Screening & Secondary Prevention of Traumatic Stress after Injury

1. Screening & Secondary Prevention of Traumatic Stress after Injury Flaura Winston, MD, PhD Nancy Kassam-Adams, PhD Angela Marks, MSEd TraumaLink, Children’s Hospital of Philadelphia Funded by: Maternal & Child Health Bureau (MCHB) Emergency Medical Services for Children Program (EMSC)

2. Injury & traumatic stress • Life threat (self or others) • Fear, helplessness, horror • Symptoms • Avoidance • Intrusive thoughts • Hyperarousal

3. Acute traumatic stress reactions are common, but… 88% of injured children 83% of their parents report at least one acute PTS symptom in the first month after child injury

4. Significant minority has persistent symptoms 16% of injured children 15% of their parents have persistent PTS symptoms & impairment 4 to 8 months after child injury Can we identify those at risk? Can we prevent persistent symptoms?

5. STEPP screener • Development sample • Traffic injured • Hospitalized • 12 items: child, parent, chart Child Parent Sens 88% 96% Spec 48% 53% PPV 25% 27% NPV 95% 99% Winston, FK, Kassam-Adams, N, et al JAMA, 290 (5): 643-649, 2003.

6. Targeted Issue Study • Develop screening protocol • ED-based screening protocol • Develop systematic follow-up protocols • Trauma d/c letters • Prompted screening via EMD in Primary Care • Develop 2o prevention interventions • Universal • Selective for those with identified risk factors

7. 1. ED-based screening protocol Feasibility: • 250 STEPP screeners by 70 nurses • Easy-to-use (89%), Length OK (97%) • Discomfort with asking perceived life threat (33%) Validity: • In ED, general injury population? • No Lessons learned: • In-patient screening doesn’t translate to ED • Format OK • Review wording

8. 2. Systematic follow-up • Transition to primary care when emergency / acute care is complete • Mail info with discharge letter • Automated electronic alerts as part of EMD • Goals for child’s next primary care encounter • Ask: How are you doing now? • Provide info and anticipatory guidance • Monitor or refer as appropriate

9. Primary MD training

10. 2a. Trauma d/c letter Trauma surgeon as educator • Included with trauma d/c letter • Paragraph “I would like to highlight the importance of addressing traumatic stress in all injured patients…” • Brochure & patient handout Lessons learned: • Well-received by MDs

11. 2b. Prompted screening via EMR Products developed: • Primary Care MD alert to recent injury • Template with prompts, dx, & handout Lessons learned: • Alerts not noticed (generic problem with EMR) • Too long (time pressure), Unease (limited referrals) • Shorten length, limit role of MD, clear action plan

12. INDICATED Persistent distress • MH intervention SELECTIVE Some risk factors present • Follow-up several wks post-injury • Anticipatory guidance • Referral if distress / risk persists UNIVERSAL Generally well-functioning child and family • Minimize potentially traumatic aspects of medical care • Provide general support & information • Promote child / family positive coping • Screen (in healthcare setting) for indicators of higher risk 3. Secondary prevention interventions

13. 3a. Universal psycho-education • Products developed: • Print handout • Key messages • Low literacy • Catchy graphics • PDF - downloadable • Lessons learned: • Well-received • Healthcare & families • Randomized trial planned

14. 3b. Selective intervention • Products developed for those with identified risk: • Workbook & Manualized Protocol • Accurate assessment of symptoms • Child’s symptoms as distinct from parent’s • Creation of a coping plan • Anxiety sensitivity training • Avoidance training • Lessons learned: • Well-received by parents & children • Requires referral protocol • Randomized trial planned

15. Impact Surveillance In-Depth Study Publish Research Intervention TraumaLink approach Identify Issues Research to Action to Impact