A simple, yet effective interactive app—dubbed “Story-Telling Medicine”—appears to effectively reduce preoperative anxiety in children.
“Preoperative anxiety … is associated with many adverse postoperative outcomes,” said Cheryl Chow, MS, a doctoral candidate at McMaster University, in Hamilton, Ontario. “What’s more, children who are anxious have problems with anesthetic induction, postoperative emergence delirium, increased pain and delayed recovery.
“And while numerous attempts have been made to help reduce anxiety, many of these interventions are not readily available because of the costs associated with them, potential undesirable side effects and also the time that it takes to administer them.”
On the heels of a recent systematic review—which suggested that audiovisual interventions are effective at alleviating preoperative anxiety—Ms. Chow and her colleagues developed the novel, interactive Story-Telling Medicine app to help prepare children for upcoming elective surgeries. To date, no study has examined the effects of a tablet-based, virtual reality–based intervention for this all-too-common side effect.
As Ms. Chow described at the 2016 annual meeting of the Canadian Anesthesiologists’ Society (abstract 152286), Story-Telling Medicine is an age-appropriate, customizable program that simulates the children’s hospital environment by guiding them through the physical settings they will encounter before surgery. “We take pictures of the hospital and recreate them into cartoon format,” she explained. “And it walks the child through the day of surgery to help them understand what the entire experience will be.
“There’s a cartoon character that narrates along the hospital scenery,” she continued. “It tells the child what to expect along the way. And in the end, they will be in the operating room, where the kids can actually click on different pieces of equipment and learn about their function.”
To help determine the efficacy of the app, the investigators enrolled 40 children (ages 8-13 years) undergoing elective outpatient surgery into the trial. Patients were randomly allocated to receive either the Story-Telling Medicine app and usual care (n=20) or usual care alone (n=20) seven to 14 days before surgery.
More Effective Than Usual Care?
“Usual care includes routine preparation by child life specialists, anesthesiologists and pediatric nurses,” Ms. Chow reported. Self-rated perioperative anxiety levels were measured using the Children’s Perioperative Multidimensional Anxiety Scale at three time points: seven to 14 days before surgery, on the day of surgery and one month after the procedure.
The researchers reported that patients who received usual care only saw their mean anxiety scores fall by 126.6±122.5. By comparison, those who combined Story-Telling Medicine and usual care saw their anxiety scores fall by a mean of 246.5±127.2 (P=0.015), suggesting that the app is effective in reducing children’s perioperative anxiety.
“This is the first study to show the effectiveness of a tablet-based application for reducing perioperative anxiety in children undergoing outpatient surgery,” she said. “And since many children do not have access to adequate services to manage preoperative anxiety, this app will optimize perioperative care for every child in need. What’s more, it can be adapted to many different hospital settings.” The app could one day be made available to any pediatric patient with internet access, providing equal access regardless of socioeconomic status.
Members of Ms. Chow’s audience could not help noticing that the study comprised older children, and wondered whether plans were being laid for a younger audience as well.
“Absolutely,” she replied. “We chose the older group for a few reasons. They’re able to self-report their anxiety, which is important since this application is the first of its kind, and we really wanted to see whether or not it is effective. However, we are able to modify it for different age settings and environments, and that is in development right now.”
Ms. Chow and her colleagues were not the only researchers at the meeting who examined ways to combat preoperative anxiety in children. In another presentation (abstract 149282), a University of British Columbia research team examined the effects of preoperative child life preparation on anxiety levels in 58 children, aged 3 to 10 years.
Upon arrival to the surgical day care unit, children in the trial were randomly assigned to either receive standard practice only (n=31) or standard practice plus a minimum of 15 minutes of child life preparation (n=27), which comprised role-play, expectation-setting and the instruction of coping strategies. Anxiety levels were assessed using the modified Yale Preoperative Anxiety Scale, which rates anxiety from 23 (lowest anxiety) to 100 (highest anxiety).
The researchers reported that the median baseline anxiety level was 29 in each group, increasing to 35 in controls (range, 23-47) before IV insertion in the operating room. In comparison, children in the child life preparation group maintained their anxiety levels at 29 (range, 23-33).
A ‘Knowledge Intervention’
As Ms. Chow described, future research should help fine-tune the effects of these interventions. In the case of Story-Telling Medicine, the researchers hope to determine children’s experience of physiologic responses in accordance with their behavioral changes. “We also want to further optimize the intervention’s content to see whether or not it’s also effective in other surgical settings.”
David Moore, MD, associate professor of anesthesia of anesthesiology and pain medicine at the Cincinnati Children’s Hospital Medical Center, told Anesthesiology News that preoperative anxiety can be alleviated by three primary types of interventions: knowledge, control and medication. The current study, he noted, only examined knowledge.
“As a knowledge intervention, the study application appears to work well for preoperative anxiety,” he said. “However, there does not appear to be any outcomes measured other than anxiety. If the application decreases anxiety but not postoperative pain, emergence delirium or negative postoperative behaviors at home, then it is interesting … but not useful.”
Either way, Dr. Moore called the study a “good start.” “In the end,” he added, “I’m not sure that this intervention would help any more than watching YouTube or movies on an iPad to help children relax on induction. Ultimately, I think it depends on the mix of children, comparisons of various preoperative interventions and the outcomes measured.”