OBJECTIVES

Virtual reality (VR) therapy is growing in use and popularity during pediatric medical procedures. Currently, data that describe the hospital resources used during pediatric procedures with off-the-shelf VR games that are not tailored to medical procedures are lacking. In this study, we aimed to characterize procedural resources associated with VR use during venipuncture in a pediatric emergency department.

METHODS

This was a secondary analysis of a 2-arm randomized, controlled pilot trial with an external group. Resource use was evaluated in 3 groups: child life (CL)-supported VR engagement, CL support without VR, and a reference group that received no intervention (ie, no CL and no VR).

RESULTS

The study sample (N = 55) included the following: 15 patients randomly assigned to VR, 20 patients randomly assigned to CL, and 20 patients in the reference group. There was a significant difference in procedure duration, with the VR group exhibiting the longest duration compared with the CL and reference groups (P = .01).

CONCLUSIONS

Longer procedure times associated with VR use during venipunctures (4–6 minutes on average) may be attributed to pauses to troubleshoot VR games not tailored for medical procedures. Although they are inexpensive and accessible, nontailored VR games may warrant the need for dedicated staff to provide restraint and/or assistance to navigate the VR application. In this study, we offer a protocol on the application of nontailored VR games for pediatric procedures. For those considering a VR program in an inpatient setting, the benefits of pain/anxiety reduction must be weighed against the resources needed, including device costs, staff availability, and increased procedure duration.

Children’s venipunctures are among the most common painful procedures in pediatric emergency departments (PEDs).1  The optimal approach to minimize pain during these procedures is undetermined, and the standard of care varies across pediatric hospital units. Individuals who support children during procedures can include caregivers, clinical staff, or child life (CL) specialists. Supportive strategies may include guided calming techniques, distraction with toys, games, or electronics, or adjunct medications.

Recent research has revealed that virtual reality (VR) is a promising tool to reduce children’s pain and anxiety during venipuncture procedures.2,3  Despite the growing literature on the clinical efficacy of VR, a potential barrier to its widespread adoption is a paucity of information on resource use associated with VR. Some resource use information is available for specialty-designed VR programs (eg, procedural duration with VR and number of first needle successes).4,5  However, to our knowledge, in no previous investigation have these outcomes been examined with a commercially available VR headset and programs. In this study, we aimed to characterize procedural resources associated with VR use during venipuncture in the PED.

The study population included 55 children who were enrolled in a 2-arm randomized, controlled trial with an external group that evaluated coping during painful procedures in the PED (www.clinicaltrials.gov NCT03686176). The 3 study groups consisted of a CL-supported VR engagement group, a CL support without VR group, and a reference group that received no intervention (ie, no CL and no VR). The study was conducted in an academic, tertiary care PED. Recruitment occurred between June 2019 and March 2020 and was terminated because of institutional research guidelines during the coronavirus disease 2019 pandemic.

To participate, patients had to be 7 to 22 years old and undergoing a procedure in the PED. Procedures included the following: blood draw, intravenous line placement, burn debridement, laceration repair, abscess incision and drainage, fracture reduction and/or cast placement, and central venous line access. This secondary analysis describes resource use associated with venipuncture and thus includes the subgroup that received either blood draw or intravenous line placement. Children were excluded from participation if they had any severe developmental delays, seizures, blindness, trauma or infection on the head or face, altered mental status, medical urgency, or were non-English speakers. Patients were allocated into randomly assigned blocks of 2, 4, 6, and 8 (R version 3.2.2; R Foundation, Vienna, Austria), and stratified by procedure type. The randomization module was implemented through Research Electronic Data Capture6,7  by research assistants.

Over several weeks, before starting the study, the certified CL specialists and research assistants received training on VR through individual practice with the VR headset and during nonprocedural scenarios with patients. Children randomly assigned to the CL-supported VR condition (the VR group) played a preferred game(s) on a commercially available VR headset with CL support during their venipuncture procedure. Meanwhile, the active control group (the CL group) received CL support and distraction modalities on the basis of the CL specialist’s assessment and patient preference. The reference group received no standardized form of support. Children randomly assigned to VR wore disposable surgical caps and disposable, VR-shaped face shields for infection precautions. The VR headset and hand controllers were cleaned with disinfectant wipes between use. Before the start of the procedure, CL provided fitting of the VR headset and a brief orientation to the selected VR game. During venipuncture procedures, an independent evaluator coded characteristics and resource use outcomes: procedure duration, venipuncture success rates, use of physical restraints on patients, proceduralist-rated ease of procedure (range 0–10: 0 = easy, 10 = difficult), and CL-rated level of support (range 0–10: 0 = none, 10 = significant). The start of the procedure was defined as when the tourniquet was first placed, whereas the completion of the procedure was defined as when an adhesive dressing was placed after all venipuncture attempts. Demographic characteristics (age, sex, race, and ethnicity) were compared between groups by using analysis of variance and Fisher’s exact tests for continuous and categorical variables, respectively. Primary outcomes were compared in a similar fashion according to the intention-to-treat principle. CL support level between the groups was evaluated by using Student’s t test. All procedures were approved by the institution’s internal review board.

The final sample (N = 55) included the following: 15 patients randomly assigned to VR, 20 patients randomly assigned to CL, and 20 patients in the reference group. Demographic characteristics of age, sex, race, and ethnicity were well balanced between groups (P = .08, .72, .20, and .30, respectively). Mean (SD) ages for the VR, CL, and reference groups were 12.1 (3.5), 15.2 (4.0), and 15.5 (4.2), respectively. None of the venipuncture procedures were ultrasound guided. Table 1 summarizes the resource use outcomes between groups. There was a significant difference in procedure duration, with the VR group exhibiting the longest duration compared with the CL and reference groups (P = .01). Additionally, the VR group had more patients requiring restraint and proceduralists noted more difficulty. However, there were no other significant differences between the groups for venipuncture success, physical restraint use, ease of procedure, or level of CL support.

TABLE 1

Resource Use During Venipuncture

ReferenceCLVRTotalP
Patients, n (%) 20 (36.4) 20 (36.4) 15 (27.3) 55 (100) — 
Procedure duration, mean (SD), min 5.1 (5.0) 7.7 (5.5) 11.6 (7.0) — .01* 
Venipuncture success, n (%)      
 First attempt successful 17 (85.0) 16 (80.0) 13 (86.7) 46 (83.6) .91 
 2+ attempts 3 (15.0) 4 (20.0) 2 (13.3) 9 (16.4)  
Physical restraint or holding, n (%)      
 Required a restraint 0 (0.0) 2 (10.0) 3 (20.0) 5 (9.1) .12 
 No restraint 20 (100.0) 18 (90.0) 12 (80.0) 50 (91.9)  
Proceduralist-rated ease of procedure (score range: 0 [easy] to 10 [difficult]), mean (SD) 0.7 (1.3) 0.3 (0.7) 1.5 (2.8) — .11 
Level of CL support (score range: 0 [none] to 10 [significant]), mean (SD) — 2.1 (2.8) 2.9 (2.7) — .29 
ReferenceCLVRTotalP
Patients, n (%) 20 (36.4) 20 (36.4) 15 (27.3) 55 (100) — 
Procedure duration, mean (SD), min 5.1 (5.0) 7.7 (5.5) 11.6 (7.0) — .01* 
Venipuncture success, n (%)      
 First attempt successful 17 (85.0) 16 (80.0) 13 (86.7) 46 (83.6) .91 
 2+ attempts 3 (15.0) 4 (20.0) 2 (13.3) 9 (16.4)  
Physical restraint or holding, n (%)      
 Required a restraint 0 (0.0) 2 (10.0) 3 (20.0) 5 (9.1) .12 
 No restraint 20 (100.0) 18 (90.0) 12 (80.0) 50 (91.9)  
Proceduralist-rated ease of procedure (score range: 0 [easy] to 10 [difficult]), mean (SD) 0.7 (1.3) 0.3 (0.7) 1.5 (2.8) — .11 
Level of CL support (score range: 0 [none] to 10 [significant]), mean (SD) — 2.1 (2.8) 2.9 (2.7) — .29 

—, not applicable.

*

P <.05.

Children who used VR during venipunctures had significantly longer procedure times, by 4 to 6 minutes on average, compared with the CL and reference groups. Longer procedure duration with VR may likely be attributed to nurses or technicians pausing to ensure VR functionality in a game that was not tailored to a needle-based procedure. Tailored VR games might include visual or auditory cues that correspond to the procedure, or gameplay that limits patient motion (eg, animation that simulates light touch might correspond with the skin-cleansing step of venipuncture; a VR scenario with a limited field of view can discourage head movement). There were instances in which procedures were briefly paused to assist in navigating VR games or menus, provide guidance on VR hand controller functions, or to change VR games midprocedure. By comparison, VR games that are tailored to medical procedures may have minimal to no menus, lack hand controllers, or lack game options, which will, in turn, minimize the need for technical assistance. The increased procedure time found in our study is in contrast to data from previous studies conducted in various pediatric settings (PED, outpatient clinic, postanesthesia care unit), which revealed no difference in pediatric procedure duration with VR games designed specifically for medical procedures.4,5,8  Although there was no statistically significant difference in the number of patients requiring restraint, a greater proportion of children needed prompts to remain still because of immersion and active engagement in VR gameplay. Similarly, CL specialists described providing more verbal coaching to children to navigate the VR applications.

In the inpatient setting, VR has been successfully applied to children and adolescents during burn wound care,9,10  physical therapy,11  and sickle cell pain.12  However, these studies offer limited to no descriptions of staffing needs, restraint of undesired movement, or procedure duration. Whereas pediatric patients appear to benefit from VR through reduced pain and anxiety during venipuncture,4,13,14  several considerations must be taken into account for adoption in the hospital setting. Specifically, pediatric hospital units should anticipate a potential increase in procedure duration by several minutes. Consideration must also be given to staff availability (eg, CL) for observation of a patient’s tolerance of VR and troubleshooting of technical difficulties. Selection of games must also take in to account the need for limited head and/or hand movements.

The main limitation included a relatively small sample size because the current study was not powered to detect differences in resource use. Despite this limitation, this study offers preliminary data and insights into the implementation of a commercial VR headset within a clinical workflow. Another limitation is the lack of control for factors that can influence venipuncture success and/or duration, such as the proceduralist’s experience level, patient hydration status, etc. Although there is a possibility of unbalanced distribution of these factors, the randomization of the study design would be expected to address this possible bias.

At the time of this writing, the cost of an off-the-shelf VR headset ranges from $299 to $699 (plus $0–$29 per game), whereas medical therapeutic VR systems are upwards of $3000/y and include VR experiences tailored to medical settings plus training and customer support. Given this substantial price difference, it is worthwhile for pediatric hospitals to weigh the potential benefits of VR against the costs and resources needed to facilitate its use. Whereas commercially available VR headsets are relatively inexpensive, these findings suggest that nontailored VR games may be associated with a slight increase in procedure duration and the need for dedicated staff to provide restraint and/or assistance to navigate the VR application.

We thank Anna Biddle, Patrice Brylske, and Peyton Hutchins.

Dr Canares participated in conceptualization, methodology, investigation, resources, data curation, interpretation of analysis, writing the original draft, reviewing and editing, visualization, and funding acquisition; Drs Parrish and McGuire participated in conceptualization, methodology, interpretation of analysis, reviewing and editing, supervision, and funding acquisition; Ms Stewart participated in conceptualization, methodology, investigation, resources, interpretation of analysis, reviewing and editing, and funding acquisition; Dr Kleinman participated in conceptualization, methodology, interpretation of analysis, reviewing and editing, and funding acquisition; Ms Santos participated in methodology, investigation, data curation, interpretation of analysis, writing the original draft, reviewing and editing, visualization, and project management; Dr Psoter participated in methodology, formal analysis, interpretation of analysis, and reviewing and editing; Ms Badawi participated in formal analysis, investigation, data curation, interpretation of analysis, writing the original draft, reviewing and editing, visualization, and project administration; and all authors approved the final manuscript as submitted.

This trial has been registered at www.clinicaltrials.gov (identifier NCT03686176).

The study’s data are available on request.

FUNDING: Supported by the Thomas Wilson Foundation, Baltimore, Maryland. The funder or sponsor did not participate in the work.

1.
Shave
K
,
Ali
S
,
Scott
SD
,
Hartling
L
.
Procedural pain in children: a qualitative study of caregiver experiences and information needs
.
BMC Pediatr
.
2018
;
18
(
1
):
324
2.
Gold
JI
,
Mahrer
NE
.
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
.
2018
;
43
(
3
):
266
275
3.
Dumoulin
S
,
Bouchard
S
,
Ellis
J
, et al
.
A randomized controlled trial on the use of virtual reality for needle-related procedures in children and adolescents in the emergency department
.
Games Health J
.
2019
;
8
(
4
):
285
293
4.
Chan
E
,
Hovenden
M
,
Ramage
E
, et al
.
Virtual reality for pediatric needle procedural pain: two randomized clinical trials
.
J Pediatr
.
2019
;
209
:
160
167.e4
5.
Walther-Larsen
S
,
Petersen
T
,
Friis
SM
,
Aagaard
G
,
Drivenes
B
,
Opstrup
P
.
Immersive virtual reality for pediatric procedural pain: a randomized clinical trial
.
Hosp Pediatr
.
2019
;
9
(
7
):
501
507
6.
Harris
PA
,
Taylor
R
,
Minor
BL
, et al
;
REDCap Consortium
.
The REDCap consortium: building an international community of software platform partners
.
J Biomed Inform
.
2019
;
95
:
103208
7.
Harris
PA
,
Taylor
R
,
Thielke
R
,
Payne
J
,
Gonzalez
N
,
Conde
JG
.
Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support
.
J Biomed Inform
.
2009
;
42
(
2
):
377
381
8.
Jeffs
D
,
Dorman
D
,
Brown
S
, et al
.
Effect of virtual reality on adolescent pain during burn wound care
.
J Burn Care Res
.
2014
;
35
(
5
):
395
408
9.
Hua
Y
,
Qiu
R
,
Yao
WY
,
Zhang
Q
,
Chen
XL
.
The effect of virtual reality distraction on pain relief during dressing changes in children with chronic wounds on lower limbs
.
Pain Manag Nurs
.
2015
;
16
(
5
):
685
691
10.
Hoffman
HG
,
Rodriguez
RA
,
Gonzalez
M
, et al
.
Immersive virtual reality as an adjunctive non-opioid analgesic for pre-dominantly Latin American children with large severe burn wounds during burn wound cleaning in the intensive care unit: a pilot study
.
Front Hum Neurosci
.
2019
;
13
:
262
11.
Soltani
M
,
Drever
SA
,
Hoffman
HG
, et al
.
Virtual reality analgesia for burn joint flexibility: a randomized controlled trial
.
Rehabil Psychol
.
2018
;
63
(
4
):
487
494
12.
Agrawal
AK
,
Robertson
S
,
Litwin
L
, et al
.
Virtual reality as complementary pain therapy in hospitalized patients with sickle cell disease
.
Pediatr Blood Cancer
.
2019
;
66
(
2
):
e27525
13.
Piskorz
J
,
Czub
M
.
Effectiveness of a virtual reality intervention to minimize pediatric stress and pain intensity during venipuncture
.
J Spec Pediatr Nurs
.
2018
;
23
(
1
):
e12201
14.
Gold
JI
,
Kim
SH
,
Kant
AJ
,
Joseph
MH
,
Rizzo
AS
.
Effectiveness of virtual reality for pediatric pain distraction during i.v. placement
.
Cyberpsychol Behav
.
2006
;
9
(
2
):
207
212

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.