Faculty’s research aids post-surgery care for patients with PTSD

While helping with a training activity at the Veterans Affairs Pittsburgh Healthcare System, Donnamarie Lovestrand saw more than a decade of inquiry put into practice.

That inquiry began in 2011 when Lovestrand, now an associate professor of nursing at Pennsylvania College of Technology, was a staff nurse in the post-anesthesia care unit of Bayne-Jones Army Community Hospital at Fort Polk (now Fort Johnson) in Louisiana.

“It was not infrequent that I would have these soldiers who would wake up (from anesthesia) hallucinating that they were back on the battlefield – and there was nothing we could do to turn them around,” she said.

The patients were experiencing “emergence delirium” (or emergence agitation), a known phenomenon in the post-anesthesia period that is characterized by restlessness and confusion. It has a 3% occurrence in the general population. But among patients with post-traumatic stress disorder, the number reaches 36%.

Emergence delirium can occur following surgery in combat veterans and others with PTSD because both PTSD and general anesthesia affect the amygdala, a region of the brain that activates the fight-or-flight response, and the hippocampus, which is involved in processing emotions.

“Contrary to a normal agitation presentation, these soldiers re-experienced battlefield events after general anesthesia, which mentally placed them in a combat situation,” Lovestrand and teammates wrote in “Posttraumatic Stress Disorder and Anesthesia Emergence,” published in the June 2013 AANA Journal. It was the first of three pieces Lovestrand co-authored on the topic.

“In conjunction with the flashbacks, these soldiers attempted to get out of bed to ‘get to the lines,’ pulled at monitoring equipment, and yelled battle instructions,” they wrote.

Attempts to reorient the patients using traditional methods were ineffective.

Lovestrand searched for answers, and found that evidence-based research was absent.

“I had found the proverbial ‘gap in the literature,’” she said.

She teamed with nurse anesthetists Maj. Steven Phipps, Col. Denise Beaumont and Maj. Jonathan Yost; her husband, family physician Dr. Daniel Lovestrand; and her brother-in-law Steven Lovestrand, Ph.D., a clinical psychologist, who all worked with Lovestrand at Bayne-Jones, to begin brainstorming.

“We started a process of trying to find some intervention plan that would help,” Lovestrand said.

The ideas they developed were the base of the 2013 AANA Journal article. The publication is the scholarly journal of the American Association of Nurse Anesthesiology.

At the same time, Lt. Col. Tyler Wilson, an Army anesthetist, and Cmdr. Jason McGuire, a Navy anesthetist, were researching the same topic and applying their findings. They published their work within two months of the Bayne-Jones group.

“We didn’t know each other and weren’t aware of each other’s work,” said Lovestrand, who began collaborating with them.

Their work together led to “Management of Emergence Delirium in Adult PTSD Patients: Recommendations for Practice,” which was published in 2017 in the Journal of PeriAnesthesia Nursing, Vol. 32, No. 4.

In the piece, Lovestrand et al. suggest asking patients questions and observing hyperarousal and nervousness before surgery to help identify individuals at risk for emergence delirium.

During surgery, the writers suggested, anesthetists and nurses should be aware of the reactions of anesthetics and medications in combination with PTSD and choose them accordingly. Following surgery, providing a quiet environment and being thoughtful about mannerisms when approaching patients may prevent triggers of emergence delirium. Additionally, asking patients about what they are seeing, hearing and feeling, even as they are hallucinating, can begin the healing process.

Further work by Lovestrand and collaborators led to the development of a simulation training exercise that was published in the AANA Journal in June 2021 (Vol. 89, No. 3).

Lovestrand’s publications have been cited 61 times. She has spoken on the topic 11 times, including two presentations in Belarus in 2017; she most recently presented at the 2022 National Conference for the American Society of PeriAnesthesia Nurses.

The lectures led her to Maj. William Pileggi and the VA Pittsburgh Healthcare System – home of “Project Golden Eagle” – where, last fall, Lovestrand provided subject-matter expertise as Pileggi taught perioperative health care professionals about the interventions Project Golden Eagle applies to prevent and treat emergence delirium.

“It’s perfect,” Lovestrand says. “It’s the very next step to putting everything in place.”

The project started when two nurses at the VA Pittsburgh facility began a program that helped to identify patients with PTSD by placing them in quiet rooms and providing gold surgical caps so that staff would be aware of their increased risk for emergence delirium. (Most patients receive blue caps.) In 2017, Pileggi teamed up with colleagues to expand Project Golden Eagle, conducting more research and further developing the strategies suggested by the work of Lovestrand and her co-authors.

With the implementation of Project Golden Eagle, the incidence of emergence delirium in the VA Pittsburgh Healthcare System dropped quickly to 2.7% in high-risk PTSD patients.

Pileggi and the Project Golden Eagle team received a 2020 Gears of Government Award from the U.S. Department of Veterans Affairs and a 2021 I Am Patient Safety Achievement Award from Pennsylvania’s Patient Safety Authority.

Lovestrand is thrilled to see research growing and interventions being put in place.

“To be able to make a difference like that is incredibly rewarding,” Lovestrand said. “Besides being rewarding for me, the reward is watching people do better. It wasn’t possible 10 years ago.”

In addition to her connection with the VA hospital in Pittsburgh, she is interacting with Walter Reed National Military Medical Center. Both are employing strategies to reduce emergence delirium. Lovestrand hopes that the knowledge will continue to be disseminated more widely, because PTSD affects not only combat veterans, but many others, including survivors of natural disasters, abuse and other traumatic events.

“It can be anybody so that’s why we really want to get it out there,” she said.

She also wants the results to encourage others to seek answers when they see room for improvement.

“What’s really fun for me, is I use this illustration all the time with my students,” she said. As part of the Leadership & Management in Nursing class she teaches at Penn College, students are required to collaborate to identify problems in nursing care delivery and propose process improvements. “I was a staff nurse. I wasn’t an instructor; I didn’t yet have my master’s degree. I was just a nurse who saw a problem with patients and didn’t know what to do. So, I just kept looking.”

“People have said to me, ‘Are you going to get your doctorate?’” Lovestrand added. “I would never have been able to do all this work and make a difference in people’s lives if I had been working toward a doctorate. This was more important, and it was what needed to be done.”

“Donna has been doing what nurses are called to do, and that is put research into practice,” said Tanae A. Traister, assistant dean of nursing and health sciences. “Her authored and co-authored works reflect that.”

“It’s wonderful to be part of,” Lovestrand said. “I want to encourage people: If you see something that needs to be fixed: Go ahead. I was just Donna. I only had ‘RN’ after my name. If you see a problem, go ahead. Because you don’t know where it’s going to take you. I had no idea that I was going to wind up as the subject matter expert.”

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