Virtual reality: feasibility of implementation in a regional burn center.

OBJECTIVE: Burn care providers continue to search for non-pharmacologic adjuncts for pain control. Virtual reality (VR) has been shown to be a useful adjunct by reducing pain during burn care and therapy. The feasibility of implementation for clinical use (non-research related) has not been studied in a burn center. The purpose of this study was to determine staff resources needed to implement VR in a regional burn center. METHODS: Ten patients with burns participated in VR during occupational or physical therapy sessions. A portable computer and VR head mounted device (Proview VO35, Kaiser Electro-Optics, Inc.) and the "SnowWorld" software (Patterson and Hoffman, University of Washington) were used. Two staff members trained in the use of VR participated in each session in order to adhere to infection control policies. VR set-up time, patient instruction time, VR therapy time, and equipment cleaning time were recorded and rounded to the nearest minute. RESULTS: A mean of 59 staff time minutes (S.D. 18; range 29-85) were required for set-up, instruction, VR therapy, and cleaning. Set-up required the most time, averaging 23min. Instruction, participation, and clean-up means were 6, 13, and 16min respectively. Time for set-up decreased over time, however technical difficulties with the VR equipment accounted for most of the variability in the time required. CONCLUSIONS: These results suggest VR requires a significant time commitment from staff for implementation. One clear disadvantage was the lack of on-site technical support for equipment troubleshooting. In the current healthcare environment where therapists and nurses are accounting for each minute, it would be difficult for smaller burn centers to allocate staff and resources to implement a VR program. Further research is needed to determine if VR benefits are worth the implementation costs.

Responding to SUPPORT: an academic medical center examines its end-of-life care practices. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

The purpose of this exploratory study was to examine the end-of-life (EOL) care rendered to patients and families within a large midwestern academic medical center during a recent one-year period. An investigator-developed audit tool was used to review the final hospitalization records of 100 patients. Data were collected regarding demographic variables, final hospitalization, medical diagnoses and histories, and documented end-of-life care. Major findings included a majority of deaths occurring within medical services on critical care units, a frequent short length of stay, a majority of Do Not Resuscitate or Withdrawal of Support orders being written 1-3 days prior to death, an unstable health status prior to admission, and presence of at least one significant chronic illness in the past medical history. Findings are being used to address EOL care related issues within the institution.

A nurse-run inpatient pain consultation service.

As hospitals across the country work to improve pain management in the face of ever-shrinking resources, one challenge that must be addressed is the delineation of specialized pain management services. Although pain management is an interdisciplinary process, nurses are in a unique position to provide leadership in both the organization and delivery of clinical services. This article describes the development and 2-year experience of a nurse-run inpatient pain management consultation service in an academic tertiary care hospital. The structure of the service, and nature and volume of consults is discussed along with recommendations for institutions considering this strategy.

Assessment of the validity and reliability of the University of Wisconsin Children's Hospital Pain scale for Preverbal and Nonverbal Children.

PURPOSE: This study tested the reliability and validity of a pain scale that was developed at University of Wisconsin Children's Hospital for the preverbal child (less than 3 years old) and the nonverbal child (children who cognitively were not able to communicate a pain rating on traditional pain scales). METHOD: Content validity was established by expert review. Construct validity was demonstrated by having the nurse rate the child's pain before and after analgesic and during a procedure. Inter-rater reliability was achieved by two nurses simultaneously and independently rating the child's pain. Criterion validity was determined by comparing ratings with those obtained on the Wong-Baker Faces scale. Internal consistency was calculated using Cronbach's alpha. FINDINGS: Seventy-four patients provided data for 124 observation times. At 58 of the observation times, two nurses independently used the newly developed University of Wisconsin Children's Hospital (UWCH) scale, resulting in 182 pain ratings. Internal consistency of the scale (Cronbach's alpha) was 0.93. Mean pain scores were significantly higher prior to pain medication administration and during procedures than following analgesic administration. Inter-rater reliability was 0.92. Correlation of the new scale with the Wong-Baker Faces Scale was r = .62. CONCLUSIONS: Initial testing of the construct validity, internal reliability, and internal consistency of the UWCH Pain Scale for Preverbal and Nonverbal Children were acceptable. Parents provided ratings for most of the faces scale, which could account for the low correlation in the construct validity testing.

Perceived control mediates the relationship between pain severity and patient satisfaction.

The factors that account for patient satisfaction with acute pain management remain a mystery. Consistently, there has been an inverse, but very small association between pain severity and patient satisfaction; most patients are in severe pain, yet report they are satisfied with pain management. The hypothesis that perceived control mediates the relationship between pain severity and patient satisfaction was examined in 137 patients who underwent elective inpatient orthopedic surgery. Postoperatively, patients rated their pain severity (the highest level of pain experienced), their perceptions of control over the pain and taking pain medication, and their satisfaction with the relief they obtained from analgesics. Path analysis using LISREL was used to test for mediation. Pain severity was associated inversely with perceptions of control over pain and with satisfaction. There was a significant association between perceived control and satisfaction and perceived control partially mediated the relationship between pain severity and satisfaction. Although individuals who report experiencing severe pain are less satisfied with pain relief than individuals with less pain, it is the interpretation or perception of having control over the pain that most relates to satisfaction with pain relief. Clinically, it is important to examine ways in which individuals control their pain, teach them methods to exert control, and educate them that it is preferable to not allow pain to become severe--it is easier to "control" pain if you intervene at an early point.

Relationships between patient attitudes, subjective norms, perceived control, and analgesic use following elective orthopedic surgery.

The theory of planned behavior guided this exploration of postoperative analgesic use among adults (N = 137) undergoing elective orthopedic surgery. Patients who had a more positive attitude toward taking pain medication and had positive subjective norms intended to take more medication than those who had a negative attitude and had negative subjective norms. Perceived control over taking pain medications was not related to intentions. Intentions to take analgesics did not relate to the actual amount of analgesics used, but did relate to the subjective report of medication use. The discrepancy in association between intentions, objective behavior, and subjective behavior raises issues for examining complex behavior using the theory of planned behavior.

Perception of control and appraisal of illness in chronic low back pain.

People who experience chronic low back pain face significant changes in their lives, and it is unclear why some people adapt to the pain situation better than others. Using a cognitive appraisal model, outcomes of the pain situation were examined in 40 chronic low back pain patients using situational control and appraisal of illness as predicted mediating factors. This article presents background of the problem and the results of the study.