Clinician of the Month: Sunil K Bhudia

DigitalHealth.London caught up with Mr Sunil K Bhudia, to find out how he’s using virtual reality to help reduce the incidence of post-operative delirium.

Health Impact

Throughout his surgical experience both at Harefield Hospital and at University Hospital Coventry and Warwickshire NHS Trust, Sunil has witnessed that an increasing number of patients undergoing cardiac surgery develop post-operative delirium. It affects 3 – 53% of those undergoing major surgery, and up to 83% of critically ill patients. It is associated with worse operative outcomes, increased morbidity & mortality, and prolonged cognitive impairment in survivors.

It is difficult to identify pre-operatively, which patients are likely to have delirium. In Cardiac Surgery, there are lots of risk factors which could predispose patients to delirium: patient factors, the scale of the operation, the anaesthesia, being hooked to a heart-lung machine (which is used to perform most cardiac operations). These factors have also been shown to have an impact on neurological outcomes. But delirium also presents in patients that have not been exposed to all of these factors.

One would expect that elderly patients are at risk of this, as age is a risk factor, but it is also found in younger patients. For example Sunil remembers a patient who was fairly young, in his 50s, who pre-operatively through the standard pre-operative assessment, would not have been identified as a patient at risk of Delirium. However by day 3 post operation the patient was quite delirious and ended up in ICU and high dependency for extra 2 days. Ideally, at day 4 post operation the patient should have been discharged, but he had to stay an extra 4-6 days. This incident Sunil describes as one that nudged him to explore solutions for addressing this problem in more detail.

Patients with post -operative delirium demand prolonged and closer nursing care in either high dependency or Intensive care unit environments, which has an impact on length of stay, patient safety risks, and costs of care to the NHS.  For example when we talk about patient safety, depending on what type of delirium whether active or inactive, a patient may be connected to lines and tubes, which often they pull at when in a delirious state.

Inspiration

Sunil started to consider potential opportunities to influence this complex problem. The pre-operative survey designed to identify patients at risk of delirium may only pick up some of these patients. Cardiac surgery anaesthesia and post operation management are fairly standard these days. Anaesthesia is extremely safe and post -operative management practices are pretty routine across NHS trusts.  So what other aspects could be influenced?

One day, abroad in a hotel, Sunil awoke in the night feeling disorientated. For about 5 seconds or so, he was confused, didn’t know where he was, and needed reassurance. He then started to recover and realised where he was. The experience got him thinking.

Relating this back to his day job, patients who have just undergone an operation, have possibly never seen or experienced the ‘operative’ environment before. It may be their first time coming to a hospital, being confronted with strangers, lots of things being done to them, lots of noise and beeping sounds, and people telling them what to do.

Introducing Innovation

Through the use of Virtual Reality patients are exposed to the environment they will actually experience, from ward to anaesthetic room to the intensive care unit or recovery care unit bed, before being admitted into hospital to undergo their operation. Every hospital will have its own footage.

The only other way to expose patients to their environment pre-operatively would be to physically take the patient to the environment, to all the various rooms. But this may frighten them, particularly if they witness unexpected incidents and emergencies. The nursing staff would likely not have time to supervise this. This would also create issues around privacy with regard other patients in the rooms.

A high definition 360 degree recording takes the patient through the actual journey they will make as follows:

1. Ward – although one problem faced was not being able to predict which bed the patient would be admitted in to
2. Journey from ward to operating theatre suite
3. Anaesthesia room
4. Operating theatre
5. Record up to the point when they get the anaesthetic
6. ICU or Recovery Care Unit with sounds, beeps, people talking to them, proximity of staff to the bed, and equipment.

The recording will be from the perspective of the patient as they are being wheeled from place to place. The vision is that every patient that comes through the pre-assessment clinic will be given the opportunity to see the recording if they consent to it. Patients are able to use this unsupervised, and can watch the recording for as long as they like, stopping it when they like. Alternatively, patients can take the VR head set home to watch it.  In addition, urgent case patients admitted from other hospitals will also be offered the VR immersive experience.

Driving adoption

So far Sunil, supported by Dr Keith Grimes has successfully completed the proof of concept. Dr Keith Grimes is a VR advocate and activist in Primary Care. The scope of the Proof of Concept is one 360 degree recording downloaded onto a laptop and a Samsung phone of a patient journey at Harefield hospital. This included:

• One ward
• Journey from ward to the theatre suite
• Hospital corridor including paintings on the wall
• The lift journey
• One of the ITU beds in a quiet side room

The 360 camera was placed on a hospital bed for 30 seconds. The quality of the recording at this stage is not high definition, so one is not able to completely distinguish the exact facial identify of people that may appear in the video. The recording can be viewed using one currently available VR headset.

The recording has been shown to one anaesthetist, who happens to also be keen to explore the application of VR in Post Traumatic Stress Disorder (PTSD) in healthcare versus the army where it has been evidenced. The recording has also been shown to one other cardiac surgeon, who was supportive, two ward nurses, three advanced nurse practitioners, and two pre-assessment nurses. Further, one respiratory physician who is interested in looking after patients on ICU was also shown the recording, as well as three ICU nurses.

The pre-assessment nurses see all routine patients and were asked to request with the patients if they would be willing to view the recording. Two patients were shown the recording as part of the proof of concept. The feedback from both was positive.

Developing and scaling the concept

To develop this to the next phase, which is ‘feasibility’ pilot study a more refined and high definition recording is required for two wards, plus a noisy true to life ITU environment. Timing of the recordings is also crucial in order to accurately reflect the environment the patient will be exposed to. At Royal Brompton and Harefield NHS Foundation Trust, for example, cardiac patients tend to have surgery in the morning or just after midday.

The application of VR goes far beyond cardiac surgery, as post-operative delirium is a potential impact of all major surgery. This provides a future opportunity to scale this to other ICU units on a hospital basis as opposed to a speciality basis.

Furthermore, there is increasing interest in the application of VR in PTSD.

There is a lot of hard work ahead, and some hurdles anticipated to moving this forward.

• There is currently no research available to support the use of virtual reality in reducing the incidence of post-operative delirium.
• There is no current baseline to measure impact against. The literature says 3-80% pf patients may have post-operative delirium.
• To prove whether this has any impact at all, it is likely that a randomised controlled trial (RCT) will need to be conducted, for which Sunil and his team will require expert support and funding. Ethics approval will also have to be sought.
• Further funding is required to ensure high quality recording, and to buy the VR head set equipment through which to immerse the patients. For instance, to support 1000 surgical cases per year, the trust will need 20 headsets which are safe from an infection cross contamination perspective.
• Finally, for many whether that be NHS staff or patients, the use of a technology traditionally associated with gaming might take some time to be accepted, until firm evidence is developed. Whilst for others, the early adopters and innovators, the application of VR in healthcare to reduce the incidence of post- operative delirium may be seen as a welcomed development.

The future vision for this technology extends to embedding pop-up ‘I’ information boxes linked to items visible in a 360 recording that allow the patient to access further information, pitched at an educational level. For example, if the patient wanted to find out more about the purpose of a drip stand or one of the monitor’s. Sunil hopes that such technology could be used to broaden the scope of information dissemination to the patient, to healthcare advice such as post -operative tips on exercise, smoking cessation, diet, rehabilitation, once the patient returns home, to prepare them for their general recovery and rehabilitation.

There is also potential to extend the use of this VR technology to the health care professional to enable them to see the hospital from the patient’s perspective. This might provide the insight required to support training and development of bed side manner skills.

Impact on the healthcare system

The desired and predicted impact of virtual reality applied in this way is that it will reduce the incidence of post- operative delirium, although this needs to be fully tested as part of an RCT.

Post- operative delirium presents:

• Patient safety issues: with patients in an active state of delirium and agitated inadvertently pulling on tubes, drains or lines. Further if a patient has to stay in hospital longer than planned this can increase the risk of complications such as infections and DVTs.
• Increased risk of medication related side effects: due to the medications that have to be administered to manage the patient in their delirious post -operative state.
• Prolonged length of stay: has a cost implication on the trust and the NHS. Patients with delirium will need more nursing care on ICU and high dependency units. For the trust if patients can be released home in a shorter period of time, surgeons can do more cases. This is because one of the bottlenecks is the availability of recovery beds and / or ICU beds. This points to a financial incentive for the trust.

The cost of post- operative delirium across all major surgeries is $38 – $152 billion per annum in the USA.

In the UK we do not have comparative data as in the North America. However, the clinical and economic burden will be similar. Importantly, any intervention that has a positive impact on clinical and economic outcomes in the NHS means that another over-stretched part of the NHS can be helped.

Sunil has learned a lot from his innovation experience to date. He shares his 4 key learnings with DigitalHealth.London, that might benefit other health care professionals out there trying to navigate their way through turning their idea into a reality:

1. If you have an idea, don’t just keep it as an idea, start working towards it. Start finding people you can work with.
2. Keep knocking on doors – and persevere. You may knock on a door and it may not open, or you may knock on another door, and the person on the other side says they can’t help.
3. Don’t give up. Dyson never gave up. You may get to a point where you think this is not what you’ve trained to do, you’ve been trained to be a doctor or a surgeon , and that you have family at home to support. Keep going. Don’t give up until you’re absolutely satisfied that your idea is not going to go anywhere.
4. Don’t just narrow your reading to your own speciality. The answer you seek may be found in other disciplines, outside of medicine entirely.