is subjective, and it’s hard to think of a more useful or reliable alternative primary outcome, particularly when we don’t necessarily expect the VR to make the procedure faster or easier, just to make the whole experience less unpleasant and traumatic for the child – but that’s not necessarily all about pain. Something to ponder, perhaps.
What did they find?
Recruitment occurred over 7 months and involved randomisation of 123 subjects from ED (59 to standard of care, 64 to VR) and 131 from pathology (68 to standard of care, 63 to VR). Two of the pathology patients withdrew assent after randomisation to the standard of care group, but even with these patients excluded the authors had achieved a sample size of more than 114 in each setting.
Interestingly, most of the ED patients were for cannulation (100, vs 23 for venepuncture) while all of the pathology patients were for venepuncture. Most of the patients in both standard of care groups had some sort of alternative distraction therapy (73% in ED, 86% in pathology).
In both groups, the authors found that VR decreased pain from baseline in the ED and demonstrated a smaller increase in pain from baseline in pathology, compared to standard of care, as shown below;
ED: Standard of Care: +0.39 (95% confidence interval -0.67 to 1.45)
ED: VR: -1.39 (95% confidence interval -2.42 to -0.36)
Pathology: Standard of Care: +2.76 (95% confidence interval 1.79 to 3.72)
Pathology: VR: +1.37 (95% confidence interval 0.50 to 2.23)
In fact, the results suggest that in the ED, VR actively reduced pain from baseline whereas in all other circumstances the procedure increased pain despite distraction with VR or other methods. This is interesting and a little unexpected; I would have thought the rather more stressful environment in the ED might have predicted an increase in pain in both groups more akin to that seen in pathology, but perhaps there are other factors at play here that we are struggling to capture. When we look at table 3 in more detail, there doesn’t seem to be much difference between ED and pathology in number of needle attempts, number of people restraining the child, or in caregiver’s distress rating – so there’s no explanation here as yet. Another one to ponder, perhaps.
The authors collected a lot of other data, all of which is interesting but as the study was powered around the primary outcome of change from baseline pain this is really where we should focus.
What is especially interesting is the qualitative data; contained in table 5, there are a number of comments and reflections from the patients themselves, their carers and those undertaking the procedure, addressing the usefulness of VR for distraction, reduction of pain and reduction of distress, the usefulness of VR in keeping the child still and calm, and suggestions for improvement. There’s quite a spectrum of responses and, although most are positive about the VR experience from all three perspectives, it’s interesting how differently things are perceived. For example, a couple of carers commented that the VR blocking the child’s view of the needle made them more calm, while others felt that being able to see and understand what was happening was more helpful to their child.
What does it all mean?
This is by no means a definitive study but it does provide some evidence that VR could be a useful (albeit likely expensive) addition to our distraction arsenal, improving paediatric patient experience in ED. It contains some nice reminders about giving the child as much control and agency as we can (encouraging them to assent to participation and perhaps to give them the option of seeing the needle versus being completely distracted) and is almost worth reading for these dimensions alone.
Christmas is coming (well… isn’t it always?) so on the offchance your hospital has a charity looking for tangible and evidence-based ways to improve patient experience in the ED, this is a nice little example you could use. It might not be as useful as several new beds and a load of additional nursing staff, though…
- 1.Brazil V, Spurr J. Simulation Podcast. Simulcast. http://simulationpodcast.com/. Published 2017. Accessed 2019.
- 2.May N. It’s not OK. St Emlyn’s. https://www.stemlynsblog.org/its-not-ok/. Published 2017. Accessed 2019.
- 3.May N. Paediatric Pain and Sedation. St Emlyn’s. https://www.stemlynsblog.org/paediatric-pain-and-sedation/. Published 2015. Accessed 2019.
- 4.Chan E, Hovenden M, Ramage E, et al. Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials. The Journal of Pediatrics. June 2019:160-167.e4. doi:10.1016/j.jpeds.2019.02.034
- 5.IASP I. Faces Pain Scale. International Association for the Study of Pain. https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1519. Published 2001. Accessed 2019.