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Abstract
BACKGROUND Similar to the significant rise in the geriatric population in the United States, trauma centers have seen an increase in geriatric trauma patients. These patients present with additional challenges such as a higher likelihood of undertriage, mortality, and frailty. In addition, the varying presence of advanced directive documentation increases the importance of early palliative care consultations for geriatric trauma patients. OBJECTIVE In 2018, a Level I trauma center in the Midwest reviewed the American College of Surgeons Trauma Quality Improvement Program's Palliative Care Best Practice Guideline to identify opportunities for improvement to strengthen the collaboration between the palliative care consult service and trauma program. METHODS The guideline drove improvements, which included documentation changes (i.e., expansion of palliative care consultation triggers, frailty assessment, advanced directives questions, depression screening, and addition of palliative care consultation section on the performance improvement program form) and training (1-hr lecture on palliative care and 5-hr palliative care simulation training) opportunities. RESULTS A 3-month manual chart review (March 2019 through May 2019) revealed that by May 2019, 87.2% of admitted geriatric trauma patients received frailty assessments, which surpassed the benchmark (≥85%). In addition, advanced care planning questions (i.e., health care power of attorney, do not resuscitate order, or living will) exceeded the benchmarks set forth by the guideline (≥90%), with all of the questions being asked and documented in 95.7% of those same patient charts by May 2019. CONCLUSION This quality improvement project has applicability for trauma centers that treat geriatric trauma patients; using the guidelines can drive changes to meet individual institution needs.
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Addressing Behavioral Health Concerns in Trauma: Using Lean Six Sigma to Implement a Depression Screening Protocol in a Level I Trauma Center. Qual Manag Health Care 2020; 29:218-225. [PMID: 32991539 DOI: 10.1097/qmh.0000000000000266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with physical injuries or chronic conditions may be impacted by mental health conditions, which significantly affect their participation and progress in treatment. The Patient Health Questionnaire-2 (PHQ-2) depression screening can identify patients who are at greatest risk for depression to provide better whole-person care. OBJECTIVE The quality improvement project objective was to identify and design a process that would result in the PHQ-2 depression screening for admitted trauma patients with a minimum 75% completion rate. METHODS Lean Six Sigma (LSS) process design methodology, DMADV (define, measure, analyze, design, and verify), drove process improvement. Medical records from before (December 2018 through February 2019) and after (March 2019 through May 2019) the intervention were evaluated using frequencies, percentages, χ, and multivariable logistic regression to determine the effectiveness of the intervention. RESULTS PHQ-2 document location was imperative to successful compliance, which increased from 60.74% (78 of 128) to 80.56% (87 of 108). Specifically, weekend compliance increased from 42.9% (18 of 42) to 82.8% (24 of 29). CONCLUSION LSS DMADV methodology helped health care professionals design a process to facilitate compliance with the PHQ-2 depression screening protocol in trauma patients. Adherence with this screening can help increase the number of behavioral health consultations, which in turn improves the treatment of traumatic injury survivors.
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Sakran JV, Ezzeddine H, Schwab CW, Bonne S, Brasel KJ, Burd RS, Cuschieri J, Ficke J, Gaines BA, Giacino JT, Gibran NS, Haider A, Hall EC, Herrera-Escobar JP, Joseph B, Kao L, Kurowski BG, Livingston D, Mandell SP, Nehra D, Sarani B, Seamon M, Yonclas P, Zarzaur B, Stewart R, Bulger E, Nathens AB. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures. J Am Coll Surg 2020; 230:819-835. [PMID: 32201197 DOI: 10.1016/j.jamcollsurg.2020.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Joseph V Sakran
- Division of Acute Care Surgery, Departments of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Hiba Ezzeddine
- Division of Acute Care Surgery, Departments of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C William Schwab
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia
| | - Stephanie Bonne
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Karen J Brasel
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health Sciences University, Portland, OR
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children's National Medical Center, Washington, DC
| | - Joseph Cuschieri
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - James Ficke
- Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barbara A Gaines
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joseph T Giacino
- Division of Rehabilitation Neuropsychology, Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, Charlestown
| | - Nicole S Gibran
- Division of Restorative Burn Surgery, Division of Trauma, Burn
| | - Adil Haider
- Medical College in Pakistan, The Aga Khan University, Karachi, Pakistan
| | - Erin C Hall
- MedStar Washington Hospital Center, Washington, DC; Department of Surgery, Washington, DC
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bellal Joseph
- Division of Trauma, Acute Care, Burn and Emergency Surgery, Department of Surgery, the University of Arizona College of Medicine, Tucson, AZ
| | - Lillian Kao
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Brad G Kurowski
- Division of Physical Medicine and Rehabilitation, Cincinnati Children's Hospital Medical Center; Department of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Livingston
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Samuel P Mandell
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - Deepika Nehra
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery (Sarani), Georgetown University School of Medicine, Washington, DC
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia
| | - Peter Yonclas
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Ben Zarzaur
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine, Madison, WI
| | - Ronald Stewart
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX; Committee on Trauma, Chicago, IL
| | - Eileen Bulger
- Critical Care, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA; Committee on Trauma, Chicago, IL
| | - Avery B Nathens
- American College of Surgeons; Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Karabatzakis M, Den Oudsten BL, Gosens T, De Vries J. Psychometric properties of the psychosocial screening instrument for physical trauma patients (PSIT). Health Qual Life Outcomes 2019; 17:172. [PMID: 31718663 PMCID: PMC6852899 DOI: 10.1186/s12955-019-1234-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023] Open
Abstract
Background Early detection of psychosocial problems post-injury may prevent them from becoming chronic. Currently, there is no psychosocial screening instrument that can be used in patients surviving a physical trauma or injury. Therefore, we recently developed a psychosocial screening instrument for adult physical trauma patients, the PSIT. The aim of this study was to finalize and psychometrically examine the PSIT. Methods All adult (≥ 18 years) trauma patients admitted to a Dutch level I trauma center from October 2016 through September 2017 without severe cognitive disorders (n = 1448) received the PSIT, Impact of Events Scale-Revised (IES-R), Patient Health Questionnaire-9 (PHQ-9), Rosenberg Self-Esteem Scale (RSES), State-Trait Anxiety Inventory-State (STAI-S), and the World Health Organization Quality of Life-Abbreviated version (WHOQOL-Bref). After 2 weeks, a subgroup of responding participants received the PSIT a second time. The internal structure (principal components analysis, PCA; and confirmatory factor analysis, CFA), internal consistency (Cronbach’s alpha, α), test-retest reliability (Intraclass Correlation Coefficient, ICC), construct validity (Spearman’s rho correlations), diagnostic accuracy (Area Under the Curve, AUC), and potential cut-off values (sensitivity and specificity) were examined. Results A total of 364 (25.1%) patients participated, of whom 128 completed the PSIT again after 19.5 ± 6.8 days. Test-retest reliability was good (ICC = 0.86). Based on PCA, five items were removed because of cross-loadings ≥ 0.3. Three subscales were identified: (1) Negative affect (7 items; α = 0.91; AUC = 0.92); (2) Anxiety and Post-Traumatic Stress Symptoms (4 items; α = 0.77; AUC = 0.88); and (3) Social and self-image (4 items; α = 0.79; AUC = 0.92). CFA supported this structure (comparative fit index = 0.96; root mean square error of approximation = 0.06; standardized rood mean square residual = 0.04). Four of the five a priori formulated hypotheses regarding construct validity were confirmed. The following cut-off values represent maximum sensitivity and specificity: 7 on subscale 1 (89.6% and 83.4%), 3 on subscale 2 (94.4% and 90.3%), and 4 on subscale 3 (85.7% and 90.7%). Conclusion The final PSIT has good psychometric properties in adult trauma patients.
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Affiliation(s)
- Maria Karabatzakis
- Trauma TopCare, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Tilburg, The Netherlands
| | - Brenda Leontine Den Oudsten
- Center of Research on Psychological and Somatic Disorders (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Taco Gosens
- Trauma TopCare, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Tilburg, The Netherlands.,Department of Orthopaedics and Traumatology, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Tilburg, The Netherlands
| | - Jolanda De Vries
- Trauma TopCare, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Tilburg, The Netherlands. .,Center of Research on Psychological and Somatic Disorders (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands. .,Department of Medical Psychology, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), P.O. Box 90151, 5000 LC, Tilburg, The Netherlands.
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Thorsen MM, Patena JV, Guthrie KM, Spirito A, Ranney ML. Using High-Risk Adolescents' Voices to Develop a Comprehensible Cognitive Behavioral Therapy-Based Text-Message Program. Behav Med 2018; 44:89-99. [PMID: 27594559 PMCID: PMC5336547 DOI: 10.1080/08964289.2016.1223597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
At-risk adolescents' comprehension of, and preferences for, the content of a text-message (SMS) delivered, cognitive behavioral therapy (CBT)-based depression prevention intervention was investigated using two qualitative studies. Adolescents with depressive symptoms and a history of peer violence were recruited from an urban emergency department. Forty-one participants completed semi-structured qualitative interviews. Thematic analysis using deductive and inductive codes were used to capture a priori and emerging themes. Five major themes were identified: CBT-based messages resonated with at-risk adolescents; high levels of peer violence, comorbid symptoms, and prior exposure to the mental health system were variables affecting preferred content; participants endorsed emotional regulation messages, but found mindfulness content difficult to understand via SMS; cognitive awareness and restructuring content was most acceptable when framed by self-efficacy content; adolescent participants generated applicable CBT content in their own voices. Overall, CBT-informed content was able to be distilled into 160-character text messages without losing its comprehensibility.
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Affiliation(s)
| | - John V. Patena
- School of Public Health, Brown University, Providence, RI
| | - Kate Morrow Guthrie
- Centers for Behavioral & Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI
| | - Anthony Spirito
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI
| | - Megan L. Ranney
- Emergency Digital Health Innovation Program, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
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Roden-Foreman K, Robinson R, Bennett M, Roaten K, Petrey L, Powers MB, Warren AM. Posttraumatic growth in a heterogeneous sample of traumatically injured patients 1 year postinjury. J Clin Psychol 2017; 74:989-1003. [PMID: 29193058 DOI: 10.1002/jclp.22563] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/05/2017] [Accepted: 09/21/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Posttraumatic growth (PTG) describes positive change resulting from challenging life events. The current study examined factors associated with PTG in traumatically injured patients 1 year postinjury. METHOD Participants (N = 221) in this prospective cohort study included adults admitted to a Level I trauma center. Over half the participants (60%) were male, with a mean age of 47. Participants completed baseline measures during hospitalization. PTG was assessed at 12-month follow-up. RESULTS Greater PTG was associated with minority race/ethnicity, lower income, automotive collision, and premorbid psychological disorder other than depression or posttraumatic stress (PTS). These variables are also known to predict PTS in trauma patients. Analysis confirmed that greater PTS at follow-up was associated with more growth. CONCLUSION Participants with the most growth also experienced the most distress. This finding demonstrates the importance of implementing psychological screening and intervention for trauma patients in the acute care setting to reduce PTS and facilitate growth.
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A Retrospective, Pilot Study of De Novo Antidepressant Medication Initiation in Intensive Care Unit Patients and Post-ICU Depression. Crit Care Res Pract 2017; 2017:5804860. [PMID: 29104806 PMCID: PMC5615950 DOI: 10.1155/2017/5804860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/13/2017] [Accepted: 08/06/2017] [Indexed: 11/20/2022] Open
Abstract
Post-ICU Syndromes (PICS) remain a devastating problem for intensive care unit (ICU) survivors. It is currently unknown if de novo initiation of an antidepressant medication during ICU stay decreases the prevalence of post-ICU depression. We performed a retrospective, pilot study evaluating patients who had not previously been on an antidepressant medication and who were started on an antidepressant while in the trauma surgical, cardiothoracic, or medical intensive care unit (ICU). The PHQ-2 depression scale was used to ascertain the presence of depression after ICU discharge and compared this to historical controls. Of 2,988 patients admitted to the ICU, 69 patients had de novo initiation of an antidepressant medication and 27 patients were alive and available for study inclusion. We found the prevalence of depression in these patients to be 26%, which is not statistically different than the prevalence of post-ICU depression in historical controls [95% CI (27.6%, 51.6%)]. De novo initiation of an antidepressant medication did not substantially decrease the prevalence of post-ICU depression in this retrospective, pilot study.
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Agtarap S, Boals A, Holtz P, Roden-Foreman K, Rainey EE, Ruggero C, Warren AM. The effect of depressive symptoms on social support one year following traumatic injury. J Affect Disord 2017; 207:398-405. [PMID: 27770732 DOI: 10.1016/j.jad.2016.08.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 07/26/2016] [Accepted: 08/24/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Depression is a common mental health outcome after traumatic injury, negatively impacting physical outcomes and increasing the cost of care. Research shows that the presence and quality of support is a leading protective factor against depression post-injury; however, research is vague on the directional effects of both factors over the course of recovery. METHODS 130 patients admitted to a Level I Trauma Center were recruited to a prospective study examining overall outcomes one-year after injury. Effects of social support and depression at baseline and 12-months post-injury were examined using correlational and cross-lagged path model analyses. Additional follow-up analyses were conducted for depression on specific types of social support. RESULTS Findings replicated previous research suggesting depression and social support were inversely related. Initial depression at time of traumatic injury was predictive of social support 12-months after their injury, but initial social support levels did not significantly predict depression at 12-months. Additionally, initial depression significantly predicted attachment, social integration, reassurance of worth, and guidance 12-months later. LIMITATIONS Findings of the analyses are limited by lack of experimentation and inability to control for other related variables. CONCLUSIONS Findings of the present study support the notion that initial depression predicts poorer social support in recovery, in lieu of prevailing theory (i.e., initial support buffers against later depression) in a sample of trauma patients. These findings highlight the need for medical staff to target specific factors during inpatient stay, such as addressing depressive symptoms and preparing family members and caregivers prior to discharge.
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Affiliation(s)
| | - Adriel Boals
- University of North Texas, Denton, TX, United States
| | - Pamela Holtz
- University of North Texas, Denton, TX, United States
| | | | - Evan E Rainey
- Baylor Research Institute, Dallas, TX, United States
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