A comparative effectiveness trial of an information technology enhanced peer-integrated collaborative care intervention versus enhanced usual care for US trauma care systems: Clinical study protocol

Advancing Concerns of Spanish-Speaking Physical Injury Survivors: Equitable Trauma Care System Service Delivery

Objective: Few investigations have focused specifically on engaging Spanish-speaking patients in early post-injury comparative effectiveness trials. The goal of this study was to identify and categorize hospitalized Spanish-speaking injury survivors' posttraumatic concerns. Method: A secondary analysis of baseline data collected as part of a larger randomized comparative effectiveness trial was conducted. Participants were 22 male and female Spanish, non-English, speaking survivors of intentional and unintentional injuries, ages ≥ 18. At baseline, while hospitalized, each patient was asked to describe the nature and severity of their post-injury concerns. Patient concern narratives were audio-recorded and later transcribed. Raters coded patients' transcribed concerns into content domains. The associations between patient self-reported concern severity and posttraumatic stress disorder symptoms assessed with the PTSD Checklist and depressive symptoms assessed with the PHQ-9 were also ascertained. Results: The concerns of Spanish-speaking patients were reliably categorized into previously described content domains (i.e., work and finance, physical health, social, psychological, medical, and legal domains). The composite Kappa statistic across domains was 0.83 (95% Confidence Interval = 0.74, 0.92). Spanish-speaking patients also expressed novel concerns, including immigration, discriminatory experiences, and Coronavirus pandemic, related concerns. The number of severe patient concerns was highly correlated with PHQ-9 depressive symptom levels (r = 0.52, p < .05). Conclusions: The concerns of Spanish-speaking trauma survivors can be readily elicited and reliably interpreted. Future research could integrate concern narrative elicitation and amelioration into stepped care intervention procedures in order to engage diverse Spanish-speaking injury survivors and advance equitable trauma care system service delivery.

The 12-Month Effects of the Trauma Collaborative Care Intervention: A Nonrandomized Controlled Trial

BACKGROUND

Studies have suggested that patient-centered collaborative care in the early phases of recovery may assist providers and patients in managing the multifactorial consequences of injury and may lead to better outcomes. This cluster-controlled trial, conducted at 12 U.S. Level-I trauma centers, was designed to evaluate the impact of the Trauma Collaborative Care (TCC) program on 1-year outcomes following severe musculoskeletal injury.

METHODS

Patients with high-energy orthopaedic trauma requiring surgical fixation were prospectively enrolled. Six sites implemented the TCC intervention as well as the Trauma Survivors Network (TSN), and the other 6 sites provided the standard of care. Participants were followed for 1 year, and a composite primary outcome measure composed of the Short Musculoskeletal Function Assessment (SMFA) Dysfunction Index, Patient Health Questionnaire-9 (PHQ-9), and Posttraumatic Stress Disorder Checklist (PCL) was assessed. A 2-stage, Bayesian hierarchical statistical procedure was used to characterize treatment effects. Sensitivity analyses were conducted to account for an error in the delivery of the intervention.

RESULTS

There were 378 patients enrolled at 6 trauma centers implementing the TCC program, and 344 patients enrolled at 6 trauma centers providing usual care. Patient utilization of treatment components varied across the intervention sites: 29% of patients in the intervention group received all 5 key components (TSN handbook education, peer visits, recovery assessment, and calls before and after recovery assessment). Posterior estimates of the intention-to-treat effect suggested that the intervention did not have an appreciable effect: the odds of the composite outcome for the TCC group increased by 5% (95% credible interval, -40% to 63%). The estimates of the effect of receiving all 5 key intervention components were similar.

CONCLUSIONS

Despite prior work showing early positive effects, this analysis suggests that the TCC program as delivered did not have positive effects on patient outcomes at 1 year. It is not known whether programs that improve compliance or target specific subgroups would better meet the psychosocial needs of trauma survivors.

LEVEL OF EVIDENCE

Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Nationwide Survey of Trauma Center Screening and Intervention Practices for Posttraumatic Stress Disorder, Firearm Violence, Mental Health, and Substance Use Disorders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms, firearm violence events, alcohol and drug use problems, and major depression and suicidal ideation are endemic among patients admitted to US trauma centers. Despite increasing policy importance, the current availability of screening and intervention services for this constellation of conditions in US trauma centers is unknown.

STUDY DESIGN

Trauma program staff at all Level I and Level II trauma centers in the US. (N = 627) were contacted to complete a survey describing screening and intervention procedures for alcohol and drug use problems, PTSD symptoms, depression and suicidality, and firearm violence. Additional questions asked trauma centers about the delivery of peer interventions and information technology capacity for screening and intervention procedures.

RESULTS

Fifty-one percent of trauma centers (n = 322) responded to the survey. More than 95% of responding sites endorsed routinely screening and/or intervening for alcohol use problems. Routine services addressing PTSD were less common, with 28% of centers reporting routine screening. More than 50% of sites that screened for PTSD used previously established trauma center alcohol use services. Programmatic screening and intervention for firearm injury sequelae was occurring at 30% of sites.

CONCLUSION

Alcohol screening and intervention is occurring frequently at US trauma centers and appears to be responsive to American College of Surgeons Committee on Trauma verification requirements. Routine screening and intervention services for PTSD and firearm injury were occurring less frequently. Regular national surveys may be a key element of tracking progress in national mental health and substance use screening, intervention, and referral policy.

Catalyzing the Translation of Patient-Centered Research Into United States Trauma Care Systems: A Case Example

BACKGROUND

The expedient translation of research findings into sustainable intervention procedures is a longstanding health care system priority. The Patient-Centered Outcomes Research Institute (PCORI) has facilitated the development of "research done differently," with a central tenet that key stakeholders can be productively engaged throughout the research process. Literature review revealed few examples of whether, as originally posited, PCORI's innovative stakeholder-driven approach could catalyze the expedient translation of research results into practice.

OBJECTIVES

This narrative review traces the historical development of an American College of Surgeons Committee on Trauma (ACS/COT) policy guidance, facilitated by evidence supplied by the PCORI-funded studies evaluating the delivery of patient-centered care transitions. Key elements catalyzing the guidance are reviewed, including the sustained engagement of ACS/COT policy stakeholders who have the capacity to invoke system-level implementation strategies, such as regulatory mandates linked to verification site visits. Other key elements, including the encouragement of patient stakeholder voice in policy decisions and the incorporation of end-of-study policy summits in pragmatic comparative effectiveness trial design, are discussed.

CONCLUSIONS

Informed by comparative effectiveness trials, ACS/COT policy has expedited introduction of the patient-centered care construct into US trauma care systems. A comparative health care systems conceptual framework for transitional care which incorporates Research Lifecycle, pragmatic clinical trial and implementation science models is articulated. When combined with Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE), employed as a targeted implementation strategy, this approach may accelerate the sustainable delivery of high-quality patient-centered care transitions for US trauma care systems.

A Rapid Ethnographic Assessment of the Impact of the COVID-19 Pandemic on Mental Health Services Delivery in an Acute Care Medical Emergency Department and Trauma Center

A rapid ethnographic assessment of delivery of mental health services to patients at a Level I trauma center in a major metropolitan hospital undergoing a COVID-19 surge was conducted to assess the challenges involved in services delivery and to compare the experience of delivering services across time. Study participants were patients and providers who interacted with or otherwise were observed by three clinicians engaged in the delivery of care within the Emergency Department (ED) and Trauma Center at Harborview Medical Center from the COVID-19-related "surge" in April to the end of July 2020. Data were collected and analyzed in accordance with the Rapid Assessment Procedures-Informed Clinical Ethnography (RAPICE) protocol. Community and institutional efforts to control the spread of the coronavirus created several challenges to providing mental health services in an acute care setting during the April surge. Most of these challenges were successfully addressed by standardization of infection control protocols, but new challenges emerged including an increase in expenses for infection control and reduction in clinical revenues due to fewer patients, furloughs of mental health services providers and peer specialists in the ED, services not provided or delayed, increased stress due to fear of furloughs or increased workload of those not furloughed, and increases in patients seen with injuries due to risky behavior, violence, and substance use. These findings illustrate the rapidly shifting nature of the pandemic, its impacts on mental health services, and the mitigation efforts of communities and healthcare systems.

Is Distance Between Home and Treatment Site a Risk Factor for Complications After Treating Mandibular Fractures?

PURPOSE

Our level I trauma center provides care over a large geographic area including Alaska, Washington, Idaho, Montana, and Wyoming, with many patients traveling hundreds of miles to receive care. Distance to a treatment site is documented to be an independent risk factor for complications after multisystem trauma, but it is unclear if it is a risk factor for isolated mandibular fractures. The study purpose was to measure the association between distance to treatment site and risk for postoperative complications after treatment of isolated mandibular fractures.

MATERIALS AND METHODS

The investigators designed and implemented a retrospective cohort study and enrolled a sample derived from patients treated for isolated mandibular fractures at Harborview Medical Center by the oral and maxillofacial surgery service between June 2012 and December 2016. The primary predictor variable was distance (miles) between the patient's residence and site of treatment (Harborview Medical Center). The primary outcome variable was postoperative complication (yes or no), subcategorized as major and minor. Secondary outcome variables were time to treatment between injury and operative treatment (days) and length of hospital stay (LOS) (days). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between distance to treatment site and postoperative complications, time to treatment, and LOS. The level of statistical significance was set at P ≤ .05.

RESULTS

The study sample was composed of 403 subjects with a mean age of 32.6 ± 14.3 years and 80% were men. The average distance from the patient's residence to treatment site was 44.8 ± 128.6 miles (range, 0 to 1,440 miles; median, 20.4 miles). Major complications occurred in 11.6% of patients. The average distance between patients with and without postoperative complications was not significantly different (42.3 ± 55.8 miles vs 45.5 ± 141.7 miles; P = .8). Increasing distance was significantly associated with longer LOS (r = 0.16; P < .001) but not time to treatment (r = .04; P = .4).

CONCLUSIONS

In contrast to other studies regarding multisystem trauma, complications after treating isolated mandible fractures were not associated with increasing distance to treatment site. Increasing distance may be associated with longer LOS but not time to treatment.

Rapid ethnographic assessment of the COVID-19 pandemic April 2020 'surge' and its impact on service delivery in an Acute Care Medical Emergency Department and Trauma Center

OBJECTIVES

Assess the impacts of the COVID-19 pandemic on service delivery by frontline healthcare providers in acute care medical and emergency department settings and identify strategies used to cope with pandemic-related physical and mental health demands.

DESIGN

Rapid clinical ethnography of patient-provider encounters during an initial pandemic 'surge' conducted by a team of clinician-researchers using a structured protocol for qualitative data collection and analysis.

SETTING

Level 1 trauma centre at Harborview Hospital in Seattle Washington in April 2020.

PARTICIPANTS

Frontline clinical providers serving as participant observers during performance of their clinical duties recorded observations and summaries of conversations with other providers and patients.

RESULTS

We identified four different kinds of impacts: procedural, provider, patient and overall. Each impact highlighted two or more levels of a socioecological model of services delivery: (1) the epidemiology of COVID-19, (2) outer setting, (3) inner or organisational setting and (4) individual patient and provider. Despite significant changes in procedures that included COVID-19 screening of all admitted patients, social distancing and use of personal protective equipment, as well as changes in patient and provider behaviour, the overall impact of the pandemic on the emergency department and acute care service delivery was minimal. This is attributed to having a smaller surge than expected, a quick response by the healthcare system to anticipated demands for service delivery and protection of patients and providers, adequate supplies and high provider morale.

CONCLUSIONS

Although limited to one setting in one healthcare system in one community, the findings offer some important lessons for healthcare systems that have yet to be impacted as well as systems that have been more severely impacted. Each of the socioecological framework levels was found to impact service delivery to patients, and variations at each of these levels account for variations in that quality of care globally.

A Pragmatic Approach to Psychometric Comparisons between the DSM-IV and DSM-5 Posttraumatic Stress Disorder (PTSD) Checklists in Acutely Injured Trauma Patients

Objective: Prior investigations suggest the relative equivalence of the DSM-IV and DSM-5 versions of the Posttraumatic Stress Disorders (PTSD) Checklist, yet no investigations have assessed the psychometric properties of the scales in pragmatic trials of acutely injured trauma survivors. Method: DSM-IV and DSM-5 versions of the PTSD Checklist were included in follow-up interviews of physically injured patients enrolled longitudinally in a pragmatic clinical trial; pragmatic trials aim to efficiently implement research procedures to inform healthcare system policy changes. Psychometric comparisons of the DSM-IV, DSM-5, and a 20-item blended version of the scale included evaluations of internal consistency, correlational assessments, evaluation of item level agreements, and estimation of DSM-5 cutoffs that optimize electronic health record screening protocols. Results: 128 patients were included in the pragmatic psychometric study. Cronbach's alphas for the 3 versions of the PTSD Checklist ranged from 0.93 to 0.95. Correlations between the 3 scales ranged from 0.79 to 0.99. All 3 measures demonstrated excellent convergent and discriminant properties. Item level agreement ranged from 70-80%. For the DSM-5 and blended versions of the scale, a score of 30 and 24, respectively, best approximated the DSM-IV cutoff of ≥35 that had previously optimized PTSD detection in conjunction with EHR screening. Conclusions: Among injured trauma survivors, the psychometric performance of the DSM-IV PTSD Checklist with the addition of the 4 new DSM-5 PTSD Checklist items is nearly equivalent to the DSM-5 PTSD Checklist. The investigation also suggests that pragmatic psychometric methods can catalyze the rapid translation of research findings into real-world practice settings.

Experiences and Insights from the Early US COVID-19 Epicenter: A Rapid Assessment Procedure Informed Clinical Ethnography Case Series

OBJECTIVE

The Coronavirus disease (COVID-19) outbreak has evolved into a pandemic crisis, with King County in Washington State emerging as the early US epicenter. A literature review revealed few reports providing front-line clinical and research teams guidance related to multilevel, rapidly evolving COVID-19 directives.

METHOD

The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method was used to develop a clinical case series and conduct participant observation during an ongoing comparative effectiveness trial of peer-integrated, patient-centered interventions after traumatic injury. Participants were patients enrolled in the intervention arm of the ongoing trial, as well as front-line clinicians, patient peer interventionists, and clinical research team members implementing the trial. All participants were exposed to the Washington State COVID-19 outbreak.

RESULTS

Primary and secondary COVID-19 prevention strategies were feasibly integrated into ongoing care coordination and behavioral interventions for at-risk patients. Beyond the compilation of case studies, as an iterative method, RAPICE data collection naturalistically evolved to include observations of intervention team activity occurring within the larger pandemic epicenter context. A daily clinical research team huddle that flexibly accommodated virtual participation was also feasibly implemented.

CONCLUSIONS

Primary and secondary COVID-19 prevention strategies can be feasibly integrated into ongoing clinical interventions during the pandemic. Routine, proactive clinical and research team communication that transparently addresses ethical tensions and health-sustaining activities may promote well-being for providers grappling with rapidly evolving pandemic directives. Proactive assessments of individual provider vulnerabilities for severe COVID-19 related respiratory illness may also be a crucial element of the health care system pandemic responses.