Sam Geuens1, Sanne Nauts2, Anas Abdelrazeq3, Michael Aertsen1, Gunnar Buyse1, Philippe Demaerel1, Jurgen Lemiere1, Jessica Nijs1, Greet Pauwels4, Marlies Potoms5, Saini Privender2, Kate Sauer4, Marie Sjölinger 6, Olov Ståhl6, Marlies Treunen7, Sofie Van Cauter8,9, Leen Wouters8,9, and Barbara Weyn7
1University Hospitals Leuven, KU Leuven, Leuven, Belgium, 2Philips, Eindhoven, Netherlands, 3RWTH Aachen University, Aachen, Germany, 4AZ Sint-Jan Brugge, Brugge, Belgium, 5Jessa Ziekenhuis, Hasselt, Belgium, 6RISE, Stockholm, Sweden, 7KU Leuven, Leuven, Belgium, 8Ziekenhuis Oost-Limburg, Genk, Belgium, 9Center for Translational Psychological Research TRACE, Ziekenhuis Oost-Limburg, Genk, Belgium
Synopsis
Undergoing an awake MRI-scan can be very stressful for young children and bears the risk that image quality is poor due to motion artefacts. Behavioral training by an experienced trainer has shown success in preparing children before a scan, however, this approach is costly and trainer dependent. We have designed a mobile app to prepare children for an upcoming MRI-scan at home. This app was tested by 52 children in four different hospitals. First data show that children and parents appreciate the app very much and that learning goals can be reached with a digital application at home.
Introduction
For children, undergoing an MRI-scan can be a stressful event. MRI-scans are noisy, occur in an unfamiliar setting and can take a long time. Additionally, children are expected to lie still for an extended period. Consequently, pediatric MRI-scans can sometimes yield poor image quality (e.g. due to motion artefacts). Therefore, scans are sometimes performed using sedation or general anesthesia, which may improve image quality but at higher costs for the healthcare system, prolonged time in the hospital and possibly negative long-term effects1. Different interventions have been tested in clinical practice to reduce anxiety and sedation, ranging from VR-apps2 and multifaceted children-centered care concepts3 to therapy dog-interventions4,5. A comprehensive face-to-face training protocol was developed at the University Hospitals Leuven, Belgium (the “Cosmo protocol”). In this protocol, a trainer teaches children about different aspects of MRI through storytelling about space travel, relating the MRI-scan to different aspects of travelling through space (e.g. comparing MRI-sounds to the sounds of a rocket). To scale up this resource-intensive live training, our European consortium developed a smartphone app to prepare children with a gamified mobile app6. We report the learning goals of the app, as well as initial data of users’ experiences with the app. Methods
Based on the Cosmo-protocol, a group of experts (incl. child psychologists and MRI technologists) created a list of learning goals that children need to master in order to successfully complete an MRI-scan. Games were developed to teach children about these learning goals along with a reward system, all in a space-themed story. A small quiz-like game was included to evaluate the gained knowledge. The game was developed as a smartphone app through an iterative development process including user tests with small groups of children. The final version was used in a multicenter study in four Belgian hospitals with children between 4 and 10 years old. A welcome package with a smartphone with the app and a baseline questionnaire was sent home one week before the MRI-appointment so the child was able to play with the app. While playing, user and usage data were logged on the smartphone. On the day of the MRI-scan, the child was welcomed by a trained researcher. If the child did not meet the predefined criteria to be ready for the MRI-scan, extra face-to-face training was given to prepare the child. Both parents and children completed questionnaires about user preferences before and after the scan. This research project was conducted following the approval of the medical ethical committees of the involved hospitals. Results
Seven learning goals were defined by the group of experts: 1) learn about the MRI-procedure, 2) familiarization with MRI-sounds, 3) familiarization with the size of the MRI-scanner, 4) understanding the timing and duration, 5) practice lying still, 6) learn about accessories such as earplugs and head coil, and 7) understand that metal is not allowed in the MRI-room7. Mini games were designed around these learning goals to form the app. A space and astronaut training camp was designed to be used as the overall app theme.
Fifty-two children in four different Belgian hospitals used this app at home in the week before having the scan. The average age was 7.02 years (SD = 1.66, range 4-10 years). Children played an average of 133.29 (SD = 3.67) minutes with the app. Parents rated the app as helpful in preparing their children for their MRI (M = 8.60, SD = 2.91; scale 1 not helpful; 10 very helpful). They also rated their overall satisfaction about using the app with an average of 9.0 (SD = 1.14, scale 1-10). Children themselves gave a score of 4.32 out of 5 (SD = 1.00) on experienced pleasure of playing with the app. Although 62% did not know what an MRI-scanner was before playing with the app, they rated themselves 4.02 out of 5 (SD = 1.00) on the question how much they know about an MRI scan after playing with it. Results from the quiz-like game showed every child passed the quiz with more than 50% correct answers (M = 90.00%, SD = 0.09%). Discussion
For children, stress and anxiety can negatively impact an MRI-scan and result in poor image quality. Next to anesthesia/sedation, behavioral training is successfully used to prepare children for an MRI scan to optimize the outcome. However, this approach is time consuming and highly dependent upon trained personnel. The current consortium defined seven different learning goals to prepare children for an MRI-scan and turned them into a digital smartphone application children can play with at home.
Preliminary results of our multicenter study suggest children and parents appreciate the app, and that children report they learned a lot about MRI-scans from this app. Results also suggest that learning goals can be reached with a digital application at home. Further research is ongoing to investigate if the app is successful in reducing anxiety and stress and facilitating cooperation during MRI-scans. Conclusion
Results show that children and parents appreciate the app very much and that the learning goals are reached. The COSMO app has shown promise as a useful aid in supporting awake pediatric MRI-scans. Acknowledgements
We genuinely thank all the children, parents and healthcare providers who participated in or helped with this study. This project was funded by EIT health. References
1 Vanderby, S. A., Babyn, P. S., Carter, M. W., Jewell, S. M., & McKeever, P. D. (2010). Effect of anesthesia and sedation on pediatric MR imaging patient flow. Radiology, 256(1), 229-237.
2 Liszio, S., Graf, L., Basu, O., & Masuch, M. (2020, June). Pengunaut trainer: a playful VR app to prepare children for MRI examinations: in-depth game design analysis. In Proceedings of the Interaction Design and Children Conference (pp. 470-482).
3 Runge, S. B., Christensen, N. L., Jensen, K., & Jensen, I. E. (2018). Children centered care: Minimizing the need for anesthesia with a multi-faceted concept for MRI in children aged 4–6. European journal of radiology, 107, 183-187.
4 Perez, M., Cuscaden, C., Somers, J. F., Simms, N., Shaheed, S., Kehoe, L. A., ... & Greer, M. L. C. (2019). Easing anxiety in preparation for pediatric magnetic resonance imaging: a pilot study using animal-assisted therapy. Pediatric radiology, 49(8), 1000-1009.
5 Munn, Z., & Jordan, Z. (2013). Interventions to reduce anxiety, distress, and the need for sedation in pediatric patients undergoing magnetic resonance imaging: a systematic review. Journal of Radiology Nursing, 32(2), 87-96.
6 https://eithealth.eu/project/cosmohome/
7 Sjölinder, M., Stahl, O., Einebrant, E., Vesselenyi, L.S., Stor Swinkels, N., Abdelrazeq, A., Khodaei Dolouei, S., Hohlbaum, K., Weyn, B., Verly, M., Geuens, S., Nijs, J., Treunen, M., Nauts, S., Privender S., Tasar, O., Heuvelink, A. (2021). The COSMO@Home Application – Iterative Development and Implementation of the Learning Goals. The Fourteenth International Conference on Advances in Computer-Human Interactions - ACHI 2021, July 17-22, 2021, Nice, France.