The Impact of Virtual Reality on the Patients and Providers Experience in Wide-Awake, Local-Only Hand Surgery

Abstract

Purpose

Virtual reality (VR) is an emerging technology with the potential to enhance patient care by reducing pain and anxiety for a variety of medical procedures. The aim of this study was to evaluate an immersive VR program as a nonpharmacologic intervention to reduce anxiety and increase satisfaction in patients undergoing wide-awake, local-only hand surgery. The secondary aim was to assess providers’ experience with the program.

Methods

An implementation evaluation was employed to assess the experience of 22 patients who used VR during outpatient, wide-awake hand surgery at a veterans affairs hospital. We assessed the patients’ anxiety scores and vital signs before and after the procedure as well as postprocedural satisfaction measures. The providers’ experience was also assessed.

Results

Patients who used VR exhibited lower anxiety scores after the procedure compared with what they exhibited before the procedure and had high satisfaction levels with their VR experience. Surgeons who used the system reported that VR improved their ability to teach learners and better focus on the procedure.

Conclusions

Virtual reality, as a nonpharmacologic intervention, reduced anxiety and contributed to the patients’ perioperative satisfaction with wide-awake, local-only hand surgery. As a secondary finding, VR positively impacted the providers’ experience by increasing their ability to concentrate on tasks during the surgery.

Clinical relevance

Virtual reality represents a novel technology that can reduce anxiety and contribute to a positive experience for both patients and providers during wide-awake, local-only hand procedures.

Virtual reality (VR) is an advanced technology that allows users to immerse themselves in a computer-generated environment that may include auditory, 3-dimensional visual, and, sometimes, tactile or olfactory stimuli.¹ It was originally developed for military training and as an entertainment tool.^2,3 Over the last 2 decades, VR has been explored as a resource to enhance patient care in the medical setting as a distraction therapy for pain and anxiety.⁴ Humans have finite attentional resources; therefore, it is believed that distracting them with a task leaves less cognitive capacity for processing negative emotions and stimuli. Virtual reality has been effective as a distraction technique in a variety of wide-awake procedures, including chemotherapy administration, needle sticks, burn care, cutaneous procedures, and dentistry.5, 6, 7, 8

Wide-awake, local-only upper-extremity surgery has become increasingly popular to reduce costs and increase efficiency in minor hand procedures, such as carpal tunnel and trigger finger releases.^9,10 The use of local-only anesthesia reduces risk by avoiding sedation and facilitates more rapid discharge after the procedure.10, 11, 12 Our Veterans Affairs Healthcare System (VAHCS) hospital offers a range of hand and upper-extremity surgical interventions. In addition to the main operating room, a minor procedure room is available for cases that can be performed without sedation. These nonsedation surgeries include carpal tunnel release, trigger finger release, and small-mass excisions and are completed with local anesthesia only. However, some providers and patients are not comfortable with the idea of wide-awake surgery. For example, patients may have anxiety about potential pain despite procedures being generally painless after local anesthetic infiltration. Providers who are accustomed to sedated patients may also have the additional cognitive burden of interacting with awake and potentially nervous patients while performing procedures.

The veteran population is unique and has a greater likelihood of posttraumatic stress disorder and anxiety, which may be exacerbated in stressful situations such as the hospital setting.¹³ Furthermore, increased anxiety may increase the perception of pain and decrease patient satisfaction.¹³ The use of immersive VR as a distraction therapy in the clinical setting has the potential to have a substantial impact on this patient population. Recent literature has suggested a benefit of the use of VR during wide-awake hand surgery in reducing patient anxiety and improving patients’ experience.14, 15, 16 However, further work is indicated to better understand this technology in different patient populations and settings as well as understand its impact on providers and clinical workflow. This study sought to assess whether immersive VR could decrease patient anxiety in veterans and what impact it had on both patients’ and providers’ experience during wide-awake, local-only hand surgery in a minor procedure room at a VAHCS hospital.

Methods

Patients presenting for a minor hand surgery at our VAHCS hospital between December 2021 and February 2022 were offered the use of VR during their procedure. All consecutive patients presenting for wide-awake local-only hand surgery in the minor procedure room during this time period were offered the use of the technology. The purpose of the project was explained to the patients at the time of check-in for their procedure, and they were given the opportunity to participate. They were also given the option to decline and listen to music instead if they preferred. The exclusion criteria included patients with vertigo, motion sickness, or claustrophobia. The patients were reminded that they could request to discontinue use at any time during the procedure. This study received a Determination of Non-Research from our institutional review board and was exempted from review. There were no ethical concerns.

The first intervention consisted of the AppliedVR’s SootheVRx content platform on the Pico G2 4k head-mounted display (HMD), which offered the participants several potential virtual environments to choose from. However, the multiple options, user orientation, and setup resulted in clinical workflow delays and were, therefore, abandoned prior to initiation of data collection.

Then, the WayaHealth procedural-specific content platform was trialed. The WayaHealth headset used in our study was provided to the VAHCS at no cost because it was completed in collaboration with the national-level Veterans Health Administration Collaborative Research and Development Agreement. This HMD required no setup and consisted of a single, preloaded environment selected by the company, which immersed the patients in a virtual transparent geodesic dome with forested horizon, sky, Northern Lights, and soothing, drowsiness-inducing music. This is a passive program, meaning the patient does not interact with the VR environment. The HMD was placed on the patient’s head as their operative extremity was prepared per standard surgical protocol (Fig.). The HMD was sanitized and charged between each patient’s use.

Figure.

VR setup during the procedure.

The participants completed a standardized questionnaire in the procedure room both before and after the procedure. This included demographics and a standardized anxiety score: the State-Trait Anxiety Inventory Scale-5 question form (Table 1). The State-Trait Anxiety Inventory Scale-5 is a widely used tool to measure anxiety and has demonstrated high degrees of sensitivity and validity for the evaluation of anxiety in the clinical, procedural setting.17, 18, 19 Items are rated on a 4-point scale from “not at all” to “very much,” with a maximum score of 20 for the highest levels of anxiety in the short, 5-question form. The patients’ vital signs, which consisted of heart rate and blood pressure, were also recorded immediately before and after the procedure. The Student paired t test was used to assess changes before and after the procedure. Statistical significance was set at an alpha of 0.05.

Table 1.

State-Trait Anxiety Inventory Scale-5

Item No.	Statements	Not At All	Somewhat	Moderately So	Very Much So
1	I feel upset	1	2	3	4
2	I feel frightened	1	2	3	4
3	I feel nervous	1	2	3	4
4	I am jittery	1	2	3	4
5	I feel confused	1	2	3	4

After the VR-enabled procedure, an additional patient questionnaire that was created for this study, consisting of a 5-point Likert scale (with 1 being the lowest and 5 the highest) using the following 3 questions, was administered: “how satisfied were you with the VR experience,” “how likely would you be to use VR in a future procedure,” and “did the use of VR change your perception of the VA?” Additionally, the patients were asked to provide any narrative feedback about their experience. After completion of the data collection period, an additional survey was sent to the 5 hand surgeons who performed the cases for narrative feedback about their experience with the project.

Results

A total of 22 patients, with a mean age of 64 years (range, 43–77 years), participated in this study. Nineteen men and 3 women participated, a ratio consistent with overall VA demographics. The procedures performed included 11 carpal tunnel releases, 8 trigger finger releases, 2 retinacular cysts excisions, and 1 lipoma excision (Table 2). One patient did not meet the criteria given a history of motion sickness. Three patients declined participation in favor of listening to music instead. No patients requested to stop the use of the headset during the procedure.

Table 2.

Patient Demographics

Mean age (y), mean (range)	64 (43–77)
Men, n (%)	19 (86)
Women, n (%)	3 (14)
Carpal tunnel release, n (%)	11 (50)
Trigger finger release, n (%)	8 (36)
Retinacular cyst excision, n (%)	2 (9)
Lipoma excision, n (%)	1 (5)

The average preprocedural anxiety score was 6.2 (range, 5–9), and the average postprocedural anxiety score was 5.1 (range, 5–7) (P = .04). Patients with a higher preprocedural anxiety score had a greater drop in postprocedural testing. The heart rate remained stable pre- and post-operatively whereas the systolic blood pressure decreased to an average of 20 mm Hg (Table 3). The average postprocedural satisfaction score was 4.3 (range, 3–5), the likelihood of the use of VR again in a future procedure was 4.4 (range, 2–5), and the impression of VA was 4.1 (range, 3–5). There was no difference in the patients’ scores based on the surgeon or procedure performed.

Table 3.

Preprocedural and Postprocedural Measures

Measure	Preprocedure	Postprocedure	P
STAIS-5	6.2 (5–9)	5.1 (5–7)	.04
Heart rate	75.8 (61–110)	75.1 (61–106)	.27
Systolic blood pressure	157.2 (121–197)	137.1 (116–185)	.09

STAIS-5, State-Trait Anxiety Inventory Scale-5.

Seventeen of the 22 patients provided free text-written feedback. This feedback was categorized into positive and negative feedback as well as ease-of-use categories. The majority (12/17) of the patients reported a good experience with the technology and found it simple to use. Most narrative feedback was positive, with comments such as “this is so cool,” “I always wanted to see the Northern Lights,” “relaxing, good experience,” and “helpful, good distraction.” Three patients specifically stated that they would have preferred watching the surgery instead, whereas 2 stated that they did not like the HMD and would have found listening to music more relaxing. Several liked the experience but found the singular environment boring and would have preferred a more interactive environment with either a rotating scene or more variety of visual input. Several patients commented that VR positively improved their opinion or perception of VA as a provider of patient-centered care through the use of innovative technology. The full patient comments are provided in Appendix 1 (available on the Journal’s website at www.jhsgo.org).

Narrative feedback was also obtained from the 5 surgeons who participated in the project. None of the surgeons had previously used VR technology. The providers found the VR technology to be generally helpful as well. Some reported that the technology was easily incorporated into the procedure room’s workflow, with minimal disruption and added time. Some providers noted that it reduced their own anxiety because they did not have to distract nervous patients and could provide their full attention to the procedure. One provider stated, “the VR made me feel more relaxed.” Virtual reality also allowed some providers to better focus on learners, such as residents and medical students, improving the teaching experience. One provider did note, however, that it reduced their ability to discuss postoperative instructions with the patient during the procedure. The full provider comments are available in Appendix 2 (available on the Journal’s website at www.jhsgo.org).

Discussion

We reported the use of VR HMDs for procedural distraction during wide-awake, local-only hand surgeries in a VAHCS minor procedure room. Both the patients and providers found value in the use of VR. Most VAHCS patient participants found the technology helpful and reported a desire to use it again during future procedures. The providers also appreciated the distraction that VR provided to the patients, allowing them to place more focus on the procedure itself or on trainee education.

The initial HMD and content used allowed the patients to choose a VR environment. This setup was confusing to our older population and caused delays in workflow. The WayaHealth platform uses a single preloaded scene. Although no specific times were recorded, narrative feedback from the providers indicated that they felt that VR integrated well into the workflow of the procedure room, with minimal additional time and effort.

The self-reported patient anxiety was reduced after procedures during which they used the VR system, with patients with higher preprocedural anxiety reporting the greatest overall reduction. This may have been influenced by the use of the technology; however, the effect of anxiety reduction due to completing the procedure cannot be excluded. Relief from removal of the tourniquet in some cases may also have contributed to lower anxiety scores. Additionally, there is no literature to support a minimum clinically important difference in the State-Trait Anxiety Inventory Scale-5 measure. Therefore, statistical significance for changes in the anxiety level should be interpreted with caution and may not represent a clinically meaningful change.

There was a moderate reduction in blood pressure; however, overall, the vital signs did not change appreciably before and after the procedure. It is possible that the use of epinephrine for local injection as well as the use of a forearm tourniquet in some cases may have influenced the measurements of these vital signs. Many patients also reported in free text comments that VR positively improved their opinion and perception of VA as a provider of patient-centered care through the use of innovative technology.

Another important finding was the overall positive response from the providers. Those who performed the surgeries reported that the use of VR improved their ability to teach trainees and allowed them to better concentrate on the procedures. Although the time for the procedures was not specifically recorded, we believe that the use of VR did not appreciably increase procedure times because the headset was fitted before the procedure began. Room turn-over times were also not specifically recorded. However, as reflected in the providers’ narrative comments, the use of the headset added minimal additional time to patient setup as best as they were able to determine.

The use of VR during wide-awake, local-only procedures had a few notable limitations. Importantly, veterans represent a unique population, who are more likely to be men, have multiple comorbidities, and have a greater likelihood of anxiety and posttraumatic stress disorder, limiting generalizability. Additionally, it is possible that patients with claustrophobia, vertigo, or motion sickness may be triggered by the use of a fully immersive HMD. However, in our experience, our patients were self-aware of a history of such conditions and were able to inform the team that VR was likely not a good fit for them. The cost of the device could also be a barrier to implementation. The WayaHealth headset used in our study was provided to the VAHCS at no cost because it was completed in collaboration with the national-level Veterans Health Administration Collaborative Research and Development Agreement. The cost of the device with the procedural platform is approximately $2,500. This represents a single initial investment but, nonetheless, should be considered for broader implementation of this technology.

Finally, patient distraction using VR may potentially take away from physician-patient interaction. Wide-awake surgery provides an opportunity for education and communication with the surgical team, which could be compromised by the use of VR. Nonetheless, our patients who used VR were still able to hear the surgeons’ instructions, and cooperation was easy and immediate, for example, in the case of requests to move the digit. As noted by one provider, the opportunity for longer, more in-depth postoperative education while performing the operation was hindered, requiring additional time after the procedure to discuss instructions. This represents a potential area for further development to build standardized postoperative instructions into the VR experience.

At our institution, VR was shown to positively influence the patients’ and providers’ experience during wide-awake, local-only hand surgery, without any significant disruption in clinical workflow. Virtual reality is a viable nonpharmacologic intervention that research has supported to be effective in reducing periprocedural anxiety; yet, it has not been widely integrated into mainstream clinical practice. The experience of this project may help promote awareness of the potential benefits of the use of VR during wide-awake, local-only hand surgeries.