Reducing Pain and Anxiety During Dressing Changes After Burn Surgery Using Virtual Reality

The Ross Tilley Burn Centre (RTBC) is the largest burn care centre in Canada, admitting ~300 patients/year. Most of these severely injured patients require numerous dressing changes and skin grafting procedures which cause extensive pain and anxiety in patients already facing potential losses in terms of function and independence. Poorly managed pain can reduce patient engagement and participation in effective rehabilitation, result in chronic opioid dependence, and worsen post-traumatic stress disorder.

While burn health practitioners specialize in the use of multi-modal pharmacological approach in an attempt to reduce patients' reliance on opioid, there is an increasing recognition of the importance of non-pharmacological strategies to reduce painful procedures in hospital. A number of studies have demonstrated reductions in pain, anxiety and analgesic medications with the use of Virtual Reality (VR) during procedures in hospital. VR can be applied in a variety of ways, with considerable variations in terms of cost, efficacy, and applicability. The burn injury VR literature includes predominantly small cases/series and is lacking on using VR-360 videos as a distraction technique in burn patients. Thus, VR remains under-utilized in most burn centres locally and internationally. To address this lack of knowledge, this study proposes to use VR-360 video as a distraction tool in patients during dressing changes after skin graft surgery.

This study aims to improve burn pain management by reducing opioid requirements, pain and anxiety during painful dressing changes, while also improving patient safety and satisfaction.

The study hypothesis is that immersive virtual reality use in the burn centre will reduce the cumulative dosage of analgesia used during the first two dressing changes after skin graft surgery when compared with patients not utilizing the technology.

The primary objective of this study is to evaluate the effect of VR-360 distraction video on opioid analgesic consumption during burn dressing changes.

The secondary objectives are to investigate the effect of VR-360 on pain, requirement for conscious sedation, additive effect of multiple VR exposures, anxiety, dressing change efficiency, patient reported outcome and satisfaction. Finally, patient and staff surveys will be undertaken which will allow iterative adaptation of 3600 immersive videos to the patients' preferences optimal distraction from the painful stimuli during dressing change.

The majority of patients suffering from burn injuries are committed to undergoing long, complex treatment plans that have significant physical and emotional impact. Pain is a challenge within this population and many patients require high doses of opioids. Indeed, a sizable proportion of burn patients may still require opioids as long as three months after discharge, delaying their reintegration into society and increasing the chance of opioid dependence. VR is a strategy that helps patients alter pain behavior. This study will be the first randomized trial to apply practitioner-designed VR-videos with patient input for greatest impact. It will compare opioid use, pain scores and patient satisfaction scores between this new, state of the art intervention, and current standard practice. By demonstrating VR's 'non-pharmacologic' effectiveness to alter pain perception the study team will develop a cost-effective, accessible tool that can align with practice at Sunnybrook. Furthermore, this team-based quality improvement initiative involving nurses, social workers, physio/occupational therapy and physicians aims to introduce VR as an evidence-based innovative non-pharmacological strategy to reduce opioid requirements and optimize the use of resources, workflow, and improve staff experience in burn centres across Canada and internationally

Inclusion criteria

• Age ≥ 18
• Patients anticipated to receive only one skin autograft surgery for acute burn injury at RTBC (patients may have received an allograft skin procedure prior to the autograft)
• Patients who will require inpatient stay for at least two consecutive daily dressing changes
• Patients alert and oriented, and able to watch immersive video and respond to questions

Exclusion criteria

• Patients on mechanical ventilation
• Patients receiving intravenous sedation
• Patients with significant face, neck or scalp burn wounds
• Patients with confirmed resistant bacteria (MRSA, CPE, VRE)
• Patients with history of significant motion sickness (i.e. occur during exposure to physical, visual and virtual motion, cybersickness, etc.) verbally declared by patient
• Patients unable to communicate