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Journal Description

JMIR Perioperative Medicine (JPOP, Editor-in-chief: John F. Pearson MD, Harvard Medical School) is an open access journal focusing on technologies, medical devices, apps, engineering, informatics and patient education for perioperative medicine and nursing, including pre- and post-operative education, preventative interventions and clinical care for surgery and anaesthesiology patients, as well as informatics applications in anesthesia, surgery, critical care and pain medicine.

We are read by clinicians and patients alike and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

During a limited period of time, there are no fees to publish in this journal. Articles are carfully copyedited and XML-tagged, ready for submission in PubMed Central.

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Recent Articles:

  • Source: freepik; Copyright: peoplecreations; URL:;

    Preoperative Fasting Practices Across Three Anesthesia Societies: Survey of Practitioners


    Background: Pulmonary aspiration of gastric contents is recognized as a complication of anesthesia. To minimize that risk, anesthesiologists advised fasting for solid foods and liquids for an often prolonged period of time. However, 30 years ago, evidence was promulgated that fasting for clear liquids was unnecessary to ensure an empty stomach. Despite a strong evidence base and the knowledge that fasting may be physiologically harmful and unpleasant for patients, the adoption of society guidelines recommending short fasting periods for clear fluids into clinical practice is uncertain. Objective: This study aimed to determine the current practices of anesthetists with respect to fasting guidelines. Methods: An electronic internet survey was distributed to anesthetists in Canada (CAN), Australia and New Zealand (ANZ), and Europe (EUR) during April 2014 to February 2015. The anesthetists were asked about fasting guidelines, their recommendations to patients for the consumption of clear fluids and solid foods, and the reasons and consequences if these guidelines were not followed. Results: A total of 971 anesthetists completed the survey (CAN, n=679; ANZ, n=185; and EUR, n=107). Although 85.0% (818/962) of these participants claimed that their advice to patients followed current society guidelines, approximately 50.4% (476/945) enforced strict fasting and did not allow clear fluids after midnight. The primary reasons given were with regard to problems with a variable operating room schedule (255/476, 53.6%) and safety issues surrounding the implementation of clear fluid drinking guidelines (182/476, 38.2%). Conclusions: Many anesthetists continue to follow outdated practices. The current interest in further liberalizing preoperative fluid intake will require more change in anesthesia culture.

  • Source: iStock by Getty Images; Copyright: Sasha_Suzi; URL:; License: Licensed by the authors.

    An Automated Text Messaging System (Tonsil-Text-To-Me) to Improve Tonsillectomy Perioperative Experience: Exploratory Qualitative Usability and Feasibility...


    Background: Inexperience and forgetting perioperative care instruction are significant drivers of parental stress during pediatric tonsillectomy care. With the widespread use of mobile technology, parents now desire a system that provides them with information that is timely, accessible, and comprehensive. Tonsil-Text-To-Me (TTTM) is a text messaging system that sends out automated and timed texts to parents of children who are undergoing tonsillectomy. Objective: The objective of this study was to pilot-test TTTM to assess for feasibility and usability and collect suggestions for system improvements desired by parents from a pediatric otolaryngology text message service. Methods: Parents of pediatric patients who were being scheduled for tonsillectomy with or without adenoidectomy were prospectively enrolled. An exploratory qualitative study using a semistructured interview guide was performed after parents received the automated texts 2 weeks before and 1 week after their child’s surgery. Results: A total of 7 parents were interviewed (data saturation was reached). Participants were all of maternal relation to the patient. Overall, all parents felt that the TTTM service was an improvement to the current standard model of information delivery. Parents also reported that the text messages reduced their anxiety and improved their performance when caring for their children during the perioperative period. No parents expressed privacy concerns about receiving texts and regarding the information included in the messages. Service suggestions showed that parents were eager for more information and had a high threshold for message reception regarding their child’s surgical care. Conclusions: All parents expressed enthusiasm for a text message service during their child’s tonsillectomy perioperative period. The care instructions and reminders provided to parents via automated and timed text messages may be a strategy to improve information delivery in a simple and accessible format that could empower families in their own health care.

  • Source: Freepik; Copyright: pressfoto; URL:; License: Licensed by JMIR.

    Potential Benefits and Drawbacks of Virtual Clinics in General Surgery: Pilot Cross-Sectional Questionnaire Study


    Background: Escalating demand for specialist health care puts considerable demand on hospital services. Technology offers a means by which health care providers may increase the efficiency of health care delivery. Objective: The aim of this study was to conduct a pilot study of the feasibility, benefits, and drawbacks of a virtual clinic (VC) in the general surgical service of a busy tertiary center. Methods: Patient satisfaction with current care and attitudes to VC were surveyed prospectively in the general surgical outpatient department (OPD; n=223). A subset of patients who had undergone endoscopy and day surgery were recruited to follow-up in a VC and subsequently surveyed with regard to their satisfaction (20/243). Other outcomes measured included a comparison of consultation times in traditional and virtual outpatient settings and financial cost to both patients and the institution. Results: Almost half of the patients reported barriers to prospective use of VCs. However, within the cohort who had been followed-up in the VC, satisfaction was higher than the traditional OPD (100% as compared with 187/223, 83.9%). Significant savings in both time (P=.003) and financial costs to patients and the institution were found. Conclusions: For an appropriately selected group of patients, VCs offer a viable alternative to traditional OPD. This alternative can improve both patient satisfaction and efficiency of patient care.

  • Subject during the stimulation in a VR environment, including the whole setup. Source: Image created by Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Comparing the Relaxing Effects of Different Virtual Reality Environments in the Intensive Care Unit: Observational Study


    Background: After a prolonged intensive care unit (ICU) stay, approximately 50%-75% of all critically ill patients suffer from neurocognitive late effects and a reduction of health-related quality of life. It is assumed that the noisy and stressful ICU environment leads to sensory overload and deprivation and potentially to long-term cognitive impairment. Objective: In this study, we investigated three different virtual reality environments and their potentially restorative and relaxing effects for reducing sensory overload and deprivation in the ICU. Methods: A total of 45 healthy subjects were exposed to three different environments, each 10 minutes in length (dynamic, virtual, natural, and urban environments presented inside the head-mounted display, and a neutral video on an ICU TV screen). During the study, data was collected by validated questionnaires (ie, restoration and sickness) and sensors to record physiological parameters (240 hertz). Results: The results showed that the natural environment had the highest positive and restorative effect on the physiological and psychological state of healthy subjects, followed by the urban environment and the ICU TV screen. Conclusions: Overall, virtual reality stimulation with head-mounted display using a dynamic, virtual and natural environment has the potential, if directly used in the ICU, to reduce sensory overload and deprivation in critically ill patients and thus to prevent neurocognitive late effects.

  • Source: Unsplash; Copyright: Sharon McCutcheon; URL:; License: Licensed by JMIR.

    Listening to the HysterSisters: A Retrospective Keyword Frequency Analysis of Conversations About Hysterectomy Recovery


    Background: In the postoperative period, individual patient experiences vary widely and are based on a diverse set of input variables influenced by all stakeholders in and throughout the surgical process. Although clinical research has primarily focused on clinical and administrative datasets to characterize the postoperative recovery experience, there is increasing interest in patient-reported outcome measures (PROMs). The growth of online communities in which patients themselves participate provides a venue to study PROMs directly. One such forum-based community is HysterSisters, dedicated to helping individuals through the experience of hysterectomy, a major surgery which removes the uterus. The surgery can be performed by a variety of methods such as minimally invasive approaches or the traditional abdominal approach using a larger incision. The community offers support for “medical and emotional issues [...] from diagnosis, to treatment, to recovery.” Users can specify when and what type of hysterectomy they underwent. They can discuss their shared experience of hysterectomy and provide, among other interactions, feedback, reassurance, sympathy, or advice, thus providing a unique view into conversations surrounding the hysterectomy experience. Objective: We aimed to characterize conversations about hysterectomy recovery as experienced by users of the HysterSisters online community. Methods: A retrospective keyword frequency analysis of the HysterSisters Hysterectomy Recovery forum was performed. Results: Within the Hysterectomy Recovery forum, 33,311 unique users declared their hysterectomy date and type and posted during the first 12 weeks postsurgery. A taxonomy of 8 primary symptom groups was created using a seed list of keywords generated from a term frequency analysis of these threads. Pain and bleeding were the 2 most mentioned symptom groups and account for almost half of all symptom mentions (19,965/40,127). For symptoms categories such as pain and hormones and emotions, there was no difference in the proportion of users mentioning related keywords, regardless of the type of hysterectomy, whereas bleeding-related or intimacy-related keywords were mentioned more frequently by users undergoing certain minimally invasive approaches when compared with those undergoing abdominal hysterectomy (AH). Temporal patterns in symptom mentions were noted as well. The majority of all posting activity occurred in the first 3 weeks. Across all keyword groups, individuals reporting minimally invasive procedures ceased forum use of these keywords significantly earlier than those reporting AH. Peaks in conversation volume surrounding particular symptom categories were also identified at 1, 3, and 6 weeks postoperatively. Conclusions: HysterSisters Hysterectomy Recovery forum and other such forums centered on users’ health care experience can provide novel actionable insights that can improve patient-centered care during the postoperative period. This study adds another dimension to the utility of social media analytics by demonstrating that measurement of post volumes and distribution of symptom mentions over time reveal key opportunities for beneficial symptom-specific patient engagement.

  • Source: flickr; Copyright: BCcampus_News; URL:; License: Public Domain (CC0).

    Impact of an Intensive Care Information System on the Length of Stay of Surgical Intensive Care Unit Patients: Observational Study


    Background: The implementation of computerized monitoring and prescription systems in intensive care has proven to be reliable in reducing the rate of medical error and increasing patient care time. They also showed a benefit in reducing the length of stay in the intensive care unit (ICU). However, this benefit has been poorly studied, with conflicting results. Objective: This study aimed to show the impact of computerization on the length of stay in ICUs. Methods: This was a before-after retrospective observational study. All patients admitted in the surgical ICU at the Rouen University Hospital were included, from June 1, 2015, to June 1, 2016, for the before period and from August 1, 2016, to August 1, 2017, for the after period. The data were extracted from the hospitalization report and included the following: epidemiological data (age, sex, weight, height, and body mass index), reason for ICU admission, severity score at admission, length of stay and mortality in ICU, mortality in hospital, use of life support during the stay, and ICU readmission during the same hospital stay. The consumption of antibiotics, biological analyses, and the number of chest x-rays during the stay were also analyzed. Results: A total of 1600 patients were included: 839 in the before period and 761 in the after period. Only the severity score Simplified Acute Physiology Score II was significantly higher in the postcomputerization period (38 [SD 20] vs 40 [SD 21]; P<.05). There was no significant difference in terms of length of stay in ICU, mortality, or readmission during the stay. There was a significant increase in the volume of prescribed biological analyses (5416 [5192-5956] biological exams prescribed in the period before Intellispace Critical Care and Anesthesia [ICCA] vs 6374 [6013-6986] biological exams prescribed in the period after ICCA; P=.002), with an increase in the total cost of biological analyses, to the detriment of hematological and biochemical blood tests. There was also a trend toward reduction in the average number of chest x-rays, but this was not significant (0.55 [SD 0.39] chest x-rays per day per patient before computerization vs 0.51 [SD 0.37] chest x-rays per day per patient after computerization; P=.05). On the other hand, there was a decrease in antibiotic prescribing in terms of cost per patient after the implementation of computerization (€149.50 [$164 USD] per patient before computerization vs €105.40 [$155 USD] per patient after computerization). Conclusions: Implementation of an intensive care information system at the Rouen University Hospital in June 2016 did not have an impact on reducing the length of stay.

  • The telePORT app providing an overview of the cases running in the main operating rooms. Source: BC Children's Hospital Research Institute; Copyright: BC Children's Hospital Research Institute; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Development and Implementation of the Portable Operating Room Tracker App With Vital Signs Streaming Infrastructure: Operational Feasibility Study


    Background: In the perioperative environment, a multidisciplinary clinical team continually observes and evaluates patient information. However, data availability may be restricted to certain locations, cognitive workload may be high, and team communication may be constrained by availability and priorities. We developed the remote Portable Operating Room Tracker app (the telePORT app) to improve information exchange and communication between anesthesia team members. The telePORT app combines a real-time feed of waveforms and vital signs from the operating rooms with messaging, help request, and reminder features. Objective: The aim of this paper is to describe the development of the app and the back-end infrastructure required to extract monitoring data, facilitate data exchange and ensure privacy and safety, which includes results from clinical feasibility testing. Methods: telePORT’s client user interface was developed using user-centered design principles and workflow observations. The server architecture involves network-based data extraction and data processing. Baseline user workload was assessed using step counters and communication logs. Clinical feasibility testing analyzed device usage over 11 months. Results: telePORT was more commonly used for help requests (approximately 4.5/day) than messaging between team members (approximately 1/day). Passive operating room monitoring was frequently utilized (34% of screen visits). Intermittent loss of wireless connectivity was a major barrier to adoption (decline of 0.3%/day). Conclusions: The underlying server infrastructure was repurposed for real-time streaming of vital signs and their collection for research and quality improvement. Day-to-day activities of the anesthesia team can be supported by a mobile app that integrates real-time data from all operating rooms.

  • A Panda app notification prompting parents to give their child medication. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    A Postoperative Pain Management Mobile App (Panda) for Children at Home After Discharge: Usability and Feasibility


    Background: Emphasis on outpatient pediatric surgical procedures places the burden of responsibility for postoperative pain management on parents or guardians. Panda is a mobile phone app that provides scheduled medication alerts and allows parents to track their child’s pain and medication administration. We have previously tested and optimized the usability and feasibility of Panda within the hospital setting. Objective: The purpose of this study was to evaluate and optimize the usability and feasibility of Panda for use at home based on alert response adherence (response to any medication notification within 1 hour) and parents’ satisfaction. Methods: Parents or guardians of children aged 3 to 18 years undergoing day surgery were recruited to use Panda at home for 1 to 7 days to manage their scheduled medications and to assess their child’s pain. After the surgical procedure, a research assistant guided parents through app setup before independent use at home. We aimed to recruit 10 child-caregiver pairs in each of three rounds of evaluation. Each user’s adherence with the recommended medication alerts was analyzed through audit-trail data generated during the use of the app. We used the Computer System Usability Questionnaire and a poststudy phone interview to evaluate the app’s ease of use and identify major barriers to adoption. Suggestions provided during the interviews were used to improve the app between each round. Results: Twenty-nine child-caregiver pairs participated in three rounds, using the app for 1 to 5 days. Alert response adherence (response to any medication notification within 1 hour) improved as the study progressed: participants responded to a median 30% (interquartile range [IQR] 22%-33%) of alerts within 1 hour in round 1, and subsequently to median 60% (IQR 44%-64%) in round 2 and median 64% (IQR 56%-72%) in round 3 (P=.005). Similarly, response times decreased from median 131 (IQR 77-158) minutes in round 1 to median 31 (IQR 18-61) minutes in round 2 and median 10 (IQR 2-14) minutes in round 3 (P=.002). Analysis of interview feedback from the first two rounds revealed usability issues, such as complaints of too many pages and trouble hearing app alerts, which were addressed to streamline app function, as well as improve visual appearance and audible alerts. Conclusions: It is feasible for parents or guardians to use Panda at home to manage their child’s medication schedule and track their pain. Simple modifications to the app’s alert sounds and user interface improved response times.

  • Source: Freepik; Copyright: Freepik; URL:; License: Licensed by JMIR.

    Children’s Use of and Experiences With a Web-Based Perioperative Preparation Program: Directed Content Analysis


    Background: Web-based technology is useful as an alternative means of providing preparation programs to children in pediatric care. To take full advantage of Web-based technology, there is a need to understand how children use and learn from such programs. Objective: The objective of this study was to analyze children’s use of and experiences with a Web-based perioperative preparation program in relation to an educational framework of children’s learning. Methods: This study is the final part of a three-phase study in which all families with children aged 3 to 16 years (N=32) admitted for outpatient surgery over 1 week were asked to participate. Children were interviewed before (phase 1) and after (phase 2) anesthesia and surgery and 1 month after hospitalization (phase 3). The data in this study (phase 3) relate to six children (5 to 13 years) who participated in the follow-up interviews in their homes a month after hospitalization. The study used a directed qualitative interpretative approach. The interviews were conducted in a semistructured manner as the children—without guidance or influence from the interviewer—visited and navigated the actual website. The data were analyzed based on a combination of the transcribed interviews and field notes, and were subjected to a previous theoretical investigation based on children’s learning on a website in pediatric care. Results: Six children, five boys (5-12 years) and one girl (13 years), participated in the follow-up study in their homes a month after hospitalization. The children were selected from the 22 initially interviewed (in phases 1 and 2) to represent a variation of ages and perioperative experiences. The children’s use of and experiences with the website could be explained by the predetermined educational themes (in charge of my learning, discover and play, recognize and identify, and getting feedback), but additional aspects associated with children’s need for identification, recognition, and feedback were also revealed. The children used the website to get feedback on their own experiences and to interact with and learn from other children. Conclusions: This analysis of children’s use of and experiences with a Web-based preparation program emphasizes the importance of including a theoretical educational framework of children’s learning in the development and design of websites in pediatric care. Creating opportunities for Web-based communication with others facing similar experiences and possibilities for receiving feedback from adults are important factors for future consideration.

  • 360 degree video tour demonstration in patient consultation room. The video can be viewed by the patient and the child life therapist simultaneously. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An Interactive Virtual Reality Tour for Adolescents Receiving Proton Radiation Therapy: Proof-of-Concept Study


    Background: Child life therapists provide patient education for children undergoing radiation therapy to assist in coping with and understanding their treatment. Objective: This proof-of-concept study aimed to determine the feasibility of incorporating a 360-degree video tour via a virtual reality system for children scheduled to receive radiation therapy. The secondary objective was to qualitatively describe each subject’s virtual reality experience. Methods: Children aged ≥13 years scheduled to receive proton radiation therapy were included in the study. Subjects watched the 360-degree video of the radiation therapy facility in an immersive virtual reality environment with a child life therapist experienced in coaching children receiving radiation therapy and completed a survey after the tour. Results: Eight subjects consented to participate in the study, and six subjects completed the 360-degree video tour and survey. All the enrolled patients completed the tour successfully. Two subjects did not complete the survey. Two subjects requested to pause the tour to ask questions about the facility. Five subjects said the tour was helpful preparation before undergoing proton radiation therapy. Subjects stated that the tour was helpful because “it showed [them] what’s to come” and was helpful to see “what it’s like to lay in the machine.” One subject said, “it made me feel less nervous.” Six subjects stated that they would like to see this type of tour available for other areas of the hospital, such as diagnostic imaging rooms. None of the subjects experienced nausea or vomiting. Conclusions: The 360-degree video tour allowed patients to explore the treatment facility in a comfortable environment. Participants felt that the tour was beneficial and would appreciate seeing other parts of the hospital in this manner.

  • Patient lying in supine position. Source: Unsplash; Copyright: Marlon Lara; URL:; License: Licensed by JMIR.

    The Trendelenburg Position and Cognitive Decline: A Case-Control Interventional Study Involving Healthy Volunteers


    Background: Postoperative cognitive decline (POCD) is defined as a new cognitive impairment arising after a surgical intervention. Aspects of cognitive function can be assessed using various validated cognitive function tests including the N-back task, the Stroop task, and the lexical decision-making task (LDT). There is some concern that prolonged Trendelenburg positioning during laparoscopic colorectal surgery may cause POCD. Objective: The objective of this study was to assess the effect of time spent in the Trendelenburg position on cognitive function. Methods: Volunteers were placed in the Trendelenburg position for 3 hours and, then, supine for 30 minutes. Validated cognitive function tests including 1-, 2-, and 3-back tasks, Stroop test, and LDT were performed at baseline and every 30 minutes after Trendelenburg positioning. Cognitive decline was defined per the International Study of Postoperative Cognitive Dysfunction trial: a decrease in accuracy from the volunteers’ baseline or an increase in response time from the volunteers’ baseline by >2 control group SDs. Results: We recruited 15 healthy volunteers (8 males, 7 females) with an average age of 69 years (range 57-81) and average body mass index of 27.7 kg/m2 (range 20.9-33). Accuracy remained within 2 SDs at all time points. An increase in response time did occur, and of 15 participants, 3 (20%) showed cognitive decline in the Trendelenburg position after 30 minutes, 4 (27%) after 1 hour, 5 (33%) after 90 minutes, 4 (27%) after 120 and 150 minutes, and 6 (40%) after 180 minutes. On moving to a supine position, 33% (5/15) participants showed cognitive decline. Conclusions: The results of this study indicate that Trendelenburg positioning leads to cognitive decline. This may have implications for patients undergoing prolonged Trendelenburg positioning during laparoscopic colorectal surgery.

  • Patient interacting with home monitor to send blood pressure measurements to clinicians. Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Postoperative Home Monitoring After Joint Replacement: Retrospective Outcome Study Comparing Cases With Matched Historical Controls


    Background: A retrospective cohort study was conducted in patients undergoing postoperative home monitoring (POHM) following elective primary hip or knee replacements. Objective: The objectives of our study were to compare the cost per patient, readmissions rate, emergency room visits, and mortality within 30 days to the historical standard of care using descriptive analysis. Methods: After Research Ethics Board approval, patients who were enrolled and had completed a POHM study were individually matched to historical controls by age, American Society of Anesthesiology class, and procedure at a ratio 1:2. Results: A total of 54 patients in the study group and 107 in the control group were eligible for the analysis. Compared with the historical standard of care, the average cost per case was Can $5826.32 (SD 1418.89) in the POHM group and Can $9198.58 (SD 1513.59) for controls. After 30 days, there were 2 emergency room visits (3.7%) and 0 readmissions in the POHM group, whereas there were 8 emergency room visits (7.5%) and 2 readmissions (1.9%) in the control group. No mortalities occurred in either group. Conclusions: The POHM study offers an early hospital discharge pathway for elective hip and knee procedures at a 38% reduction of the standard of care cost. The multidisciplinary transitional POHM team may provide a reliable forum to minimize readmissions, and emergency room visits within 30 days postoperatively. Clinical Trial: NCT02143232; (Archived by WebCite at

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