The Role of Nurses in General Practice: An Integrative Review.

Emergence delirium (ED) (i.e., agitation or excitation) is a transient behavioral condition that may occur when a patient awakens from an anesthetic and/or adjunct agent (Cole et al. ; S.-J. Lee and Sung ; Lepouse et al. ; Taylor and Pileggi ; Taylor et al. ; Tolly et al. ; Urits et al. ). ED may elicit harmful patient behaviors, including thrashing, kicking, punching, attempting to exit the bed/table, and hallucinations (Cole et al. ; S.-J. Lee and Sung ; Taylor and Pileggi ; Taylor et al. ; Tolly et al. ; Urits et al. ). In one study, 70% of ED-associated safety event reports described patients engaging in “dangerous” behavior(s) and there was a statistically significant relation with injuries (Taylor and Pileggi ). The same study estimated that “…54% of [the ED] events described patient behavior that created an immediate and high risk of harm for the staff” (Taylor and Pileggi ). Several studies of ED have explored medication and screening care strategies used by anesthesia providers intending to prevent and/or treat occurrence of ED in adults (Bartoszek et al. ; Huang et al. ; Taylor et al. ; Yuan et al. ). A comprehensive list of studies we previously identified that explored care strategies for ED is available in Supplemental Material S6 of our related publication (Taylor et al. ). However, few have assessed the effect of multiple concurrent medications plus screening care strategies on risk of ED while using a large national sample of providers who regularly care for adults at high risk of ED. Even among ED studies focused solely on medications (Taylor et al. ), the evaluations of medications possibly related to ED, which include midazolam, dexmedetomidine, ketamine, volatile anesthetics, and propofol, have produced mixed, sometimes conflicting, results indicating a need for studies of the effect of multiple medications measured concurrently on occurrence of ED, especially among patients who may have higher risk and greater vulnerability to ED. The Veterans Health Administration (VHA) is one of the largest integrated health care networks in the United States (Veterans Health Administration, ). Despite the ability to conduct large studies of ED at the Department of Veterans Affairs’ (VA) and that Veterans may be considered at high-risk for ED due to the prevalence of various risk factors, such as post-traumatic stress disorder (PTSD), (Bartoszek et al. ; Beckstead et al. ; McGuire ; Tolly et al. ; Umholtz et al. ) there are few national studies of prevalence and prevention of ED at the VA. Based upon the precedent of using staff surveys in adult ED research, (Bustos & Sambuca, ; Heily et al. ; Maasdam, ; John Tyler Wilson , ; J T Wilson and Pokorny ; Yuan et al. ) we designed a national VA-wide retrospective cross-sectional survey for VA anesthesia providers that allowed us to measure the percentage of providers who estimated ED occurring at least once per month in their patients and the care strategies they reported providing to patients at high-risk for developing ED. The survey was designed to compare findings from VA anesthesia providers across two mutually exclusive locations; Veterans Affairs’ Pittsburgh Healthcare System (PHS), where staff previously designed and implemented an intervention to prevent and treat ED, (Taylor et al. ) and all other VA facilities across the VA national care network (non-PHS). The four aims of our survey study were to: (1) assess location differences in providers’ reported use of routine screening and medication strategies (PHS versus non-PHS); (2) evaluate location differences in percentage of providers who estimated ED (PHS versus non-PHS); (3) measure associations, regardless of location, between percentage of providers who estimated ED and reported use of routine screening and medication strategies; and (4) measure differences in percentage of providers who estimated ED between PHS and non-PHS locations while adjusting for other relevant factors, including reported use of routine screening and medications. We hypothesized that PHS providers would have lower percentage of providers who estimated ED occurrence compared to providers at non-PHS facilities and the care strategies promoted at PHS would be associated with lower percentage of providers who estimated ED regardless of location.