Screening & Secondary Prevention Screening & Secondary Prevention of Traumatic Stress after Injuryof 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)

Injury & traumatic stressInjury & traumatic stress

Life threat (self or others)

Fear, helplessness, horror

Symptoms Avoidance Intrusive thoughts Hyperarousal

Acute traumatic stress Acute traumatic stress reactions are reactions are commoncommon, but…, but…

88% of injured children 83% of their parents

report at least one acute PTS symptom in the first month after child injury

Significant minority has Significant minority has persistentpersistent symptoms 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 identify those at risk?Can we prevent persistent symptoms?Can we prevent persistent symptoms?

STEPP ©

QUESTIONS FOR PARENTS No Yes

Did you see the incident (accident) in which your child got hurt? 0 1

Were you with your child in an ambulance / helicopter coming to the hospital? 0 1

When your child was hurt (or when you first heard about it), did you feel really helpless? 0 1

Before this injury, had your child ever had behavior or attention problems for a while? 0 1

QUESTIONS FOR KIDS

Was anyone else hurt or killed (when you got hurt)? 0 1

Was there a time when you didn’t know where your parents were? 0 1

When you got hurt, or right afterwards, did you feel really afraid? 0 1

When you got hurt, or right afterwards, did you think you might die? 0 1

INFORMATION FROM MEDICAL RECORD

ED triage heart rate over 104 (child under 12) over 97 (child 12 and older) 0 1

Extremity fracture? 0 1

Child is a girl 0 1

Child is 12 or older 0 1

STEPP screenerSTEPP screener

Development sample Traffic injured Hospitalized

12 items: child, parent, chart

Child ParentSens 88% 96%Spec 48% 53%PPV 25% 27%NPV 95% 99%

Winston, FK, Kassam-Adams, N, et al Winston, FK, Kassam-Adams, N, et al JAMAJAMA, 290 (5): 643-649, 2003., 290 (5): 643-649, 2003.

Targeted Issue StudyTargeted Issue Study1. Develop screening protocol

ED-based screening protocol

2. Develop systematic follow-up protocols

a) Trauma d/c letters

b) Prompted screening via EMD in Primary Care

3. Develop 2o prevention interventions

a) Universal

b) Selective for those with identified risk factors

1. ED-based screening protocol1. ED-based screening protocolFeasibility: 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?

NoLessons learned: In-patient screening doesn’t translate to ED Format OK Review wording

2. Systematic follow-up2. 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

Primary MD trainingPrimary MD training

2a. Trauma d/c letter2a. Trauma d/c letterTrauma 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

2b. Prompted screening via EMR2b. Prompted screening via EMR

Products developed: Primary Care MD alert to recent injury Template with prompts, dx, & handoutLessons learned: Alerts not noticed (generic problem with EMR) Too long (time pressure), Unease (limited referrals) Shorten length, limit role of MD, clear action plan

                            

Generally well-functioning child and family

UNIVERSAL

SELECTIVESome risk factors present

Persistent distress

MH intervention

INDICATED

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

Follow-up several wks post-injury Anticipatory guidance Referral if distress / risk persists

3. Secondary prevention interventions3. Secondary prevention interventions

3a. Universal psycho-education3a. Universal psycho-education

Products developed: Print handout

Key messages Low literacy Catchy graphics

PDF - downloadable Lessons learned:

Well-received Healthcare & families

Randomized trial planned

3b. Selective intervention3b. 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

TraumaLink approachTraumaLink approach

In-Depth Study

Publish Research

Surveillance

Identify Issues

Intervention

Impact

ResearchResearch

toto

ActionAction

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ImpactImpact