By Amy Kinoff, Evans Army Community Hospital, Department of Nursing

FORT CARSON, Colorado -- Surgery can be a scary, life changing event. But for some patients the danger is not over when they leave the operating room. For some patients waking up after surgery in a strange, unfamiliar place can result in intense agitation that can result in restlessness, confusion and combativeness.

The medical term for this is Emergence Delirium, or ED, and can be dangerous to the patient and the recovery room staff. Two years ago, Evans Army Community Hospital started the Green Star program which has helped to reduce ED encounters.

"Any given day 6-7 patients have the potential for emergence delirium," said Sheila Carroll, a registered nurse who had 33 years of emergency room and trauma nursing experience before she was hired in 2010 to work in the Evans' Post Anesthesia Care Unit, better known as the recovery room. "After being hired here, one of the first patients I saw in the PACU had on the front of their chart in 6-inch, red letters PTSD (Post Traumatic Stress Disorder) written on it. I thought that wasn't good, there has to be a better way of doing this."

Carroll saw the need for a safer environment not only for her patients, but for the PACU staff as well. Over the next couple years she watched what was happening in the PACU and slowly started implementing changes on how these possible ED patients were treated.

Two years ago, the Green Star program was officially recognized as a Performance Improvement program to reduce the amount of "Code Greens" in the PACU. A Code Green is called at the hospital when a combative person needs to be restrained either physically or verbally.

During their pre-operative consultation, the PACU staff screen patients for potential behaviors associated with ED. They ask five questions that are designed so that no matter how the patient answers, the patient does not need to respond that they have Post Traumatic Stress Disorder.

Carroll said with vague questions such as "have you had a traumatic experience or event in your life" the patient can answer yes to recent combat experiences or events that might have happened in their past, sexual assault or childhood abuse, all which can cause a person to wake up combative.

If a patient is suspected for ED mannerisms then they are identified by a green star on their chart, their identification bracelet and on their privacy curtain when they are in the recovery room.
"This is a symbol to tell people that if they didn't have business with this patient to stay away," said Carroll.

Other Green Star key elements that help reduce ED include: keeping noise to a minimum, inform patients prior to touching them, having an RN monitor the patient on a one-to-one basis when possible and having a family member or friend at their bedside.

"We have family members at their side so that when they open their eyes their family members are the first ones they see, which is very calming," Carroll said.

When Carroll initially proposed the Green Star program, there were a few non-believers who thought the program would "label" patients as having PTSD, or combative. Since the program has been in full swing, many of the non-believers are now on board with the program and wish it could have been initiated earlier.

"At first the Green Star program seemed like a big huge project," said Staff Sgt. Daniel Gallant, a licensed practical nurse and the noncommissioned officer in charge of the PACU. "But we noticed that we had a special patient population here that maybe due to their past experiences, significant events they have been through, they don't come out of anesthesia very well."

Since the program began the PACU has had more than 8,000 patients, and 1,286 of those were identified into the Green Star program. Pediatric patients are automatically Green Star patients. The result has been an 80 percent reduction in "Code Green" events.

"This drastic downtrend of violent outbursts improves safety for both the patients and my staff," Gallant said. "If they wake up with ED they are very apt to hurt themselves or my nurses who are trying to control a Code Green patient."

The safer environment created by the Green Star program is just one reason that Carroll was selected as the 2014 Western Region Medical Command Employee of the Year for Exceptional Service.

"I commend Sheila for coming up with this program," Gallant added. "I would like to see the Green Star program implemented across MEDCOM (U.S. Army Medical Command). We have seen an improvement here and there is no reason we can't see improvements in other military hospitals."