BACKGROUND:The infrequent occurrence of resuscitating critically ill pediatric patients poses educational challenges for pediatric anesthesiology residents developing competence. Traditional medical simulations, despite their utility, incur significant costs due to the need for monitors, mannequins, and personnel. Augmented reality (AR) medical simulation shows promise as an alternative clinical teaching tool. The Technology Acceptance Model (TAM) assesses usefulness, ease of use, and attitudes toward new technologies, offering insights into their adoption. Following successful application with other healthcare innovations, the TAM can also assess innovations in pediatric anesthesiology resident education, including AR medical simulation. AIMS:The primary aim identified factors that influenced acceptance of AR for medical simulation in pediatric anesthesiology using a TAM. The secondary aims assessed the model's reliability, usability, and ergonomics. METHODS:This prospective, multi-site study was carried out across nine academic children's hospitals around the United States and Hong Kong. We recruited anesthesiology residents with a minimum of two weeks of pediatric anesthesia experience, excluding those with severe motion sickness, seizures, or who wore corrective glasses. Using Magic Leap 1 headsets, participants underwent a simulated AR pediatric resuscitation scenario. Data were collected via electronic surveys, evaluating TAM factors, usability (System Usability Scale), and ergonomics (ISO 9241-400 standard). RESULTS:A total of 101 participants completed the study. The AR TAM model indicated that perceived ease of use and computer self-efficacy predicted perceived usefulness. Behavioral intention to use the AR system was influenced by perceived usefulness and perceived ease of use. System usability scores showed 83% agreement on ease of use. Ergonomic assessments indicated minimal physical discomfort. CONCLUSION:AR simulations are highly acceptable and usable for pediatric resuscitation training, with perceived ease of use and computer self-efficacy influencing AR adoption. These findings align with previous TAM studies, supporting AR's potential to supplement traditional simulations and enhance accessibility.

Simulation is evolving to include immersive technologies and artificial intelligence which provide adaptive, highly realistic and engaging learning experiences. These pedagogical tools will reshape the boundaries of simulation curriculum to provide educational experiences that foster unique scenarios beyond cardiac arrest and resuscitation skills training. For instance, extended reality simulations combined with artificial intelligence can provide challenging, humanities-based topics related to ethics, and enhance empathy through embodiment experiences, and navigate difficult conversations with compassion. In addition, unlike traditional mannikin based simulations, technology enhanced simulations have numerous advantages including asynchronous, highly adaptive learning experiences, that can be used in resource limited institutions and can conform to various cultures, languages, and customizable scenarios. This editorial explores the advantages of augmented reality and artificial intelligence simulation and shares a vision for a renewed focus on human-centered medical education.

Increased stress, anxiety, and depression hinder recovery of hospitalized patients. Mindfulness therapies, which adopt a holistic approach to patient care, reduce anxiety, and depression. This quality improvement initiative evaluated the implementation of a virtual reality (VR) therapeutic art program at Stanford Health Care from February to June 2024, providing an innovative and scalable adjunct to traditional art and music mindfulness therapies. This mixed methods project piloted 84 cumulative hours with 105 participants. Outcomes investigated satisfaction and the impact on hospitalization experience via survey questions. Data were analyzed using descriptive statistics and thematic analysis. Results (n = 40) indicated substantial improvements in patient experience, with 85% recommending the program and 97.5% reporting positive impacts from VR engagement. Thematic analysis of open-ended survey responses identified 4 key themes: escape and distraction, therapeutic benefits, enjoyment of the interactive activity, and positive facilitator interactions. Participants also expressed interest in additional VR offerings, including virtual mindfulness, and meditation. The results suggest that VR can serve as an effective adjunct to conventional mindfulness therapies and improve the inpatient experience.

BACKGROUND:Pediatric obesity is associated with increased morbidity. One common therapy within multicomponent treatment for obesity is nutrition counselling and dietary education led by a Registered Dietitian (RD). Virtual reality (VR) improves engagement when used as an educational adjunct. METHODS:The primary aim investigated immediate dietary choices when pediatric patients with obesity engaged in traditional RD nutrition counselling compared to VR-supplemented nutrition counselling. Secondary aims explored food likability, knowledge, and satisfaction. Patients, 6-20 years old, presenting for obesity counselling were recruited. The primary aim was measured by after-visit food choice. Secondary aims were measured with the Pediatric Adapted Liking Scale, an assessment of nutritional facts, and a VR satisfaction survey. Statistical analysis included Chi-square, Wilcoxon and t-tests. RESULTS:Forty participants were enroled and divided into two groups described above. There were no differences in food choice (p = 0.90). Regarding likability, the VR group liked vegetables more than those in the standard of care group (p = 0.045). CONCLUSION:There were no differences in nutritional knowledge (p = 0.574). Participants in the VR group reported high satisfaction.

INTRODUCTION:Despite advancements in pharmacological and non-pharmacological strategies, pain and anxiety during needle-related procedures affect most patients. Through activation of large diameter nerve fibers, vibration therapy has been proposed to alleviate pain by minimizing perception of concomitant painful stimuli. This study investigated the effectiveness of a Bluetooth-enabled haptic device (BHD) in reducing pain sensitivity and improving patient satisfaction during needle procedures. Given the frequency of vascular access procedures, from IV catheter placements to phlebotomy, improving patient experience during these encounters is essential. Non-pharmacologic tools like the BHD may enhance vascular access by improving patient cooperation and reducing procedure-related distress. METHODS:This was a prospective crossover study conducted at an academic hospital in Northern California. Participants included healthy adults with no history of chronic pain, who underwent a series of pinprick stimuli and different vibration patterns (A, B, C, and D) applied by the BHD. The primary outcome investigated mechanical pain sensitivity, and secondary outcomes explored mechanical pain threshold and satisfaction. Mechanical pain sensitivity was assessed using numerical pain ratings, while pain threshold and satisfaction were measured through standardized thresholds and survey responses, respectively. Data were analyzed using mixed-effect linear and logistic regression models. RESULTS:A total of 199 participants were enrolled. All vibration patterns reduced perceived pain compared to the control condition, with Pattern D achieving the greatest reduction (p < 0.001). Regarding mechanical pain threshold, Pattern A increased the odds of pain detection (odds ratio: 1.63, p = 0.019), while other patterns showed no differences. Approximately 77% of participants recommended the BHD. DISCUSSION:The BHD reduced procedural pain, supporting use of vibration therapy as a non-pharmacological strategy to improve patient comfort during needle procedures. Future studies should explore vibration patterns with clinical procedures and assess the device's impact across diverse populations.

Background:Traditional medical simulations leverage stressful scenarios to potentiate memory. Augmented reality (AR) simulations provide cost-effective experiences using holograms instead of mannequins. This study investigated the physiologic response to AR simulations. Methods:This was a noninferiority, controlled trial at an academic, pediatric hospital in Northern California among health care workers randomized to AR or traditional, in situ medical simulations. The primary outcome investigated parasympathetic tone. Biometric sensors assessed parasympathetic tone as respiratory sinus arrhythmia (RSA). A difference in RSA of less than 10% between groups was considered noninferior. Secondary outcomes explored usability, ergonomics, satisfaction, and recall with the System Usability Scale (SUS), ISO 9241-400, Simulation Design Scale (SDS), and an electronic questionnaire 5 months after the intervention, respectively. Results:A total of 111 participants were enrolled and 106 analyzed. Both groups experienced a decrease in mean RSA from baseline to during the simulation (P < .001 for both groups). Subsequently, there was an increase in RSA from the simulation period to the recovery period (P < .001 for the AR group and P = .035 for the traditional group). Regarding secondary outcomes, the mean SUS score of 70.5 suggested good usability, 65.38% of AR participants reported feeling comfortable using the headset, and satisfaction in both groups was similar except for differences in use of real-life factors. The recall assessment was completed by 12 AR and 15 traditional participants, with similar scores between the 2 groups (P = .4). Conclusions:AR simulations produced a noninferior change in parasympathetic tone compared with traditional simulations. Future investigations may explore the effectiveness of AR simulations for developing nontechnical skills during remote training. (Registration: Clinical Trials Registry NCT05674188.).

STUDY OBJECTIVE:Virtual reality (VR) is an emerging technology increasingly used to ameliorate acute and chronic pain although controlled, quantifiable data are limited. The purpose of this study is to evaluate VR's effect on heat pain threshold (HPT), pressure pain threshold (PPT), immediate pain and anxiety, and recalled pain and anxiety. DESIGN:Prospective, randomized, crossover clinical trial. SETTING:The Stanford Chariot Program conducted this study at the Stanford School of Medicine Health System. PATIENTS:Healthy participants meeting inclusion criteria were recruited by solicitation from the Stanford School of Medicine Health System. INTERVENTIONS:Participants were randomized by hand dominance and condition sequence and underwent standardized pain threshold tests with a thermode or an algometer during VR and control conditions. MEASUREMENTS:Pain threshold, numeric pain scores, and anxiety scores were immediately recorded. Recalled pain and anxiety scores were recorded 24 h later. MAIN RESULTS:A total of 80 participants were included, 40 who underwent HPT testing and 40 who underwent PPT testing. VR increased pain thresholds for both HPT (P = 0.002) and PPT (P = 0.044). The use of VR resulted in no difference in initial pain scores for HPT (P = 0.432) or PPT (P = 0.24). There was no difference in recalled pain when using VR for HPT (P = 0.851) although there was for PPT (P = 0.003). Initial and recalled anxiety scores for HPT (P = 0.006, P = 0.018, respectively) and PPT (P = 0.014, P = 0.002, respectively) were all reduced when using VR. CONCLUSIONS:This study demonstrates that VR increased pain thresholds while modulating initial and recalled experiences with anxiety, which has implications for enhancing patient experiences during medical interventions and long-term health outcomes by optimizing memories during stressful events. CLINICAL TRIAL REGISTRATION:NCT05836649, 4/19/23. IRB registration: Stanford IRB #69330.

Background: Anxiety is common in pediatric patients, especially during vascular access procedures. Most well-studied affect and anxiety scales, including the Observation Scale of Behavioral Distress-Revised (OSBD-r), the modified Yale Preoperative Anxiety Scale (mYPAS), and the modified Induction Compliance Checklist (mICC), are too cumbersome for clinical use outside of research settings. HRAD +/- (Happy, Relaxed, Anxious, Distressed with yes/no to cooperation) is a clinically-efficient observational scale that evaluates pediatric procedural affect and cooperation. This study examined the clinical utility of HRAD +/- during vascular access procedures in children. The aims were to investigate the correlation of HRAD +/- to highly reliable, research-based affect and cooperation scales and to assess inter-rater reliability (IRR) between observers in this setting. Methods: This was a prospective, observational study conducted at Lucile Packard Children's Hospital Stanford. Inpatient participants were 1 month to 25 years old and undergoing a peripheral intravenous insertion or phlebotomy. Two trained research assistants (RAs) scored each patient independently during the vascular access procedure using HRAD +/-, OSBD-r, mYPAS, and mICC. Correlation analyses computed the associations between HRAD +/- and reference scales. IRR between RAs and vascular access providers was calculated using Fleiss' Kappa. Results: A total of 234 patients were included. HRAD +/- scores strongly correlated with OSBD-r and mYPAS (p < 0.0001, p < 0.0001, respectively). The cooperation assessment of HRAD +/- demonstrated strong correlation to mICC (p < 0.0001). IRR of HRAD +/- between research assistants and vascular access providers showed moderate agreement (p < 0.0001). Conclusion: HRAD +/- demonstrated strong correlation to the reference affect and cooperation scales. This study supports the utility of HRAD +/- for rapid assessment of pediatric procedural anxiety and cooperation during vascular access procedures. HRAD +/- can serve as a practical tool for facilitating clinical decisions, and its wider incorporation into healthcare settings would importantly guide targeted interventions to reduce patient anxiety.

Background Virtual reality (VR) is a novel tool with demonstrated applications within healthcare; however its integration within clinical practice has been slow. Adoption patterns can be evaluated using a technology acceptance model (TAM).The primary study aim was to use VR TAM to assess factors that influence anesthesiologists' acceptance of VR for preoperative anxiolysis. The secondary aim assessed the model's reliability. Methods 109 clinical anesthesiologists at Stanford were exposed to a VR application developed as a distraction tool to reduce preoperative patient anxiety. Anesthesiologists were surveyed about their attitudes, beliefs, and behaviors as predictors of their likelihood to clinically use VR. The primary outcome assessed predictive validity using descriptive statistics, construct validity using confirmatory factor analysis, and standardized estimates of model relationships. The secondary outcome assessed reliability with Cronbach's α and composite reliability. Results Construct validity and reliability was assessed, where all values established acceptable fit and reliability. Hypothesized predictors of consumer use were evaluated with standardized estimates, looking at perceptions of usefulness, ease of use, and enjoyment in predicting attitudes and intentions toward using and purchasing. Past use and price willing to pay did not predict perceived usefulness. Participants in lower age ranges had higher levels of perceived ease of use than those >55 years. Conclusion All confirmatory factor analysis testing for construct validity had good fit. Perceptions of usefulness and enjoyment predicted an anesthesiologist's attitude toward using and intention to purchase, while perceived ease of use predicted perceived usefulness and enjoyment, attitude toward purchasing and using, and intention to use. Past use and price willing to pay did not influence perceptions of usefulness. Lower age predicted greater perceived ease of use. All scales in the model demonstrated acceptable reliability. With good validity and reliability, the VR-TAM model demonstrated factors predictive of anesthesiologist's intentions to integrate VR into clinical settings.

Medical simulations bridge theory and practice in immersive settings. During this unique form of education, learners experience challenging medical scenarios without risking patient harm. The effectiveness of simulations stem from their ability to induce autonomic stress responses, which potentiate memory formation. Educators have adopted virtual reality (VR) and augmented reality (AR) to supplement traditional, mannequin-based simulations. In this Pro-Con commentary article, we discuss the competitive advantages and limitations of VR and AR simulation for medical training. VR uses computer-generated images (CGI) within head-mounted displays (HMDs) to enhance learning. Gamification of medical procedures in VR improves acquisition of complex skills, positioning VR simulation as a pivotal training tool. Participant embodiment while in VR develops non-technical skills such as improved communication and enhanced empathy. The placement of participants within CGI worlds that would otherwise be difficult or impossible to recreate situate VR as the ideal next step in simulation evolution. VR is superior to AR given its lower hardware costs, expansive software libraries, and complete immersion in CGI compared to limited holographic fields of view within AR. By displaying holograms within the participant's natural world, AR is primed to replace screen and VR technologies as the premier learning adjunct. The integration of real-world instruments with AR holograms provides innumerable methods for teaching procedural skills. In addition, AR enhances pre- and intra-operative planning by overlaying holographic, radiographic patient images over their own bodies. Because AR has the unique feature of maintaining direct eye contact between participants, scenarios that improve communication skills are easily created with holograms in the real world, eliminating the need for an entirely CGI VR environment. Immersive simulation efforts should skip the costs of creating VR scenarios and redirect efforts to developing AR simulation software. Although both VR and AR have limitations related to cost and ergonomics, immersive technologies are relatively more affordable and versatile than traditional mannequins and physical simulation centers. As adjuncts to enhance traditional simulation curricula, we advocate for continued research to demonstrate the validity and utility of these immersive technologies.

Background: Virtual reality (VR) technologies have demonstrated therapeutic usefulness across a variety of health care settings. However, graduate medical education (GME) trainee perspectives on VR acceptability and usability are limited. The behavioral intentions of GME trainees with regard to VR as an anxiolytic tool have not been characterized through a theoretical framework of technology adoption. Objective: The primary aim of this study was to apply a hybrid Technology Acceptance Model (TAM) and a United Theory of Acceptance and Use of Technology (UTAUT) model to evaluate factors that predict the behavioral intentions of GME trainees to use VR for patient anxiolysis. The secondary aim was to assess the reliability of the TAM-UTAUT. Methods: Participants were surveyed in June 2023. GME trainees participated in a VR experience used to reduce perioperative anxiety. Participants then completed a survey evaluating demographics, perceptions, attitudes, environmental factors, and behavioral intentions that influence the adoption of new technologies. Results: In total, 202 of 1540 GME trainees participated. Only 198 participants were included in the final analysis (12.9% participation rate). Perceptions of usefulness, ease of use, and enjoyment; social influence; and facilitating conditions predicted intention to use VR. Age, past use, price willing to pay, and curiosity were less strong predictors of intention to use. All confirmatory factor analysis models demonstrated a good fit. All domain measurements demonstrated acceptable reliability. Conclusions: This TAM-UTAUT demonstrated validity and reliability for predicting the behavioral intentions of GME trainees to use VR as a therapeutic anxiolytic in clinical practice. Social influence and facilitating conditions are modifiable factors that present opportunities to advance VR adoption, such as fostering exposure to new technologies and offering relevant training and social encouragement. Future investigations should study the model's reliability within specialties in different geographic locations.

Pediatric patients and their caregivers often experience perioperative anxiety. Interventions reduce caregiver anxiety improve cooperation and contribute to an improved patient experience. This study seeks to evaluate the efficacy of virtual reality (VR)-assisted mindfulness on perioperative caregiver anxiety. Participants were randomized into a standard of care (SOC) group, which included snacks but no technology-based distractions, or a VR group, which included snacks and a VR-guided meditation. Caregiver anxiety was measured before and after the intervention using the Visual Analogue Scale for Anxiety (VAS-A). Secondary aims explored participants’ baseline anxiety with the State-Trait Anxiety Inventory (STAI). VR group participants completed a satisfaction survey. Linear regression models of VAS-A and STAI were used to compare group differences. Satisfaction survey results were reported with descriptive statistics. 26 participants were included, with 12 randomized to the SOC group and 14 to the VR group. VAS-A scores in the VR group were lower than those in the SOC group ( p = .002). The STAI found no change in participants’ state of anxiety in the SOC group ( p = .7108), compared to a significant reduction ( p = .014) in the VR group when controlling for anxiety traits. 12 of 14 caregivers in the VR group expressed satisfaction or strong satisfaction. This study supports the implementation of VR mindfulness as a method to reduce caregiver anxiety. VR use in the pediatric healthcare setting is safe and inexpensive, and the intervention had a high degree of participant satisfaction.

Background: In the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids . In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children. Methods: A retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia. Results: A total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non -binary, 7 were male, and 32 were male to female. 58 % had private insurance. Most common diagnosis was precocious puberty (54 %) followed by gender dysphoria (46 %). Most common procedure was implant placement (72 %). 69 % of procedures were performed in the clinic and 31 % in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded. Conclusion: VR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting. Level of Evidence: 4 (c) 2024 Elsevier Inc. All rights reserved.

Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC ( P = .457). Zero percent had ED with AR versus 0.7% with SOC ( P = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention.

Study objective: HRAD +/- was developed to quickly assess pediatric perioperative affect and cooperation. HRAD +/- represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to investigate the clinical utility of HRAD +/- as an affect and cooperation assessment tool for inhalational mask induction. Secondary aims examined inter-rater reliability (IRR) of HRAD +/- and predictive validity of induction HRAD +/- with emergence delirium. Design: This was a prospective observational investigation. Setting: We conducted this investigation at Lucile Packard Children's Hospital Stanford, an academic, quaternary care children's hospital in Northern California. Patients: A total of 197 patients were included in this investigation. Children 1-14 years of age, who underwent daytime procedures with inhalational induction of anesthesia and American Society of Anesthesiologists physical status I-III were eligible. Interventions: During mask induction, two trained research assistants (RAs) independently scored the patient's affect and cooperation. After extubation, the same investigators observed the patient's emergence. Measurements: RAs scored each mask induction using the following scales: HRAD +/-, modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC). Correlations were calculated to HRAD +/-. IRR of HRAD +/- between the RAs as well as predictive validity of HRAD +/- to Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales were calculated. Main results: HRAD +/- scores strongly correlated with mYPAS (r = 0.840, p < 0.0001) with moderate correlation to OSBD (r = 0.685, p < 0.0001) and ICC (-0.663, p < 0.0001). IRR was moderate for the affect and cooperation portion of the HRAD +/- scale, respectively (kappa = 0.595 [p < 0.0001], kappa = 0.478 [p < 0.0001]). A weak correlation was observed with PAED (r = 0.134 [p = 0.0597]) vs HRAD +/-. No correlations were observed between Watcha (r = 0.013 [p = 0.8559]) and Cravero and HRAD +/- scales (r = 0.002 [p = 0.9767]). Conclusions: HRAD +/- is a clinically useful and simple scale for evaluating pediatric affect and cooperation during inhalational mask induction. Results demonstrate correlation with commonly utilized research assessment scales.

Background Immersive technology provides adjuncts for pediatric care. However, accessibility and inadequate training limit implementation of this technology. Standardized instruction with no-cost software licensing may improve health care professionals’ facility with immersive technologies. Objective This descriptive feasibility study aimed to examine the applications of immersive technologies in pediatric health care, including virtual reality (VR) and projectors. Methods We developed immersive technology instructional guides for pediatric health care. The training guides were created for multiple software content and hardware types across several clinical scenarios. Content was available in print and digital versions. The primary outcome was technology use across sites with no-cost software agreements. The secondary outcome was the specific application types used at a single site, stratified by sessions and minutes. Data were analyzed using descriptive statistics. Results Data were collected from 19 licensed sites from January through June 2022. Among the 19 sites, 32% (n=6) used 10 or more VR units. Among the 6 sites that had projectors, half used 5 or more units. The mean minutes of use per month of all sites combined was 2199 (IQR 51-1058). Three sites had more than 10,000 minutes of total use during the 6-month review period. Secondary results indicated that active VR (977 total sessions) and passive projector streaming (1261 total sessions) were the most popular application types by session, while active projector (66,849 total minutes) and passive projector streaming (32,711 total minutes) were the most popular types when stratified by minutes of use. The active VR application with the most minutes of use was an application often used in physical therapy. Conclusions Context-specific technological instruction coupled to no-cost licenses may increase access to immersive technology in pediatric health care settings.