Virtual Reality Simulation to Improve Postoperative Cardiothoracic Surgical Patient Outcomes

Preoperative education to prepare patients for all portions of their surgical journey is beneficial. Patients undergoing cardiovascular surgical procedures commonly recover in the intensive care unit (ICU).¹  Therefore, the effects of the ICU on their recovery and their experience should be considered in preoperative education.^2,3  Literature review from 2008 through 2023 suggests a positive impact of preoperative education on ICU-related outcomes such as delirium incidence, ICU (and hospital) lengths of stay, ventilator time, and patient satisfaction.

Preoperative education modalities, as noted in literature review from 1974 through 2023, include virtual reality (VR) tours of the operative environment, in-person tours of the operative environment, and staff-led educational sessions. A search for studies on preoperative education modalities yielded 26 articles published during the period reviewed. Preoperative education modalities studied in those articles included VR tours of the operative environment, in-person tours of the operative environment, and staff-led educational sessions. The studies showed that these interventions reduced anxiety in patients scheduled for surgical procedures and had a positive impact on family members’ experiences. A few studies evaluated the effect of VR simulation on patient outcomes such as anxiety and pain management. However, these studies included patients already in the ICU and did not show significant improvements in outcomes.^4–16 

Delirium is a significant cause of morbidity and mortality for patients recovering postoperatively in the ICU. Delirium is characterized by disturbances in normal cognitive functioning that fluctuate in course and duration. Patients undergoing cardio-thoracic surgical procedures are especially affected; nearly 73% of this population develops delirium postoperatively.^17,18  Delirium increases the duration of mechanical ventilation and prolongs hospital stays. Nearly 50% of affected patients have cognitive impairment at hospital discharge, and one-third experience long-term cognitive impairment. Delirium has also been associated with increased stroke risk, hospital readmission, poorer functional status, and overall reduced quality of life.^19–21  Although the cause of delirium in the ICU is unknown, considerations include physiologic processes involved in cardiac surgical procedures and unfamiliarity with the ICU environment.²² 

A wide variety of interventions have been proposed to reduce the incidence and duration of delirium in postoperative cardiac surgical patients. However, most interventions have been designed to treat, not prevent, delirium. Preventive effects of pharmacologic agents have yet to be shown. Nonpharmacologic interventions aimed at early detection and reduction of postoperative cognitive impairment are key to delirium management. The current focus is on the development of intraoperative and postoperative delirium prevention measures.^19,23–27 

The purpose of this study was to evaluate the effect of a novel multisensory VR preoperative educational program for patients undergoing elective cardiothoracic surgery. The specific goal was to determine the effect of this program on patients’ postoperative ICU experience and on ICU-related outcomes, including delirium incidence.

This study was conducted at the Mayo Clinic, Rochester, Minnesota. The study was reviewed and approved by the institutional review board. The study was registered with the national clinical trials database (NCT05159648) and was conducted in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. The study was supported and endorsed by the entire consultant surgical staff within the Department of Cardiothoracic Surgery.

The multidisciplinary research team consisted of nurses and other clinicians from the critical care, anesthesia, and cardiothoracic surgery departments. Additional clinical team members included radiology technicians, respiratory therapists, and laboratory technicians. Experts from the institution’s medical simulation/education center, including those from the immersive and experiential technology workgroup and audiovisual recording specialists, were included.

The research team developed a novel VR simulation to introduce patients to an expected normal ICU experience after a cardiothoracic surgical procedure. The multidisciplinary team focused on addressing the patient’s feeling of safety, family presence, and reorientation and a basic understanding of the machinery and activities happening around the ICU bed. The team also addressed ways for an intubated patient in the ICU to communicate effectively.

A VR simulation video of real team members was filmed using a 360° camera with spatial audio capabilities in the ICU simulation center. The simulation was filmed from the visual perspective of a patient who has just returned from the operating room, has awakened, and is lying in an ICU bed receiving mechanical ventilation with an endotracheal tube and typical catheters and drains in place. For the video, standard ICU equipment was positioned appropriately. This equipment included intravenous pumps, mechanical ventilator, ICU cardiac monitor, cardiac pacing wires and pacing box, vascular access devices such as central catheter and arterial catheter, chest tubes and drainage container, sequential compression device pump and wraps, monitoring equipment such as blood pressure cuff and electrocardiographic leads, and call light (Figure 1).

Throughout the 10-minute VR simulation, the patient is visited by multiple members of the ICU care team, including the critical care nurse, intensivist, primary surgeon, respiratory therapist, laboratory technician, radiology technician, electrocardiography technician, and others. Each team member had a script to perform a typical interaction with a patient in stable condition in the ICU after a cardiothoracic surgical procedure. Team members provided reassurance and education on their role in care and the activities surrounding the patient.

The population of interest was patients undergoing elective cardiothoracic surgical procedures with a planned postoperative stay in the ICU. Patients were included if they had documented normal neurologic function preoperatively and were scheduled for an elective cardiothoracic surgical procedure and a planned postoperative ICU stay with postoperative use of a mechanical ventilator and endotracheal tube. Patients were excluded if they had a diagnosis of chronic dementia, Alzheimer disease, or other chronic neuropsychiatric disease (eg, bipolar disorder). Additionally, patients were excluded if they were receiving neurologic-altering medications long term.

The 2 patient groups were a historical control group and a VR simulation (intervention) group. Patients in both groups met inclusion and exclusion criteria. The historical control group consisted of patients who underwent elective cardiothoracic surgical procedures during the year before the study. For the VR simulation group, a research coordinator reviewed the upcoming cardiothoracic surgical calendar to identify patients with planned cardiothoracic surgical procedures. The coordinator approached eligible patients at a scheduled preoperative clinic visit to introduce them to this study and ask if they were interested in participating. If the patient desired to participate, the coordinator presented and reviewed a consent form.

For the historical control group, the research team reviewed medical records, extracted data, and reviewed the data for accuracy. Data collection included basic demographic data, surgical procedure, Confusion Assessment Method for the ICU scores,²⁸  duration of intraoperative cardiopulmonary bypass, durations of postoperative intravenous sedation and mechanical ventilation in the ICU, and incidence of postoperative antipsychotic medication administration in the ICU. The research coordinator contacted patients in the control group and offered them the opportunity to participate in a written survey regarding their postoperative experience in the ICU.

After patients in the VR simulation group provided consent, the research coordinator asked them a set of questions about their thoughts, feelings, and fears regarding their upcoming ICU admission. Patients then watched the 10-minute video simulation displayed on a VR headset (Oculus Quest, Meta) (Figure 2). The research coordinator then asked additional questions about what the patients learned from the VR simulation experience and how they felt this simulation experience might affect their upcoming ICU admission. The research coordinator transcribed verbal responses verbatim. After patients were discharged from the ICU to general care rooms, the research coordinator met with them to discuss their actual ICU experience. The same medical record review used for the control group was conducted for the VR simulation group.

An internal statistician assisted with statistical analysis of the medical record data. Patient characteristics were summarized using medians and IQRs for continuous variables and frequencies and percentages for categorical variables. Continuous outcomes were analyzed using linear regression. As a count variable, the number of antipsychotic medication doses was analyzed using negative binomial regression. Binary outcomes were analyzed using logistic regression. In all cases, the variable of interest was the use of VR simulation versus usual care. Univariate and multivariable models were conducted for all outcomes. Covariates included in the multivariable models included age, sex, primary procedure type, and surgery duration. In addition to these overall analyses, subgroup analyses were conducted by procedure type, surgery duration, and sex. Relevant covariates were excluded from subgroup analyses. Complete case analysis was used. Data were missing for acute postoperative delirium (21%), use of cardiopulmonary bypass (3%), and cardiopulmonary bypass duration (3%). In all cases, 2-tailed P values of .05 or less were considered significant.

A total of 138 patients admitted from June 4, 2019, to May 12, 2022, were included in the study (Figure 3). The VR simulation began in 2020. Of the 138 patients, 94 (68%) were in the historical control group and 44 (32%) were in the VR simulation group (Table 1). The median ages were 72.0 years in the control group and 50.5 years in the VR simulation group. In both groups, 77% of patients were men. Percentages of patients receiving aortic valve replacement and mitral valve replacement were similar in both groups. Coronary artery bypass graft procedures were more common in the control group (39% of patients). The cardiopulmonary bypass pump duration was longer in the VR simulation group than in the control group (Table 1). Age, procedure duration, and procedure type differed significantly between the 2 groups; patient sex distribution was similar.

The incidence of acute postoperative delirium was not different between the 2 groups (Table 2). Five of 138 patients (4 patients in the control group and 1 patient in the VR simulation group) experienced acute delirium as defined by the Confusion Assessment Method for the ICU score. The duration of postoperative intravenous sedation was 5.66 hours shorter in the VR simulation group than in the control group in the adjusted model (95% CI, −10.29 to −1.06; P = .02). The duration of postoperative mechanical ventilation was 5.69 hours shorter in the VR simulation group than in the control group in the adjusted model. Three of 138 patients (2 in the control group and 1 in the VR simulation group) received antipsychotic medications. The number of individual antipsychotic medication doses was higher in the control group (n = 16) than in the VR simulation group (n = 1). Dose models could not converge due to limited data. The mean ICU stay was 1.98 days in the control group and 1.44 days in the VR simulation group.

Patient surveys also were evaluated. Of the 94 patients in the control group who were included in the quantitative analysis, 55 accepted the invitation to participate in the survey and 26 completed the survey. All patients in the VR simulation group completed the survey. Exemplar survey responses are shown in Table 3.

Responses of patients in the control group were divided into multiple themes based on the experiences the patients reported in the surveys. Patients reported fears of the upcoming ICU admission, uncontrolled pain, loss of independence, and intubation and also reported concern for their family. Patients did not report a fear of delirium or postoperative cognitive impairment. However, they recalled that once they arrived in the ICU they felt closely monitored, safe, cared for, and informed of ICU procedures. Negative experiences reported were the endotracheal tube, severe vomiting, back pain, and feeling sedated. Anxiety was also common in this group and included perceived medication-induced anxiety and perceived altered cognition caused by medications such as ketamine. A common request of patients in this group was for preoperative education regarding their upcoming ICU admission. They also reported that knowing in advance that recovery in the ICU would have intermittent setbacks would have been beneficial. Being aware that staff members would be present and attentive to their needs and that family would be available was also important to these patients. Many patients requested that ICU staff members would “just talk to me.”

Responses of patients in the VR simulation group (after viewing the VR simulation) had multiple themes. As with the control group, patients in the VR simulation group reported preoperative anxiety and fear. However, the VR simulation helped patients know what to expect during their ICU admission. Feelings of safety and appreciation of the multidisciplinary team were common. The endotracheal tube was a common source of preoperative fear.

After the ICU stay, patients in the VR simulation group reported their actual ICU experience and the impact of the VR simulation. Overall, the reported experience in the ICU was positive. Patients reported having common symptoms of delirium. However, the VR simulation had a positive impact on their ICU experience (reported by 92% of patients) and reduced their overall anxiety. One patient reported increased anxiety due to the VR simulation. Recommendations to improve the VR simulation included shorter duration, more detailed procedural explanations, and having patients’ family members also view the VR simulation.

The preoperative VR simulation did not reduce the incidence of ICU delirium in the VR simulation group. However, the VR simulation improved other objective ICU-related patient outcomes, including reduced durations of intravenous sedation and mechanical ventilation in the ICU and reduced use of antipsychotic medications despite an overall longer cardiopulmonary bypass pump time. These improvements in patient outcomes with preoperative VR simulation education are encouraging. However, differences in ICU practices between the time periods during which the control group and the VR simulation group were hospitalized must be considered. These differences may account for some variability in sedation and extubation practices that is difficult to account for.

The most significant outcome of this study rests on patients’ reported ICU experiences after exposure to the VR simulation. Patients said the VR simulation reduced their preoperative anxiety and showed them what to expect in the ICU after the surgical procedure. The primary observations that patients made after the VR simulation were (1) feeling safe knowing that a whole team of caregivers would be attentive to their needs, (2) having a better understanding of the machinery in the ICU, and (3) less fear of the unknown.

The ICU is an unfamiliar environment to most individuals. Awakening from general anesthesia is inherently disorienting. Showing patients in advance how the environment will look and sound and what they can expect after the procedure can improve their postoperative experience in the ICU. Preoperative VR simulation also benefits the institution. Reductions in sedation need, ventilator time, and total antipsychotic medication administration can shorten patients’ ICU and hospital stays and thus reduce institutional cost.

Previous studies have evaluated the effectiveness of different preparatory or educational modalities, including VR tours, in-person tours of the operative environment, and staff-led educational sessions, for patients undergoing medical procedures. Virtual reality simulation has been shown to reduce delirium incidence and help manage pain and anxiety for patients already admitted to an ICU. To the best of our knowledge, this is the first study to evaluate the effect of a preoperative VR simulation on postoperative patient outcomes and experiences in the ICU. Continued study in this area is needed to further understand the potential impact of VR simulation on postoperative patient experience and recovery.

The primary focus of subsequent studies should be to identify the educational points desired by the learner. In this study, we focused on the concepts of safety, family presence, reorientation, and communication with the care team and provided a general understanding of the machinery and activities of the ICU. The educational focus will be different for each application. We designed the VR simulation to incorporate real-world experiences and provide appropriate educational narration to ensure that our focus topics were addressed. We believe that multiple simulations could be designed to address this patient group’s primary concerns (eg, endotracheal intubation, postoperative pain, and ICU mobility).

This study had limitations. Comparing a current intervention group (the VR simulation group) with a historical control group could lead to recall bias and be affected by changes in the sedation and extubation practices of the ICU medical team between the time periods of the 2 study groups. The ages of patients in the VR simulation and control groups were different. Because of the low incidence of delirium and the small sample size, this study was not powered to show a significant difference in delirium incidence. Conducting this study in the real-world clinical environment may have introduced other variables that could not be controlled.

Preoperative VR simulations can be used to improve the experience and outcomes of patients who will recover in the ICU after undergoing elective cardiothoracic surgical procedures. Although this study focused on a small subset of the ICU population, the concepts of VR simulation design and outcome metrics can be applied to other patients preparing to undergo medical procedures and experiences. All patients undergoing a medical procedure require pre-procedural education. Virtual reality simulation is a multisensory modality that can be easily adapted to meet this goal and significantly improve the postsurgical experience. Virtual reality simulation can be used to provide immersive education for patients recovering from surgical procedures in the ICU, thereby improving patient outcomes and the patient experience.