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Identifying Pediatric Emergence Delirium by Using the PAED Scale: a Quality Improvement Project

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Identifying Pediatric Emergence Delirium by Using the PAED Scale: a Quality Improvement Project Identifying Pediatric Emergence Delirium by Using the PAED Scale: A Quality Improvement Project MATTHEW J. STAMPER, DNP, CRNA; SHARON J. HAWKS, DNP, CRNA; BRAD M. TAICHER, DO, MBA; JULIET BONTA, BSN, RN; DEBRA H. BRANDON, PhD, RN, CCNS, FAAN ABSTRACT Pediatric emergence delirium is a postoperative phenomenon characterized by aberrant cognitive and psychomotor behavior, which can place the patient and health care personnel at risk for injury. A common tool for identifying emergence delirium is the Level of Consciousness-Richmond Agitation and Sedation Scale (LOC- RASS), although it has not been validated for use in the pediatric population. The Pediatric Anesthesia Emergence Delirium Scale (PAED) is a newly validated tool to measure emergence delirium in children. We chose to implement and evaluate the effectiveness and fidelity of using the PAED Scale to identify pediatric emergence delirium in one eight-bed postanesthesia care unit in comparison with the traditional LOC-RASS. The overall incidence of pediatric emergence delirium found by using the LOC-RASS with a retrospective chart review (3%) was significantly lower than the incidence found by using the LOC-RASS (7.5%) and PAED Scale (11.5%) during the implementation period. Our findings suggest that the PAED Scale may be a more sensitive measure of pediatric emergence delirium, and, in the future, we recommend that health care personnel at our facility use the PAED Scale rather than the LOC-RASS. AORN J 99 (April 2014) 480-494. Ó AORN, Inc, 2014. http:// dx.doi.org/10.1016/j.aorn.2013.08.019 Key words: pediatric emergence delirium, Pediatric Anesthesia Emergence Delirium Scale, PAED Scale, Level of Consciousness Richmond Agitation and Sedation Scale, LOC-RASS, quality improvement. he term emergence delirium is defined as in the pediatric population.2-9 Children who expe- “a mental disturbance during the recovery rience emergence delirium postoperatively are at T from general anesthesia consisting of hal- risk for unintentional self-injury, including removal lucinations, delusions, and confusion manifested by of catheters and drains as well as wound dehis- moaning, restlessness, involuntary physical activ- cence.10 Additionally, management of pediatric ity, and thrashing about in the bed.”1(p19) Although emergence delirium requires extra attention from emergence delirium occurs in patients of all ages, it nursing personnel, placing undue strain on nurse- appears to occur three to eight times more frequently to-patient ratios and resource allocation in the http://dx.doi.org/10.1016/j.aorn.2013.08.019 480 j AORN Journal April 2014 Vol 99 No 4 Ó AORN, Inc, 2014 PEDIATRIC EMERGENCE DELIRIUM www.aornjournal.org postanesthesia care unit (PACU).11 A recent study frequently. The incidence is highest among chil- showed that 49% of children who developed dren who emergence delirium required extra PACU personnel n are younger than six years of age, to care for them compared with only 15% of chil- n have preoperative anxiety, and 9 dren not experiencing emergence delirium. Pedi- n emerge rapidly from general anesthesia.4,7,16 atric emergence delirium also can place the RN at risk for injury if he or she tries to restrain the child Additionally, the use of sevoflurane and surgical to keep the child from hurting himself or herself.11 procedures involving the head and neck are asso- One of the keys to managing pediatric emer- ciated with an increased risk of developing pedi- 17 gence delirium is prompt recognition of the con- atric emergence delirium. Several commonly dition by anesthesia and PACU personnel. However, used IV medications (eg, propofol, fentanyl, keta- to date, there is not a recognized standard assess- mine, dexmedetomidine) that are administered at ment to identify pediatric emergence delirium. various times during the perioperative period are Consequently, a variety of rating and visual analog associated with a decreased incidence of pediatric 5,6,13,18 scales are used, many of which have not been emergence delirium. validated in the pediatric surgical population.12 Although these findings offer information about This practice variation, combined with differing preemptive medication management for children at anesthetic techniques, likely contributes to the wide risk for developing emergence delirium, the true range in the incidence of pediatric emergence effect of these strategies remains unknown because delirium (ie, 2% to 80%) that is reported in the patients often are not assessed with a validated literature.13 pediatric tool. Furthermore, without appropriate tool use, it is difficult to differentiate between DESCRIPTION OF THE PROBLEM emergence delirium and the signs and symptoms of At our facility, health care providers use the Level of pain because both emergence delirium and pain Consciousness-Richmond Agitation and Sedation may be characterized by restless behavior.12 One of Scale (LOC-RASS) to identify pediatric emergence the greatest attributes of the PAED Scale, however, delirium in the PACU. Although the LOC-RASS is that it was developed by using a theoretical is a valid and reliable measure of sedation and framework of delirium, focusing on changes in agitation in critically ill adults, it has not been consciousness and cognition, which permits dif- validated in the pediatric population.14,15 The ferentiation of emergence delirium behaviors from Pediatric Anesthesia Emergence Delirium (PAED) those behaviors associated with pain.12 Scale is a newly validated measure of emergence The PAED Scale consists of five characteristics delirium for children.12 that are each scored by using a 5-point Likert scale. The scores are summed into a final composite score REVIEW OF THE LITERATURE to determine the presence or absence of pediatric Much of the pediatric emergence delirium research emergence delirium. Two items, “the child makes is focused on determining the etiology of emer- eye contact with the caregiver” and “the child is gence delirium and on using pharmacological in- aware of his [or] her surroundings,” respectively, terventions to reduce its incidence. The cause of are reflections of the child’s state of consciousness pediatric emergence delirium is likely multifacto- and ability to focus attention and to thoughtfully rial; however, the following characteristics, either organize external stimuli. One item, “the child’s individually or in combination, have been identified actions are purposeful,” addresses changes in in children who develop emergence delirium more cognition that cause the child to behave in a manner AORN Journal j 481 April 2014 Vol 99 No 4 STAMPER ET AL outside of what is deemed appropriate. Two addi- development within this population, the assessment tional items, “the child is restless” and “the child is criteria appear to be applicable to pediatric patients inconsolable,” are measures of psychomotor and outside of this age group, which has led researchers emotional behavior, respectively, that are associ- to examine the incidence of emergence delirium in ated with delirium. Although the last two items children of all ages.6,7,9,20 Therefore, we chose to also may indicate that the patient is experiencing implement the PAED Scale to provide a more pain, assessing these measures in conjunction clearly defined set of criteria for identification of with other indicators of consciousness and cogni- pediatric emergence delirium at our facility. tion helps the health care provider differentiate be- tween emergence delirium and pain.12 PROJECT GOALS AND METHODS The developers of the PAED provided strong The primary goal of this project was to evaluate the evidence of measurement reliability and validity, identification of pediatric emergence delirium by with an internal consistency of 0.89, with delirium implementing and evaluating the use of the PAED characteristics of the Diagnostic and Statistical Scale in the children’s PACU at our facility. We Manual of Mental Disorders,19 interobserver re- compared the incidence of pediatric emergence liability of 0.84 (95% confidence interval [CI], delirium as determined by using the LOC-RASS 0.76-0.90), and sensi- during a retrospective tivity and specificity chart review to the of 0.64 and 0.86, Although the PAED Scale originally was incidence as deter- respectively, when developed to assess for emergence delirium mined by using the the composite PAED among patients between the ages of 18 months PAED Scale during scores were higher and six years of age because of a higher pro- the implementation than or equal to 10.12 pensity for emergence delirium development period. Additionally, In contrast, the within this population, the assessment criteria given that the LOC- LOC-RASS originally appear to be applicable to pediatric patients RASS remained in use was developed as “a outside of this age group. throughout the project, clinically useful tool we examined differ- to assess the level of ences in the incidence consciousness and agitated behavior in (adult) of pediatric emergence delirium by using the LOC- [intensive care unit (ICU)] patients [to] guide RASS between the retrospective and implementa- sedation therapy and improve communication tion periods. A secondary goal was to assess whether among health care providers.”14(p1341) The LOC- patient characteristics (ie, age, gender, medical RASS can be an effective component of an algo- diagnosis of attention deficit hyperactivity disorder rithm to identify pediatric emergence delirium, but [ADHD], premedication with midazolam, parental it should be used in conjunction
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