Implementation of an individualized care plan for patients with posttraumatic stress disorder symptoms in a Canadian preanesthetic assessment clinic

To the Editor,

Trauma is a ubiquitous experience with approximately 76.1% of Canadians endorsing a lifetime traumatic experience. Following such trauma, about 10% of adults in Canada have moderate to severe symptoms of posttraumatic stress disorder (PTSD), with elevated rates in women and younger adults.¹ Those with clinically significant symptoms may not receive a diagnosis as many do not, or cannot, access care. Further, illness-induced PTSD and subsyndromal PTSD may be associated with fewer or subthreshold symptoms, yet still include functional impairment.² Posttraumatic stress disorder is associated with four main symptom clusters: arousal (e.g., feeling on edge, hypervigilance), intrusions (e.g., intrusive thoughts, re-experiencing), alterations in cognition and mood (e.g., depressed mood), and avoidance.^1,2,3,4 Posttraumatic stress disorder is associated with a large range of mental and physical health comorbidities.³ The patient surgical experience represents a highly stressful event and anxiety has been identified as the worst component of the perioperative experience by patients. For patients with PTSD symptoms, medical contexts can represent a risk for retraumatization and exacerbation of symptoms leading to further impairment. Preoperative PTSD and anxiety symptoms are also associated with compromised postoperative outcomes such as delirium, sleep-disordered breathing, morbidity, length of stay, and readmission.^3,4,5 Individuals with trauma histories and PTSD symptoms are also at particularly high risk for PTSD from surgery itself, emphasizing the importance of identifying and managing posttraumatic stress symptoms in the perioperative setting.^2,3,4,5

There is no evidence-based consensus on preoperative care for individuals undergoing anesthesia who have PTSD symptomatology, representing a significant gap in care.³ Clinicians from the preanesthetic assessment clinic (PAC) at our tertiary care facility developed what we think is the first protocol in Canada to manage surgical/obstetric patients with PTSD symptomatology. This was achieved through a collaborative process involving military medical practitioners from Canada, and Psychiatry and Clinical Health Psychology departments at the University of Manitoba, together with a literature review of what is considered best practice. The protocol’s goal is to offer an individualized care and support plan for patients with posttraumatic stress symptoms and improve their hospital experience by decreasing anxiety, trauma-related stimuli, and injury to themselves and staff. This, in turn, will increase their satisfaction and safety through open communication and patient-centred care.^2,3,4,5

The role of the PAC nurses is to 1) identify these patients, 2) follow the preoperative consultation form, and 3) educate other health professionals on PTSD management (e.g., not to ask for the specific cause of the PTSD, to initiate conversation relating to comfort, and address potential triggers). They follow a structured history of PTSD, identifying symptoms, frequency, treatment (both medications and therapy) received, known triggers and exacerbating anxiety factors, coping methods, grounding strategies, and previous anesthetic reactions. The nurse clinicians add PTSD to the patient’s chronic problem list and notify the health care providers of the patient’s care plan including the preoperative holding area and recovery unit. If necessary, they refer the patient to a clinical psychologist before surgery for assessment and short-term treatment to facilitate management of symptoms throughout the perioperative period (see Table).

Table Standard work for the considerate care of patients with pre-existing posttraumatic stress disorder symptoms in the perioperative setting

Feedback since the protocol implementation in 2021 has been positive. These individualized care plans based on trauma-informed care generally increase patients’ trust in health care delivery and improve their hospital experiences. Patients’ opinions include the belief that surgery is now possible despite their trauma-related psychological symptoms, appreciation for acknowledging their needs and autonomy, and alleviation of fear associated with child delivery in prospective mothers. We believe these trauma-informed approaches warrant further attention, including evaluation of potential risks and benefits, in anesthesia settings.