Interview with Dr Chris Evans

Dr Chris Evans is Founder of The Little Spark Hospital, and an anaesthetic trainee with a passion for improving patient experiences of hospital. His vision is to reduce children’s anxiety before surgery through innovation, technology and co-design, for which, he has created a series of award-winning innovations. Chris will be delivering the keynote lecture at our upcoming London Paediatric Orthopaedic Meeting in June.

You are the creator and driving force behind the Little Journey and Little Sparks Hospital. Can you explain what these are and what they aim to deliver?

For a number of years, I’ve been looking at different methods to reduce children’s anxiety before surgery to improve short- and long-term, physiological and psychological outcomes from surgery. My interest in this area all started when working as an anaesthetic trainee in a DGH where I witnessed first-hand the distress of children having surgery, especially when physical restraint was used during the induction of anaesthesia. I looked at how we were preparing children for surgery at that DGH, which entailed giving adult information leaflets and felt that we could do better. Having seen how my nieces and nephews interacted with gaming technology and apps I felt there was a unique opportunity to gamify preparation for surgery, moving it away from hospital into the patient’s own home.

Little Sparks consists of a series of innovations, all at different stages of development, testing and adoption, designed to improve outcomes from surgery through reducing peri-operative anxiety. One of these innovations, Little Journey, is a smartphone application designed to prepare children and their parents for surgery in the comfort and safety of their own home. The Little Journey app enables children to undergo a virtual reality (VR) tour, so they can explore the hospital areas they’ll visit on the day of their procedure and interact with animated characters of hospital staff who explain what will happen in each area and how they might feel. Children can also practise relaxation and breathing exercises and play games designed to reinforce their learning from the virtual tour. For parents, we drip feed bite-sized pieces of information over the whole peri-operative period, provide checklists of what they need to bring to hospital and nudges/notifications to remind them of what needs to be done and when. Through the app we collect patient reported outcome measures assessing anxiety levels pre-operatively and outcomes post -operatively. Other Little Sparks innovations include superhero hospital gowns and a medical device to aid inhalation inductions through gamification of the anaesthetic process.

Virtual Reality (VR) technology and solutions are evolving as a result of demand from both industry and consumer/gaming solutions. What do you think will be the next developments in technology, and how do you anticipate they may be utilised further to support the patient experience?

The application of VR technology in healthcare flourished in 2018-19, as did the research into its effectiveness in different clinical settings – results pending for many studies! But the gaming industry continues to drive technology forward and with it new and exciting opportunities and applications continue be created. Mixed reality: very simply the combination of virtual and augmented reality to create an interactive experience, viewable as part of the user’s immediate surroundings rather than in a computer simulated environment, has huge potential not just as a patient facing solution but also as a surgical aid.

For me the biggest opportunity available to us as clinicians in the coming years is through better use of health data:

  • Machine learning can help identify variables that impact on patient outcomes that are typically invisible to the naked eye or simple statistical regression models.
  • Artificial Intelligence (AI) through deep learning can create tailored solutions for individuals based on this health data, continually training and improving the solutions as new data becomes available.
  • Improved interoperability and communication between primary, secondary and tertiary care systems will enable an improved understanding of the impact of surgery on patient outcomes and health behaviours.

These developments, I predict, will enable personalised medicine through care tailored to each individual’s personality and psychology based on their digital personality, not just their physiological scores and simple socio-demographics. I think provision of this tailored care will facilitate improved patient-clinician communication, risk and benefit discussions and customised patient pathways. However, interoperability of systems, data quality and regulation of AI algorithms are huge problems that need to be overcome – as well the scepticism of many healthcare professionals.

Tell us more about the links between VRHD (Virtual Reality Hypnosis Devices) and pain?

The use of VR in clinical care is not a new concept. An editorial in the British Journal of Anaesthesia proposed its use for procedural skills and simulation training back in 1995, but the quality, usability and acceptability of VR has improved greatly over the past few years, driven by the gaming industry. Early research studies assessed the benefit of VR when used as a distraction intervention for children and adults undergoing burns dressing changes and physiotherapy with good success. More recently it is being trialled as a distraction intervention in labouring women and those undergoing post-partum episiotomy repair!

Systematic reviews assessing use of VR in experimental pain perception and pain reduction in burn’s injury dressing changes have concluded its benefit. The neuro-pathophysiology of the pain reduction has been shown on functional MRI studies with a lowering of the perception of pain and activation of the descending pain-modulation system. In short, the more immersive the VR – or any distraction intervention – the better the pain reduction.

In addition, research has shown correlations between pre-operative anxiety with emergence agitation and increased analgesic requirements post-operatively; possibly due to catastrophisation secondary to distress.  The reduction of pre-operative anxiety through psychological preparation with VR would theoretically lower pain scores and analgesic requirements by reducing catastrophisation, but to my knowledge this hasn’t been researched yet. Hopefully my randomised controlled trial will show this!

You’re undertaking a PhD at University College London assessing how health technology and innovation affects paediatric peri-operative anxiety. Can you share some of the research focus and the techniques that will alleviate children’s anxiety?

The mainstay of my PhD has been developing and evaluating the effectiveness of the Little Journey app at reducing anxiety in children before surgery.

This started with a systematic review assessing studies performed in both children and adults where VR was used to reduce peri-operative anxiety. At the same time, I worked closely with a variety of healthcare professionals and NIHR Young Persons Advisory groups to co-design the Little Journey app. The mainstay of this early work was the focused on the provision of a customised VR tour with age tailored animations designed to familiarise and desensitise children to the clinical environment, staff and equipment they’ll see on the day of surgery. However, following a feasibility, acceptability and usability study at University College London, we identified that parents were the gatekeepers of information and that the greater the anxiety of the parents the less likely healthcare information would be passed down to the child.  So, we built a section of the app specifically for parents. In addition, we built extra features such as a therapeutic game and child-narrated relaxation animations to aid coping skill development through a multi-modal approach. In September 2019, we opened our first site participating in a multi-centre randomised controlled trial assessing the effectiveness of this new app compared to standard care at reducing anxiety and improving outcomes from surgery. We’ve now recruited 20% of our anticipated 304 patients and hope to have completed and published the trial in Spring 2021!

To what extent are your activities focused on orthopaedics?

At present, the mainstay of the development and research of Little Journey is focused on children having day case surgery, including orthopaedic procedures. We’ve focused on day case surgery, in particular those having their first general anaesthetic, as this first hospital experience is key to the development of negative health schemas. We hypothesise that by improving children’s first hospital and surgical experience, their long-term health behaviours such as medication adherence and delays in presentation when unwell will be improved lowering the health economic cost of illness. Moving forward, we are looking to expand the app content beyond day case surgery and to localise the information delivered for specific surgery types. This will include collecting patient reported outcome measures specific to different surgeries to enable its use in healthcare research.

Of note, we have also been exploring how we can gamify and track exercises through the app in the patient’s own home following surgery, enabling the early identification of those with delayed functional recovery.  We’ve submitted an Innovate UK application to help with this data collection and use AI to predict in advance those at risk of poor recovery and flag those recovering from surgery outside of the norm.

You are an NHS England Clinical Entrepreneur Fellow, can you explain what that involves?

I was appointed as a NHS England Clinical Entrepreneur fellow in 2016 following an online application and interview process. The scheme is designed to support and develop ‘clinical innovators and entrepreneurs’ while keeping people developing these skills in clinical training. Through regular pit stop meetings with lectures from key leaders in this field and small group interactions it attempts to facilitate those looking outside of traditional training. For me personally, the scheme has enabled me to meet many like-minded clinicians, opened doors and facilitated meetings with people who I never feel I should be sitting in a room with! Supported by NHS England, Department of Health and the GMC it has also enabled many trainees to reduce their clinical hours (LTFT) so they can focus on new ventures. Overall a great scheme to be involved with and well worth the application!

What drives you, and in particular your passion to support paediatric care?

I’ve always been interested in paediatrics and have spent a number of years working in the UK and Australia trying out different paediatric specialities. I chose paediatric anaesthesia because of the mix in skills required and interest in management of critically unwell patients. However, as an anaesthetist we rarely get to see or hear how the patients we anaesthetise recover after their operation and are typically focused on one patient at a time. A key driver to the work I’m doing with Little Sparks and Little Journey in particular, is the impact I am able to make on a much larger scale as well as the amazing feedback and gratitude we’re receiving from families across the UK.  This inspires me to push forward!

The projects, their aims and my focus have all evolved over a number of years based around my own experiences and what I’ve learnt. Many of my observations and assumptions were reinforced recently when my two-year-old son underwent surgery at a large tertiary paediatric centre. Seeing the whole peri-operative pathway from the other side was eye-opening, most notably the impact and strain that it had on my wife – a healthcare professional with a lot of experience in paediatrics. This definitely made me rethink my approach both clinically and from the Little Journey development.

Finally, I’ve been lucky enough to work with Starlight Children’s Foundation for the last 18 months, witnessing the impact that psychological support and play can have on children and their families when seriously or critically unwell outside of hospital. One story always springs to mind where Starlight Charity were able to fund a hot tub for a patient with spastic cerebral palsy. The child was suffering from significant pain from contractures. He would crawl into the hot tub and lie in it for hours on end, with huge improvements in his pain levels and joint range of movement, greatly benefiting his quality of life. Research typically focuses on whether drug or procedure A is better than drug or procedure B, forgetting about the simple changes that can make huge improvements to peoples’ lives. My work with Starlight reminds me of this.

You are the keynote speaker at ORUK’s upcoming London Paediatric Orthopaedic Meeting, without giving to much away can you tell us a little about your lecture?

When I started my PhD, I always thought that peri-operative anxiety and poor health behaviours were caused by a deficit of information and by correcting that deficit you would improve health behaviours. I’ve now come to realise that this may have been a little naïve and that people do not always behave in rationale ways!

At the London paediatric orthopaedic meeting I am hoping to discuss some of our early findings, new technical developments, patient reported outcomes and, looking to the future, how we plan on predicting and overcome irrationality through AI to improve health outcomes for all.

Who have been your main inspirations or role models to date?

I’ve been very fortunate to have a lot of support, role models and people who inspire me at different stages of my journey. My PhD supervisor, Prof Ramani Moonesinghe, has been a significant role model for me in recent years and kick started everything by taking a chance on me. As a clinical academic she performs large observational research trials across hundreds of hospitals and still manages to maintain a work life balance. My wife – cheesy as it sounds – is not just an inspiration but an integral part of the project. She guides and supports me, all while being a GP herself and looking after three children – I could not do it without her!

How do you like to spend your time when you’re not focused on your studies or charity work?

I’m very lucky though that I love what I do and have been able to tailor my work to the areas I’m most passionate about as well as have flexibility for my family. I have three children under three years old, with premature twins born earlier this year, so, all my time outside of my different roles is spent with my family. One day, I hope to get back to running, hockey, climbing and catching up on sleep!