Frequency of Operative Anesthesia Care After Traumatic Injury.

BACKGROUND: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database-the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. METHODS: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III-V. RESULTS: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P < .01), increasing injury severity score (P < .01) and higher emergency department Glasgow Coma Score (P < .01) were all associated with surgical intervention during the trauma hospitalization, after adjustment for potential confounders. In level I trauma centers, for general surgical procedures, the median time to surgery was 2.5 hours; in level II trauma centers, the median time was 1.7 hours. CONCLUSIONS: This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question.

Virtual Reality Analgesia in Labor: The VRAIL Pilot Study-A Preliminary Randomized Controlled Trial Suggesting Benefit of Immersive Virtual Reality Analgesia in Unmedicated Laboring Women.

This pilot study investigated the use of virtual reality (VR) in laboring women. Twenty-seven women were observed for equivalent time during unmedicated contractions in the first stage of labor both with and without VR (order balanced and randomized). Numeric rating scale scores were collected after both study conditions. Significant decreases in sensory pain -1.5 (95% CI, -0.8 to -2.2), affective pain -2.5 (95% CI, -1.6 to -3.3), cognitive pain -3.1 (95% CI, -2.4 to -3.8), and anxiety -1.5 (95% CI, -0.8 to -2.3) were observed during VR. Results suggest that VR is a potentially effective technique for improving pain and anxiety during labor.

Alcohol-impaired driving in US counties, 2002-2012.

BACKGROUND: Excessive alcohol consumption and alcohol-impaired driving remain significant public health problems, leading to considerable morbidity and mortality, particularly among younger populations. METHODS: Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we employed a small areas modeling strategy to estimate the county-level annual prevalence of alcohol-impaired driving in every United States county for the years 2002 through 2012, the latest year in which county identifiers were publicly available. RESULTS: Alcohol-impaired driving episodes declined from 157.0 million in 2002 (prevalence 3.8%: 95% uncertainty interval [UI], 3.7%-4.0%) to 129.7 million in 2012 (prevalence 3.7%: 95% UI, 3.5%-3.8%), a 17.4% decline. There is considerable variation in the prevalence of alcohol-impaired driving at the county level, ranging from 2.0% in the Sitka City Borough of Alaska to 9.3% in Nance County, Nebraska. Clusters of increased alcohol-impaired driving were observed in Northern Wisconsin (Marinette, Florence, Forest, Vilas, Oneida, Iron counties), North Dakota (Cavalier, Pembina, Walsh, Ramsey, Nelson, Benson, Eddy counties) and Montana (Sheridan, Daniels, Roosevelt, Valley, Phillips, Petroleum, Garfield counties). CONCLUSIONS: This study showed guarded progress with respect to the occurrence of alcohol-impaired driving episodes in the US from 2002 to 2012. Because these data rely on self-report, this likely represents an underestimate of the true prevalence of alcohol-impaired driving in the US. As the US continues to have several million episodes of alcohol-impaired driving each month, renewed efforts are needed to mitigate this high-risk health behavior.

The Nature of Trauma Pain and Its Association with Catastrophizing and Sleep.

BACKGROUND: Nearly 2.8 million people are hospitalized in the USA annually for traumatic injuries, which include orthopedic and internal organ injuries. Early post-injury pain is predictive of poor outcomes, including inability to eventually return to work, and long-term psychological distress. The goal of the present study was to improve our scientific understanding of trauma-related pain by examining (1) the nature and frequency of inpatient trauma pain and (2) the associations between inpatient trauma pain, education, opioid analgesic equivalent use, pain catastrophizing, and sleep quality. METHOD: The study included 120 patients hospitalized at a major level I regional trauma center for the care of (1) closed long bone or calcaneus fractures and/or (2) an intraabdominal injury caused by blunt force trauma and requiring surgical repair (i.e., laparotomy). Medical records were reviewed to obtain demographic information and information about opioid use during hospitalization. In addition, participants were administered measures of average pain intensity, pain catastrophizing, and sleep quality. RESULTS: Education, opioid analgesic equivalents, catastrophizing, and poor sleep quality together accounted for 28% of the variance of average pain intensity over a 24-h period (p < .001), with each variable making a significant independent association. CONCLUSION: Two of the factors associated with pain intensity in the study sample-catastrophizing and sleep quality-are modifiable. It is therefore possible that interventions that target these variables in patients who are hospitalized for trauma could potentially result in better long-term outcomes, including a reduced risk for developing chronic pain. Research to evaluate this possibility is warranted.

Methylprednisolone Therapy in Acute Traumatic Spinal Cord Injury: Analysis of a Regional Spinal Cord Model Systems Database.

BACKGROUND: The objective of this study was to assess the relationship between exposure to methylprednisolone (MP) and improvements in motor function among patients with acute traumatic spinal cord injury (TSCI). MP therapy for patients with TSCI is controversial because of the current conflicting evidence documenting its benefits and risks. METHODS: We conducted a retrospective cohort study from September 2007 to November 2014 of 311 patients with acute TSCI who were enrolled into a model systems database of a regional, level I trauma center. We linked outcomes and covariate data from the model systems database with MP exposure data from the electronic medical record. The primary outcomes were rehabilitation discharge in American Spinal Injury Association (ASIA) motor scores (sum of 10 key muscles bilaterally as per International Standards for Neurological Classification of Spinal Cord Injury, range, 0-100) and Functional Independence Measure (FIM) motor scores (range, 13-91). Secondary outcomes measured infection risk and gastrointestinal (GI) complications among MP recipients. For the primary outcomes, multivariable linear regression was used. RESULTS: There were 160 MP recipients and 151 nonrecipients. Adjusting for age, sex, weight, race, respective baseline motor score, surgical intervention, injury level, ASIA Impairment Scale (AIS) grade, education, and insurance status, there was no association with improvement in discharge ASIA motor function or FIM motor score among MP recipients: -0.34 (95% CI, -2.8, 2.1) and 0.75 (95% CI, -2.8, 4.3), respectively. Adjusting for age, sex, race, weight, injury level, and receipt of surgery, no association with increased risk of infection or GI complications was observed. CONCLUSIONS: This retrospective cohort study involving patients with acute TSCI observed no short-term improvements in motor function among MP recipients compared with nonrecipients. Our findings support current recommendations that MP use in this population should be limited.

A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care.

PURPOSE: Non-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles. METHODS: Forty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2. INTERVENTION: The study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition. OUTCOME MEASURES ON STUDY DAYS 1 AND 2: Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care. RESULTS: On Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or "presence in VR" between the two conditions were found, however. VR VS. NO VR. (STUDY DAY 2): Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, "time spent thinking about pain during wound care" was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition. CONCLUSION: The current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles.

Similar liability for trauma and nontrauma surgical anesthesia: a closed claims analysis.

BACKGROUND: Trauma care has many challenges, including the perception by nonanesthesia physicians of increased medical malpractice liability. We used the American Society of Anesthesiologists' Closed Claims Project database and the National Inpatient Sample (NIS) to compare the rate of claims for trauma anesthesia care to national trauma surgery data. We also used the American Society of Anesthesiologists' Closed Claims Project database to evaluate injury and liability profiles of trauma anesthesia malpractice claims compared to nontrauma surgical anesthesia claims. METHODS: Surgical anesthesia claims for injuries that occurred between 1980 and 2005 in the American Society of Anesthesiologists' Closed Claims Project database of 8954 claims were included in this analysis. Trauma was defined using cause of injury criteria in state trauma registries, including out-of-hospital falls. To estimate national trauma anesthesia rates, we used injury codes in NIS reports to define trauma discharges and NIS discharges with surgical procedure codes for the denominator. The year-adjusted odds ratio and P value comparing the national trauma anesthesia injury rates and American Society of Anesthesiologists' Closed Claims Project inpatient claim rates in the 1990 to 2001 time period were calculated by a multivariate logistic regression of the injury/trauma outcome on year and the NIS/Closed Claims Project indicator. Payments in claim resolution between trauma claims and nontraumatic surgical anesthesia claims were compared by χ(2) analysis, Fisher exact test for proportions, and Kolmogorov-Smirnov test for payment amounts. RESULTS: Trauma claims represented 6% of the total 6215 surgical anesthesia claims in the study period. The inpatient trauma claims rates were consistently lower than the NIS injury rates for 1990 to 2001. The year-adjusted odds ratio comparing the trauma claims rates to the NIS injury rates was 0.62 (95% confidence interval [CI], 0.53 to 0.72; P < 0.001, likelihood ratio test). Trauma claims and nontrauma surgical anesthesia claims did not differ in appropriateness of care, whether or not a payment was made to the plaintiff, or size of payments. CONCLUSION: Despite reported perceptions that trauma care involves a high risk of medical liability, there was no apparent increased risk of liability among inpatients presenting for trauma anesthesia care. The proportion in malpractice claims in trauma anesthesia care was not increased compared to nontraumatic surgical anesthesia care. With respect to medicolegal liability, these results support participation of anesthesia providers in multidisciplinary trauma care and organized systems.

Virtual reality hypnosis pain control in the treatment of multiple fractures: a case series.

This case series evaluated the use of virtual reality hypnosis (VRH) for the treatment of pain associated with multiple fractures from traumatic injuries. VRH treatment was administered on 2 consecutive days, and pain and anxiety were assessed each day before and after VRH treatment as well as on Day 3, which was 24 hours after the second treatment session. Pain reduction from baseline to Day 3 was from 70% to 30%, despite opioid analgesic use remaining stable. The subjective pain reduction reported by patients was encouraging, and the results of this case series suggest the importance of further study of VRH with larger samples using randomized controlled trials.

The Impact of Virtual Reality Hypnosis on Pain and Anxiety Caused by Trauma: Lessons Learned from a Clinical Trial.

This randomized, controlled trial tested the impact that hypnosis delivered through immersive virtual reality technology on background pain, anxiety, opioid use, and hospital length of stay in a sample of patients hospitalized for trauma. Participants were randomly assigned to receive either virtual-reality-induced hypnosis, virtual reality for distraction, or usual care during the course of their hospitalization. Mean number of treatment sessions was 3. A total of 153 patients participated in the study. Results indicated no significant differences between the experimental and control conditions on any outcome measures. This study used an early version of virtual reality technology to induce hypnosis and highlighted several important lessons about the challenges of implementation of this technology and how to improve its use in clinical settings.

Virtual reality as an adjunctive non-pharmacologic analgesic for acute burn pain during medical procedures.

INTRODUCTION: Excessive pain during medical procedures is a widespread problem but is especially problematic during daily wound care of patients with severe burn injuries. METHODS: Burn patients report 35-50% reductions in procedural pain while in a distracting immersive virtual reality, and fMRI brain scans show associated reductions in pain-related brain activity during VR. VR distraction appears to be most effective for patients with the highest pain intensity levels. VR is thought to reduce pain by directing patients' attention into the virtual world, leaving less attention available to process incoming neural signals from pain receptors. CONCLUSIONS: We review evidence from clinical and laboratory research studies exploring Virtual Reality analgesia, concentrating primarily on the work ongoing within our group. We briefly describe how VR pain distraction systems have been tailored to the unique needs of burn patients to date, and speculate about how VR systems could be tailored to the needs of other patient populations in the future.

The association between obesity and difficult prehospital tracheal intubation.

BACKGROUND: Nonphysician advanced life support (ALS) providers often perform tracheal intubation (TI) for cardiac arrest or other life-threatening indications in the prehospital setting, where airway assessment and airway management tools are limited. However, the frequency of difficult TI in obese patients in this setting is unclear. In this study we determined factors associated with TI success, and determined TI difficulty as a function of body mass index (BMI) in a system of ALS providers experienced in TI, to guide future prehospital education efforts. METHODS: A retrospective review was performed of all patients ≥15 years of age who underwent prehospital TI by paramedics in the Seattle Medic One system over a 4-year period, and were transported to the regional level 1 trauma center (Harborview Medical Center). Data were abstracted from a prospectively collected prehospital airway management database and from the hospital medical records, including demographic information, number of TI attempts, TI success or failure, and body weight/height (BMI). Descriptive statistics and multivariable logistic regression were calculated, with the primary end point being difficult TI (defined as ≥4 TI attempts or the need to use an alternative airway management technique). RESULTS: Of 80,501 patient contacts in whom 4114 TIs were attempted during the 4-year study period, 823 met study entry criteria (including a calculable BMI). The overall TI success rate in the study population was 98.5% (811 out of 823), with 6.8% (56 out of 823) meeting the predetermined definition for difficult TI. There was no significant association between difficult TI and patient age, gender, use of succinylcholine, or medical diagnosis (trauma vs. nontrauma). In comparison with the lean patient subgroup (BMI <30 kg/m(2)), patients with class III obesity (BMI >40 kg/m(2)) had a significant association with difficult TI (odds ratio 3.68; confidence interval [CI] 1.27-10.59), whereas those with class I/II obesity (BMI ≥30 kg/m(2) and <40 kg/m(2)) did not (odds ratio 0.98; CI 0.46 -2.07). CONCLUSIONS: Among prehospital ALS providers with previously documented and published successful TI performance, increased difficulty with TI was observed in patients with extreme obesity, but not in patients with lesser degrees of obesity. Because extreme obesity is an easily identifiable patient characteristic, didactic and clinical (e.g., operating room) airway management education for such providers should emphasize airway management challenges and strategies associated with obesity, including specific equipment, patient positioning, and practice recommendations that may facilitate both TI and alternative airway management techniques in this population.

Trends in hospitalisations associated with paediatric burns.

BACKGROUND: In the United States, burns are the third leading cause of unintentional injury death in children aged 1-14 years, accounting for more than 600 deaths per year in children aged 0-19 years. OBJECTIVE: To describe trends in paediatric burn hospitalisations in the United States and provide national benchmarks for state and regional comparisons. METHODS: Analysis of existing data (1993-2006) from the Nationwide Inpatient Sample-the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0-19 years were included. MAIN OUTCOME MEASURES: Estimated national annual rates of burn-related hospitalisations, stratified by age, gender, and in-hospital mortality. RESULTS: From 1993 to 2006, the estimated annual incidence rate of paediatric hospitalisations associated with burns declined 40% from 27.3 (1993-94) to 16.1 per 100,000 (p<0.001). The rates declined for all age groups and for both boys and girls. Boys were consistently more likely to be hospitalised than girls (20.3 vs 11.7 hospitalisations per 100,000 during 2004-06, p<0.001). For children less than 5 years of age, burn hospitalisations decreased 46% from 65.2 per 100,000 in 1993-94 to 35.1 per 100,000 in 2004-06 (p<0.001). Fatal hospitalisation rates also declined from 0.3 deaths per 100,000 in 1993-94 to 0.1 in 2004-06 (p<0.001). CONCLUSION: Paediatric hospitalisation rates for burns have decreased over the past 14 years. The study also provides national estimates of paediatric burn hospitalisations that can be used as benchmarks to further injury prevention effectiveness through targeting of effective strategies.

Paramedic training for proficient prehospital endotracheal intubation.

BACKGROUND: Emergency airway management is an important component of resuscitation of critically ill patients. Multiple studies demonstrate variable endotracheal intubation (ETI) success by prehospital providers. Data describing how many ETI training experiences are required to achieve high success rates are sparse. OBJECTIVES: To describe the relationship between the number of prehospital ETI experiences and the likelihood of success on subsequent ETI and to specifically look at uncomplicated first-pass ETI in a university-based training program with substantial resources. METHODS: We conducted a secondary analysis of a prospectively collected cohort of paramedic student prehospital intubation attempts. Data collected on prehospital ETIs included indication, induction agents, number of direct laryngoscopy attempts, and advanced airway procedures performed. We used multivariable generalized estimating equations (GEE) analysis to determine the effect of cumulative ETI experience on first-pass and overall ETI success rates. RESULTS: Over a period of three years, 56 paramedic students attempted 576 prehospital ETIs. The odds of overall ETI success were associated with cumulative ETI experience (odds ratio [OR] 1.097 per encounter, 95% confidence interval [CI] = 1.026-1.173, p = 0.006). The odds of first-pass ETI success were associated with cumulative ETI experience (OR 1.061 per encounter, 95% CI = 1.014-1.109, p = 0.009). CONCLUSION: In a training program with substantial clinical opportunities and resources, increased ETI success rates were associated with increasing clinical exposure. However, first-pass placement of the ETT with a high success rate requires high numbers of ETI training experiences that may exceed the number available in many training programs.

Virtual Reality to Relieve Pain in Burn Patients Undergoing Imaging and Treatment.

Pain from burn injuries is among the most excruciating encountered in clinical practice. Pharmacological methods often fail to achieve acceptable level of analgesia in these patients, especially during burn wound dressing and debridement. Virtual reality (VR) distraction is a promising analgesic technique that progressed significantly in the last decade with development of commercially available, low-cost, high-resolution, wide field-of-view, standalone VR devices that can be used in many clinical scenarios. VR has demonstrated clinical benefit as an adjunctive analgesic during burn wound dressing and other painful medical procedures. The technique has proven useful also in preparing patients for magnetic resonance imaging scans, particularly in claustrophobic patients. Modulation of pain-related brain activity at cortical and subcortical levels by VR, and its correlation with subjective improvement in various laboratory and clinical pain experiences has been demonstrated using multiple functional brain imaging studies including functional magnetic resonance imaging and brain perfusion single photon emission computed tomography.

Case Report: Virtual Reality Analgesia in an Opioid Sparing Orthopedic Outpatient Clinic Setting: A Case Study.

Immersive virtual reality is proving effective as a non-pharmacologic analgesic for a growing number of painful medical procedures. External fixator surgical pins provide adjunctive stability to a broken pelvic bone until the bones heal back together, then pins are removed. The purpose of the present case study was to measure for the first time, whether immersive virtual reality could be used to help reduce pain and anxiety during the orthopedic process of removing external fixator pins from a conscious patient in the orthopedic outpatient clinic, and whether it is feasible to use VR in this context. Using a within-subject within wound care design with treatment order randomized, the patient had his first ex-fix pin unscrewed and removed from his healing pelvic bone while he wore a VR helmet and explored an immersive snowy 3D computer generated world, adjunctive VR. He then had his second pin removed during no VR, standard of care pain medications. The patient reported having 43% less pain intensity, 67% less time spent thinking about pain, and 43% lower anxiety during VR vs. during No VR. In addition, the patient reported that his satisfaction with pain management was improved with the use of VR. Conducting simple orthopedic procedures using oral pain pills in an outpatient setting instead of anesthesia in the operating room greatly reduces the amount of opioids used, lowers medical costs and reduces rare but real risks of expensive complications from anesthesia including oversedation, death, and post-surgical dementia. These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive non-pharmacologic form of treatment for acute pain and anxiety during medical procedures in the orthopedic outpatient clinic. Recent multi-billion dollar investments into R and D and mass production have made inexpensive immersive virtual reality products commercially available and cost effective for medical applications. We speculate that in the future, patients may be more willing to have minor surgery procedures in the outpatient clinic, with much lower opioid doses, while fully awake, if offered adjunctive virtual reality as a non-pharmacologic analgesic during the procedure. Additional research and development is recommended.

Prehospital management of the difficult airway: a prospective cohort study.

The role of prehospital endotracheal intubation (ETI) remains controversial, with significant national variability in practice. The purpose of this project was to evaluate ETI management in a system of advanced life support (ALS) providers experienced in ETI and other advanced airway techniques, and describe management and outcomes of patients with a "difficult airway." Data were collected prospectively for all ETIs performed by the fire department over a 4-year period (2001-2005), and included demographics, number of laryngoscopy attempts, airway procedures, complications, and outcomes. Of 80,501 ALS patient contacts, 4091 (5.1%) underwent attempted oral ETI, with a 96.8% success rate in four or fewer attempts. The difficult airway cohort included 130 patients (3.2%), whose airway management consisted of oral ETI after more than four attempts (46%), bag-valve-mask ventilation (33%), cricothyroidotomy (8%), retrograde ETI (5%), and digital ETI (1%). Procedural success rates ranged from 14% (digital ETI) to 91% (cricothyroidotomy). Nine patients (7%) had failed airway management, of whom 5 were found in cardiac arrest. The two most common reasons subjectively reported by ALS providers for airway difficulty were anterior trachea (39%) and small mouth (30%). Overall mortality for the difficult airway cohort was 44%. Prehospital ETI can be performed with a high success rate by experienced ALS providers, but may still require advanced airway techniques in a small subset of patients. Patient anatomy is a primary factor in failed ETI. Among the advanced procedures, cricothyroidotomy had the highest success rate and should not be delayed by other interventions.

VIRTUAL REALITY HYPNOSIS.

Scientific evidence for the viability of hypnosis as a treatment for pain has flourished over the past two decades (Rainville, Duncan, Price, Carrier and Bushnell, 1997; Montgomery, DuHamel and Redd, 2000; Lang and Rosen, 2002; Patterson and Jensen, 2003). However its widespread use has been limited by factors such as the advanced expertise, time and effort required by clinicians to provide hypnosis, and the cognitive effort required by patients to engage in hypnosis.The theory in developing virtual reality hypnosis was to apply three-dimensional, immersive, virtual reality technology to guide the patient through the same steps used when hypnosis is induced through an interpersonal process. Virtual reality replaces many of the stimuli that the patients have to struggle to imagine via verbal cueing from the therapist. The purpose of this paper is to explore how virtual reality may be useful in delivering hypnosis, and to summarize the scientific literature to date. We will also explore various theoretical and methodological issues that can guide future research.In spite of the encouraging scientific and clinical findings, hypnosis for analgesia is not universally used in medical centres. One reason for the slow acceptance is the extensive provider training required in order for hypnosis to be an effective pain management modality. Training in hypnosis is not commonly offered in medical schools or even psychology graduate curricula. Another reason is that hypnosis requires far more time and effort to administer than an analgesic pill or injection. Hypnosis requires training, skill and patience to deliver in medical centres that are often fast-paced and highly demanding of clinician time. Finally, the attention and cognitive effort required for hypnosis may be more than patients in an acute care setting, who may be under the influence of opiates and benzodiazepines, are able to impart. It is a challenge to make hypnosis a standard part of care in this environment.Over the past 25 years, researchers have been investigating ways to make hypnosis more standardized and accessible. There have been a handful of studies that have looked at the efficacy of using audiotapes to provide the hypnotic intervention (Johnson and Wiese, 1979; Hart, 1980; Block, Ghoneim, Sum Ping and Ali, 1991; Enqvist, Bjorklund, Engman and Jakobsson, 1997; Eberhart, Doring, Holzrichter, Roscher and Seeling, 1998; Perugini, Kirsch, Allen, et al., 1998; Forbes, MacAuley, Chiotakakou-Faliakou, 2000; Ghoneim, Block, Sarasin, Davis and Marchman, 2000). These studies have yielded mixed results. Generally, we can conclude that audio-taped hypnosis is more effective than no treatment at all, but less effective than the presence of a live hypnotherapist. Grant and Nash (1995) were the first to use computer-assisted hypnosis as a behavioural measure to assess hypnotizability. They used a digitized voice that guided subjects through a procedure and tailored software according to the subject's unique responses and reactions. However, it utilized conventional two-dimensional screen technology that required patients to focus their attention on a computer screen, making them vulnerable to any type of distraction that might enter the environment. Further, the two-dimensional technology did not present compelling visual stimuli for capturing the user's attention.

Virtual reality pain control during burn wound debridement in the hydrotank.

OBJECTIVE: Most burn-injured patients rate their pain during burn wound debridement as severe to excruciating. We explored the adjunctive use of water-friendly, immersive virtual reality (VR) to distract patients from their pain during burn wound debridement in the hydrotherapy tank (hydrotank). SETTING: This study was conducted on inpatients at a major regional burn center. PATIENTS: Eleven hospitalized inpatients ages 9 to 40 years (mean age, 27 y) had their burn wounds debrided and dressed while partially submerged in the hydrotank. INTERVENTION: Although a nurse debrided the burn wound, each patient spent 3 minutes of wound care with no distraction and 3 minutes of wound care in VR during a single wound care session (within-subject condition order randomized). OUTCOME MEASURES: Three 0 to 10 graphic rating scale pain scores (worst pain, time spent thinking about pain, and pain unpleasantness) for each of the 2 treatment conditions served as the primary dependent variables. RESULTS: Patients reported significantly less pain when distracted with VR [eg, "worst pain" ratings during wound care dropped from "severe" (7.6) to "moderate" (5.1)]. The 6 patients who reported the strongest illusion of "going inside" the virtual world reported the greatest analgesic effect of VR on worst pain ratings, dropping from severe pain (7.2) in the no VR condition to mild pain (3.7) during VR. CONCLUSIONS: Results provide the first available evidence from a controlled study that immersive VR can be an effective nonpharmacologic pain reduction technique for burn patients experiencing severe to excruciating pain during wound care. The potential applications of VR analgesia to other painful procedures (eg, movement or exercise therapy) and other pain populations are discussed.

Impact of a statewide quality improvement initiative in improving the management of pediatric splenic injuries in washington state.

BACKGROUND: Evidence suggests that 90% of children with traumatic spleen injuries can be successfully managed nonoperatively. In Washington State, significant interhospital variation in pediatric spleen management led to the development and implementation of a statewide quality improvement initiative in 2002. We evaluated pediatric splenic injury management before and after the implementation of a statewide quality improvement initiative. METHODS: Retrospective cohort study using data from the Washington Trauma Registry for years 1999-2001 (preintervention) and 2003-2005 (postintervention). Children ages 0 to 14 years who were hospitalized with a traumatic (noniatrogenic) splenic injury were included. Multivariable regression was used to control for patient and hospital characteristics. RESULTS: Splenectomies were more common, occurring in 13.6% of children, in the preintervention period, compared with 7.8% in the postintervention period (p = 0.027). After adjusting for patient, injury, and hospital characteristics, children remained less likely to receive a splenectomy in the postintervention period than in the preintervention period (odds ratio 0.39, 95% confidence interval 0.19-0.82). Children cared for at pediatric trauma hospitals were less likely to receive splenectomy in both the preintervention and postintervention periods, compared with children treated at general trauma hospitals (p < 0.001). Splenectomy remained less common among children treated at pediatric-designated hospitals (odds ratio, 0.21; 95% confidence interval, 0.08-0.58) than among children treated in general trauma hospitals after controlling for intervention period. CONCLUSION: The statewide quality improvement initiative was associated with a reduction in the rate of splenectomy in both pediatric and general trauma hospitals. However, general trauma hospitals remained more likely to perform splenectomies than hospitals with pediatric trauma designation.

Long-term sustainability of Washington State's quality improvement initiative for the management of pediatric spleen injuries.

BACKGROUND: Initial results of Washington State's quality improvement initiative addressing the management of blunt traumatic pediatric spleen injuries were published in 2008. In this update, we evaluated whether these effects were sustained over time. METHODS: Data from the Washington Trauma Registry for years 1999-2001 (pre-intervention), 2003-2005 (post-intervention), and 2012-2014 (follow-up) were used in a retrospective cohort study. Children between ages 0 to 14 years who were hospitalized with a traumatic blunt spleen injury were included. Multivariable logistic regression was used to account for patient, injury, and hospital characteristics. RESULTS: Overall, splenectomies continued to be less common with 8.3% of pediatric patients receiving splenectomies in the follow-up period compared with 14.3% and 7.2% in the preintervention and post-intervention periods (p = 0.034). After adjustment, splenectomies remained less likely to be performed in both post-intervention (OR = 0.37; 95% CI = 0.16-0.90) and follow-up periods (OR = 0.29; 95% CI = 0.12-0.70) compared to pre-intervention. Children were much more likely to be cared for at pediatric trauma hospitals in the follow-up period (OR = 5.13; 95% CI = 2.79-9.43) after adjustment. CONCLUSIONS: Evaluation of this statewide quality improvement initiative showed that positive changes in management practices persist. This evidence suggests that statewide quality improvement initiatives can be sustainable with minimal ongoing effort. LEVEL OF EVIDENCE: Level III.