Development and Pilot Implementation of TACTICS VR: A Virtual Reality-Based Stroke Management Workflow Training Application and Training Framework

The Internet of Things in the Nutritional Management of Patients with Chronic Neurological Cognitive Impairment: A Scoping Review

BACKGROUND/OBJECTIVES

The Internet of Things (IoT) technology connects objects to the internet, and its applications are increasingly used in healthcare to improve the quality of care. However, the use of IoT for the nutritional management of patients with chronic neurological cognitive impairment is still in development. This scoping review aims to describe the integration of IoT and its applications to support monitoring, interventions, and nutritional education for patients with chronic neurological cognitive impairment.

METHODS

A scoping review was conducted using the Cochrane, PubMed/Medline, CINAHL, Embase, Scopus, and Web of Science databases following the Arksey and O'Malley framework.

RESULTS

Of the 1424 records identified, 10 were included in the review. Most of the articles were peer-reviewed proceedings from technology conferences or publications in scientific and technology journals. IoT-based innovations in nutritional management were discussed in methodological articles, case studies, or project descriptions. Innovations were identified across three key areas: monitoring, intervention, and education.

CONCLUSIONS

IoT technology offers promising innovations for the nutritional management of patients with chronic neurological cognitive impairment. However, IoT capabilities in this field are still in the early stages of development and are not yet highly specific.

Implementation and sustainment of virtual reality stroke workflow training for physician trainees at comprehensive stroke centres: a quantitative and qualitative study

BACKGROUND

Variation in stroke treatment metrics highlight a need for approaches to improve clinical processes. Training interventions can improve outcomes, but Australian physician trainees do not currently receive formal process-directed stroke training. Virtual reality (VR) stroke workflow training has proven acceptable, usable, useful and feasible in trial contexts, but how to integrate VR training into physician training remains unclear. The current study sought to document stroke staff perceptions of existing training and assess implementation of routine VR training at comprehensive stroke centres, outside of a trial context.

METHODS

Training was delivered to physician trainees via individual sessions or facilitated group workshops depending on the hospital site. VR usage data was captured automatically via Wi-Fi. Survey responses from both trainees and training staff were collected, with statistical comparisons performed for matching questions in pre- and post-training surveys. Themes identified in open-ended survey responses were enumerated and reported.

RESULTS

Forty-two TACTICS VR training sessions were logged at 2 hospitals between May 2022 and October 2023. Trainees reported receiving low amounts of prior formal stroke training; both trainees and training staff identified unmet needs and barriers to existing training. VR users (n = 30) provided positive feedback on VR hardware, software design, user experience, content, educational value and delivery approach (mean scores 3.9 to 4.7; 1 = strongly disagree, 5 = strongly agree). VR training improved confidence in: knowledge of acute stroke assessment / treatment (post-training vs. pre-training = 4.0±0.7 vs. 2.9±1.0; P < .0001), ability to effectively assess / treat stroke (4.0±0.6 vs. 3.1±1.0; P < .0001), ability to optimally communicate with colleagues (4.1±0.6 vs. 3.3±1.0; P < .001), understanding of workflow practices (4.3±0.6 vs. 3.2±1.2; P < .0001), ability to make improvements (4.1±0.8 vs. 3.0±1.2; P < .0001) and awareness of local stroke management criteria / processes (4.1±0.8 vs. 3.6±1.1; P < .01). Respondents suggested enhancements in funding, access, awareness, training populations and delivery modality to improve training sustainment.

CONCLUSIONS

VR stroke workflow training was perceived by trainees and training staff as feasible, acceptable, usable, useful and positively impacted stroke training. Respondents endorsed future use of VR training to support training at comprehensive stroke centres and identified aspects for improved future integration.

Tree: Reducing the use of restrictive practices on psychiatric wards through virtual reality immersive technology training

BACKGROUND

Restrictive practices (RPs) are defined by measures linked to physical and chemical restraints to reduce the movement or control behaviours during any emergency. Seclusion is an equal part of RPs intended to isolate and reduce the sensory stimulation to safeguard the patient and those within the vicinity. Using interventions by way of virtual reality (VR) could assist with reducing the need for RPs as it could help reduce anxiety or agitation by way of placing users into realistic and immersive environments. This could also aid staff to and change current RPs.

AIM

To assess the feasibility and effectiveness of using a VR platform to provide reduction in RP training.

METHODS

A randomised controlled feasibility study, accompanied by evaluations at 1 month and 6 months, was conducted within inpatient psychiatric wards at Southern Health National Health Service Foundation Trust, United Kingdom. Virti VR scenarios were used on VR headsets to provide training on reducing RPs in 3 inpatient psychiatric wards. Outcome measures included general self-efficacy scale, generalised anxiety disorder assessment 7 (GAD-7), Burnout Assessment Tool 12, the Everyday Discrimination Scale, and the Compassionate Engagement and Action Scale.

RESULTS

Findings revealed statistically significant differences between the VR and treatment as usual groups, in the Everyday Discrimination Scale items Q8 and Q9: P = 0.023 and P = 0.040 respectively, indicating higher levels of perceived discrimination in the VR group. There were no significant differences between groups in terms of general self-efficacy, generalised anxiety disorder assessment 9, and Burnout Assessment Tool 12 scores. A significant difference was observed within the VR group for compassionate engagement from others (P = 0.005) over time. Most respondents recorded System Usability Scale scores above 70, with an average score of 71.79. There was a significant reduction in rates of RPs in the VR group vs treatment as usual group with a fluctuating variability observed in the VR group likely due to external factors not captured in the study.

CONCLUSION

Ongoing advancement of VR technology enables the possibility of creating scenarios and simulations tailored to healthcare environments that empower staff by providing more comprehensive and effective training for handling situations.

Streamlining Acute Stroke Processes and Data Collection: A Narrative Review

(1) Background: Acute ischemic stroke treatment has been thoroughly studied to identify strategies to reduce treatment times. However, many centers still struggle to achieve fast treatment times. Additionally, studies primarily focus on larger, more advanced centers; yet, smaller centers often face longer treatment times. (2) Objectives: The aim of this study is to analyze the existing literature reviewing stroke treatment processes in primary and comprehensive stroke centers that investigated or reduced treatment times. The articles identified were categorized based on the focus areas and approaches used. (3) Results: Three main categories of improvements were identified in the literature: (1) standardization of processes, (2) resource management, and (3) data collection. Both primary and comprehensive stroke centers were able to reduce treatment times through standardization of the processes. However, challenges such as variations in hospital resources and difficulties incorporating data collection software into workflow were highlighted. Additionally, many strategies to optimize resources and data collection that can benefit primary stroke centers were only conducted in comprehensive stroke centers. (4) Conclusions: Many existing strategies to improve stroke treatment times, such as pre-notification and mass stroke team alerts, have been implemented in both primary and comprehensive stroke centers. However, tools such as simulation training are understudied in primary stroke centers and should be analyzed. Additionally, while data collection and feedback are recognized as crucial for process improvement, challenges persist in integrating consistent data collection methods into clinical workflow. Further development of easy-to-use software tailored to clinician needs can help improve stroke center capabilities to provide feedback and improve treatment processes.

The impact of simulation-based training in medical education: A review

Simulation-based training (SBT) has emerged as a transformative approach in medical education, significantly enhancing healthcare professionals' learning experience and clinical competency. This article explores the impact of SBT, tracing its historical development and examining the various types of simulations utilized today, including high-fidelity mannequins, virtual reality environments, standardized patients, and hybrid simulations. These methods offer a safe and controlled environment for students to practice and hone technical and non-technical skills, ultimately improving patient safety and clinical outcomes. The benefits of SBT are manifold, including enhanced skill acquisition, error reduction, and the opportunity for repeated practice without risk to actual patients. Immediate feedback and structured debriefing further solidify learning, making Simulation an invaluable tool in medical education. However, the implementation of SBT is challenging. It requires substantial financial investment, specialized equipment, and trained faculty. Additionally, there are concerns about the realism of simulations and the transferability of skills to real-world clinical settings. Despite these challenges, numerous case studies and empirical research underscore the effectiveness of SBT compared to traditional methods. Looking ahead, advancements in technology, such as artificial intelligence and improved virtual reality applications, promise to enhance the efficacy and accessibility of simulation training. The integration of Simulation with other training modalities and its adoption in diverse global contexts highlight its potential to revolutionize medical education worldwide. This article affirms the crucial role of SBT in preparing the next generation of healthcare professionals and its ongoing evolution driven by technological innovations.

Introducing Virtual Reality in a STEMI Coronary Syndrome Course: Qualitative Evaluation with Nurses and Doctors

In the increasing number of medical education topics taught with virtual reality (VR), the prehospital management of ST-segment elevation myocardial infarction (STEMI) had not been considered. This article proposes an implemented VR system for STEMI training and introduces it in an institutional course addressed to emergency nurses and case manager (CM) doctors. The system comprises three different applications to, respectively, allow (a) the course instructor to control the conditions of the virtual patient, (b) the CM to communicate with the nurse in the virtual field and receive from him/her the patient's parameters and electrocardiogram, and (c) the nurse to interact with the patient in the immersive VR scenario. We enrolled 17 course participants to collect their perceptions and opinions through a semistructured interview. The thematic analysis showed the system was appreciated (n = 17) and described as engaging (n = 4), challenging (n = 5), useful to improve self-confidence (n = 4), innovative (n = 5), and promising for training courses (n = 10). Realism was also appreciated (n = 13), although with some drawbacks (e.g., oversimplification; n = 5). Overall, participants described the course as an opportunity to share opinions (n = 8) and highlight issues (n = 4) and found it useful for novices (n = 5) and, as a refresh, for experienced personnel (n = 6). Some participants suggested improvements in the scenarios' type (n = 5) and variability (n = 5). Although most participants did not report usage difficulties with the VR system (n = 13), many described the need to get familiar with it (n = 13) and the specific gestures it requires (n = 10). Three suffered from cybersickness.

Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke

BACKGROUND

In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit.

MAIN TEXT

Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement.

CONCLUSIONS

The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.

TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study

BACKGROUND

Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context.

OBJECTIVE

We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact.

METHODS

The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training.

RESULTS

TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72%), improved understanding (16/18, 89%), and improved awareness (17/18, 94%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site).

CONCLUSIONS

TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways.

Implementation of Virtual Reality in Health Professions Education: Scoping Review

BACKGROUND

Virtual reality has been gaining ground in health professions education and may offer students a platform to experience and master situations without endangering patients or themselves. When implemented effectively, virtual reality technologies may enable highly engaging learning activities and interactive simulations. However, implementation processes present challenges, and the key to successful implementation is identifying barriers and facilitators as well as finding strategies to address them.

OBJECTIVE

This scoping review aimed to identify the literature on virtual reality implementation in health professions education, identify barriers to and facilitators of implementation, and highlight gaps in the literature in this area.

METHODS

The scoping review was conducted based on the Joanna Briggs Institute Evidence Synthesis methodologies. Electronic searches were conducted in the Academic Search Elite, Education Source, and CINAHL databases on January 5, 2022, in Google Scholar on February 2 and November 18, 2022, and in PubMed database on November 18, 2022. We conducted hand searches of key items, reference tracking, and citation tracking and searches on government webpages on February 2, 2022. At least 2 reviewers screened the identified literature. Eligible studies were considered based on predefined inclusion criteria. The results of the identified items were analyzed and synthesized using qualitative content analysis.

RESULTS

We included 7 papers and identified 7 categories related to facilitators of and barriers to implementation-collaborative participation, availability, expenses, guidelines, technology, careful design and evaluation, and training-and developed a model that links the categories to the 4 constructs from Carl May's general theory of implementation. All the included reports provided recommendations for implementation, including recommendations for careful design and evaluation, training of faculty and students, and faculty presence during use.

CONCLUSIONS

Virtual reality implementation in health professions education appears to be a new and underexplored research field. This scoping review has several limitations, including definitions and search words, language, and that we did not assess the included papers' quality. Important implications from our findings are that ensuring faculty's and students' competence in using virtual reality technology is necessary for the implementation processes. Collaborative participation by including end users in the development process is another factor that may ensure successful implementation in higher education contexts. To ensure stakeholders' motivation and potential to use virtual reality, faculty and students could be invited to participate in the development process to ensure that the educational content is valued. Moreover, technological challenges and usability issues should be resolved before implementation to ensure that pedagogical content is the focus. This accentuates the importance of piloting, sufficient time resources, basic testing, and sharing of experiences before implementation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37222.

Comparing approaches for selection, development, and deployment of extended reality (XR) teaching applications: A case study at The University of Newcastle Australia

The use of extended reality (XR) technology in education offers many advantages for transferring knowledge and practical skills training at the higher education level. As a result, many Universities over the past 5 + years have undertaken pilot programs to both develop XR content and assess how to best implement it within existing teaching and learning systems. Unfortunately, very few of these efforts have included structured evaluation or documentation. As such, limited published evidence exists to inform processes and approaches that may assist or hinder broad scale implementation. This leads many Universities to unnecessarily commit significant time and resources to testing identical or similar approaches, resulting in repeated identification of the same or similar challenges. In response to this situation, The University of Newcastle, Australia decided to systematically document the approach for selection, development and implementation of four new virtual-reality (VR) teaching applications. The current paper contains a detailed intrinsic case study, outlining the process and critical elements that shaped the selection of suitable teaching content, software development, hardware solutions and implementation. Details are provided on how decisions were made, what components were considered helpful, challenges identified, and important lessons outlined. These findings will be useful to organisations and individuals as they look to develop pathways and processes to integrate XR technology, particularly within their existing training and educational frameworks.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10639-022-11364-2.