Evaluating Pre-Procedural Anxiety in Adults Undergoing Interventional Radiology Procedures

PURPOSE: The purpose of this study is to evaluate pre-procedural anxiety with the Amsterdam Preoperative Anxiety and Information Scale (APAIS) in the adult population of the Interventional Radiology department at University of Kentucky Medical Center. The objective is to provide meaningful data to providers in this clinical area that could potentially facilitate better departmental workflow and also promote quality patient outcomes. METHODS: A retrospective chart review, using a pre/post design, was used to evaluate the departmental implementation of APAIS. Case logs for the department were observed from January 2018 to June 2018 and then again, following APAIS implementation, from July 2018 to December 2018. Data evaluated from the case logs included: number of cases, number of cancellations, and number of general anesthesia cases as a means to evaluate if APAIS was effective in reducing cancellations and use of anesthesia for minimally invasive procedures. In addition, data was extracted from APAIS and the electronic medical records of the 259 inpatients and outpatients that met inclusion/exclusion criteria to determine the extent of pre-procedural anxiety in Interventional Radiology (IR) and to measure if APAIS scores were a predictor of intra-procedural anxiety. Staff participation with completing the APAIS form was also evaluated. RESULTS: In this sample of 259 patients, APAIS identified 86 (34.5%) as not having any anxiety, 105 (42.2%) as having some anxiety, and 57 (22.9%) as having high anxiety prior to procedures. There was a positive correlation between needs information scores and anxiety scores, as well as a negative correlation between age and anxiety scores. For intra-procedure measures, there was no significance between anxiety levels and amount of medications received with the exception of those having percutaneous drains placed. However, there was a significant negative correlation between anxiety and level of sedation achieved. Post APAIS EVALUATING PRE-PROCEDURAL ANXIETY 2 implementation saw a decrease in all measures; although, only number of cancellations had a pvalue < 0.05. There was a 44% staff completion rate of APAIS forms. CONCLUSION: The implementation of APAIS was effective in identifying those with preprocedural anxiety, predicting some physiological measures during procedures, and with lowering case cancellations. While not all outcomes were statistically significant, there is clinical significance worth further discussion. The implementation of a validated anxiety tool is beneficial in promoting quality departmental and patient outcomes. EVALUATING PRE-PROCEDURAL ANXIETY 3 Evaluating Pre-Procedural Anxiety in Adults Undergoing Interventional Radiology Procedures Introduction Mental health is considered a state of well-being that encompasses cognitive, emotional, and behavioral processes (WHO, 2019). Having good mental health is paramount to being productive in society, coping with stressors, and adapting to change. It also plays an integral role in the ability to participate in health-promoting behavior, as mental health has a direct relationship with physical health (ODPHP, 2019). In contrast, having poor physical health, from illness and chronic diseases, can lead to a decline in mental health. It is also important to understand that poor mental health increases an individual’s risk of developing other diseases, such as cardiovascular disease and diabetes (WHO, 2019; Miller et al., 2013). There are several proposed pathophysiologic processes that could explain the negative relationship between anxiety and adverse events that increase a patient’s risk of other diseases, including: hypercortisolemia with insulin resistance, lifestyle risk factors, and sympathetic and/or vagal disturbances (Williams et al., 2013). Currently, mental health disorders are one of the main causes of disability in the United States, with the resulting burden being among the highest of all diseases. Mental health disorders ultimately lead to distress and are associated with decreased functioning, primarily by altering a person’s thinking, mood, or behavior (ODPHP, 2019). Research shows that almost 60% of adults with a mental illness did not receive mental health services in the past year and that one-in-five Americans will experience mental illness at some point in their lives, costing $193 billion in lost wages (NAMI, 2019). Therefore, it is imperative that mental health disorders be screened in all patients on a regular basis. The most common mental health disorder in the United States is anxiety. Currently, there are approximately 42 million Americans who suffer from anxiety disorders (NAMI, 2019). According to the American Psychological Association (2019), anxiety is an emotion EVALUATING PRE-PROCEDURAL ANXIETY 4 characterized by feelings of tension, worried thoughts, and physical changes. While it is a subjective emotion, many factors can influence anxiety, including genetics and environmental factors. Age, gender, procedures, hospitalizations, and inability to cope are all examples of elements that can influence anxiety (Pritchard, 2009). There are several recognized classifications of anxiety, including: generalized anxiety disorders, social anxiety disorders, panic disorders, and phobias. Although not formally recognized as a diagnosis, acute procedural anxiety is another type of disorder that can either coincide with other anxiety disorders or appear independently. Background Acute procedural anxiety is defined as an excessive fear of medical procedures that manifests as acute distress, peaking immediately before the procedure, remaining steady during the procedure and decreasing immediately following the procedure. This acute fear or anxiety, while either rational or irrational, can ultimately cause a disruption or delay in necessary interventions (Choy, 2019). When these delays occur, it can sometimes be days before the patient is rescheduled for treatment, thus, impacting such factors as: lengthening hospital stay, delaying dialysis treatment, or increasing intravenous antibiotic usage. In addition to potential disruptions or delays in procedures, studies show that left untreated, pre-procedural anxiety can cause a multitude of physiological and psychological responses including: tachycardia, hypertension, heightened senses, increased pain sensation, and changes in behaviors (Choy, 2019; Pritchard, 2009; Miller et al, 2013). These responses can prevent patients from remaining still during procedures and necessitate the use of additional medications. Other studies have shown that patients with untreated high pre-procedure anxiety, not only have longer procedure times, but also require higher doses of medications to achieve comfort (Hong, Lee, Lutharat, 2005; Ip, Abrishami, Peng, Wong, Chung, 2009; Johnson, 2010; Schupp, EVALUATING PRE-PROCEDURAL ANXIETY 5 Berbaum, Berbaum, Lang, 2005). Researchers have also examined the effects of anxiety on post-procedural outcomes. For example, higher levels of pre-procedural anxiety have been shown to be a predictor of post-operative pain and can cause depression, nausea, fatigue, and delayed wound healing (Celik & Edipoglu, 2018; Gonzales & Rutledge, 2015; Hong et al., 2009; Ip et al., 2009; Pritchard, 2009). In addition to these complications, Williams et al. (2013) found that anxiety was an independent predictor of inpatient mortality and major morbidity in the elderly population undergoing cardiac surgery. The acute procedural anxiety phenomenon could be a result of concerns or fears that the patient has about their own disease process or fear of the unknown. Interestingly, most studies have found that women have more anxiety about procedures than men (Celik et al., 2018; Gonzales et al., 2015; Moerman, van Dam, Muller, Oosting, 1996; Heyer et at.,2015). It is possible that females are more likely to report anxiety than males due to the perceived notion that women are more likely to express vulnerability; however, this has not been established. Other reasons for anxiety found in the procedural population have been: poor information, fear of contrast media, a cold and sterile environment while waiting, and loss of control (Heyer et al 2015; Lunden, Lundgren, Persson, Lepp, 2015). In order to determine the reasoning for the acute anxiety response, first a dialogue has to begin between the provider and the patient. In addition, the use of a validated tool will potentially allow providers to recognize and diagnose this issue more accurately than clinical impression alone. The Amsterdam Preoperative Anxiety and Information Scale (APAIS), used to assess and evaluate procedural anxiety and information needs, has been implemented by the Interventional Radiology (IR) department at University of Kentucky Medical Center (UKMC). This measure was initiated due to clinical and systems presentation of undocumented anxiety in IR, such as: delays in cases, inability of patients to remain still during procedures, voiced fears/concerns by EVALUATING PRE-PROCEDURAL ANXIETY 6 patients, cancellation of procedures due to anxiety, and use of general anesthesia for no other reason than severe anxiety. However, there are no processes in place to stratify the data or measure the effectiveness of this tool. Evaluation of this process will not only determine effectiveness, but will also show which areas in current practice, if any, need improvement to better address pre-procedural anxiety. Primarily, APAIS has been validated and used to assess anxiety in the population receiving anesthesia for surgery as opposed to those receiving intravenous (IV) conscious sedation for minimally invasive procedures. In addition, the focus of most studies involving anxiety in IR have been to evaluate the effects of Complementary Alternative Medicine (CAM) therapies. Literature is sparse when it comes to a comprehensive evaluation of acute procedural anxiety with minimally invasive procedures in I