Perioperative medicine: Overview

Abstract
Background: Children commonly experience high levels of anxiety prior to surgery. This distress is associated with postoperative maladaptive behaviors. Virtual reality (VR) is an innovative tool for reducing anxiety and pain during various medical procedures. Previous randomized controlled trials have demonstrated its efficacy in reducing children's anxiety in the preoperative waiting room or during induction.

Objective: The primary aim of this study was to examine the feasibility of VR distraction throughout the perioperative period, from the waiting room until the induction of general anesthesia (GA). Secondary aims were to assess its clinical utility, tolerability, and initial clinical efficacy.

Methods: A mixed methods, concurrent triangulation feasibility trial was piloted at the Shriners Hospitals for Children-Canada. Participants played an interactive VR game throughout the perioperative period, starting from the waiting room until induction. Feasibility was examined with the duration of the VR intervention, recording the number of interruptions, and taking field notes. Clinical utility was assessed using a perception questionnaire. Tolerability was evaluated by the Child Simulator Sickness Questionnaire (CSSQ). Initial clinical efficacy was assessed by the Faces Pain Scale-Revised, Faces Anxiety Scale, Graphic Rating Scale for multidimensional pain, the Induction Compliance Checklist, and the Pediatric Anesthesia Emergence Delirium scale. Quantitative data were supported with field notes and semistructured interviews with patients and parents. Quantitative and qualitative themes were compared via the triangulation protocol to produce final themes.

Results: A total of 39 patients, with a mean age of 11.9 (SD 2.8) years, undergoing elective surgery under GA participated in the study. Stakeholders, including patients, parents, and health care providers, were receptive and willing to adapt to VR. Of the 39 patients, 19 (49%) continued to use VR during transportation and 6 (15%) were induced with VR. Barriers to feasibility included (1) interruptions to VR in 92% (36/39) of patients by health care professionals, (2) unpredictable surgery delays prolonging the duration of the VR intervention (mean 23.1, SD 24.4 minutes; range 5-150 minutes), and (3) discontinuation of VR before induction due to mask seal (n=3) and discomfort with supine positioning (n=2). Patients were generally satisfied with VR, deemed it acceptable and easy to use, and would recommend it to others. VR was tolerable with no self-reported simulator sickness (CSSQ: mean 0.01, SD 0.1). The mean Faces Anxiety Score was 1.5 (SD 1.1) at baseline and 0.7 (SD 0.9) during VR.

Conclusions: While VR demonstrated good clinical utility and was well tolerated in the broad perioperative setting, this study highlighted important feasibility barriers in the waiting room and especially during induction of anesthesia, both at the organizational and technical levels. This study highlights several considerations that should be carefully addressed for the successful implementation of perioperative VR.

Abstract
Perioperative care transitions or handoffs represent a high-risk period frequently compromised by communication failures and the loss of essential patient information. Handoffs play a pivotal role in mitigating these risks. A comprehensive assessment of implementation and clinical outcomes is essential to identify protocols that enhance patient safety, improve care quality, and support reproducibility. This study identifies and synthesizes existing evidence on handoff strategies, evaluating their impact on both implementation success and clinical outcomes. A systematic search of PubMed, EMBASE, and CINAHL databases was conducted to identify observational and descriptive studies addressing preoperative, intraoperative, and postoperative handoffs. Eligible studies were published in peer-reviewed, English-language journals. The selection process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality was evaluated using the Quality Scoring System. Eleven studies evaluating the impact of handoff interventions on both implementation and clinical outcomes were included. Key implementation outcomes, including sustainability and acceptability, were commonly assessed through staff satisfaction surveys. Clinical outcomes included length of stay, duration of mechanical ventilation, and pain scores. All studies incorporated a structured preimplementation planning phase and reported significant improvements in at least 1 implementation outcome, with acceptability being the most consistently improved measure. Each study demonstrated meaningful improvements in at least 1 implementation outcome, while 7 of 11 studies reported significant enhancements in clinical outcomes. The consistent success of various methodologies-whether through expert consultation, frontline involvement, or quality improvement strategies-indicates that a tailored, site-specific approach may be more critical to success than the specific intervention strategy used.