Trauma System Support to Facilitate Recovery Stinner, Daniel; Hendrickson, Sarah B; Vallier, Heather A
Journal of orthopaedic trauma,
10/2022, Letnik:
36, Številka:
Suppl 5
Journal Article
Recenzirano
Odprti dostop
Trauma is a major public health issue. Orthopaedic trauma surgeons are skilled in the acute management of musculoskeletal injury; however, formal training and resources have not been devoted to ...optimizing recovery after trauma. Recovery entails addressing the biomedical aspects of injury, as well as the psychological and social factors. The purposes of this study were to describe existing programs and resources within trauma centers, developed to promote psychosocial recovery. Supporting research data will be referenced, and potential barriers to program implementation will be discussed. The American College of Surgeons has mandated screening and treatment for mental illness after trauma, which will raise the bar to highlight the importance of these social issues, likely enabling providers to develop new programs and other resources within their systems. Provider education will promote the informing of patients and families, with the intent of enhancing the efficiency and scope of recovery.
•One third of patients with PTSD participated in trauma recovery services programming.•Patients with severe PTSD, higher level of formal education, and commercial insurance were more likely to ...participate.•Participation in TRS may be improved by minimizing the participant commute to the program location and by increasing awareness of patient groups at risk for less engagement.
Post Traumatic Stress Disorder (PTSD) commonly occurs following acute trauma. Post-injury outcomes are negatively impacted by PTSD. Trauma Recovery Services (TRS) programming was developed at our institution in 2013 to provide psychosocial programming that increases patient satisfaction with care and ability to return to work and decreases PTSD symptoms. We sought to identify factors that influence patients’ decision to participate in programming.
Over a 3-year period at a single, urban level 1 trauma center, 172 patients over the age of 18 screened positive for PTSD on the validated PTSD checklist for DSM-5 (PCL-5) screening tool. Demographic, socioeconomic, injury, and medical comorbidity information was collected. Variables were initially compared in a univariate manner via Chi-squared, Fisher exact, t-test, or Mann-Whitney U, as appropriate. Variables that had a p-value <0.2 on univariate analysis were entered into a backward stepwise logistic regression model to identify independent predictors of participation in TRS programming.
Mean age was 37.8 years. 70.1% of patients were male. The most common mechanisms of injury were gunshot wound (33.7%), motor vehicle crash (19.0%), and burn. 33.5% of patients participated in TRS programming. Nine predictors had p<.2 on univariate analysis and were entered into the stepwise regression model. Four predictors remained in the final model. Patients with private insurance (RR=2.2, p=.038), high school diploma or greater (RR=1.53, p=.002; Table 1), and PCL-5 score greater than 50 were more likely to participate in TRS programming (RR=1.42, p=.046). Patients who live 20 or more minutes away by car from TRS were less likely to participate in programming (RR=0.47, p=.065).
Patients with more severe PTSD, higher levels of education, and private insurance were more likely to participate in TRS programming. Participation in TRS and similar psychosocial programs may be improved by minimizing the participant's potential commute to the program location.
Patient-specific factors may influence posttraumatic stress disorder (PTSD) development and warrant further examination. This study investigates potential association between patient-reported fear of ...death at the time of injury and development of PTSD.
Over 35 months, 250 patients were screened for PTSD at their first posthospitalization clinic visit and were asked "Did you think you were going to die from this injury?" (yes or no). PTSD screening was conducted using the PTSD checklist for DSM-5 questionnaire. A score ≥33 was considered positive for PTSD, and patients were offered ancillary psychiatric services. Retrospectively, medical records were reviewed for baseline demographics and injury information.
Forty-three patients (17%) indicated a fear of death. The mean age was 46 years, with patients who feared death being younger (36 versus 48, P < 0.001), and 62% were male. The most common mechanisms of injury were motor vehicle or motorcycle collisions (30%) and ground-level falls (21%). Gunshot wounds were more common among patients who feared death from trauma (44% versus 7%, P < 0.001). PTSD questionnaires were completed a median of 26 days after injury, with an average score of 12.6. PTSD scores were higher for patients with fear of death (32.7 versus 8.5), and these patients required more acute interventions (47% versus 7%), both P < 0.001. After multivariable logistic regression, patients who thought that they would die from their trauma had >13 times higher odds of developing PTSD (odds ratios: 13.42, P < 0.0001). Apart from positive psychiatric history (OR: 5.46, P = 0.001), no factors (ie, age, sex, mechanism, or any injury or treatment characteristic) were predictive of positive PTSD scores on regression.
Patients who reported fear of death at the time of injury were 13 times more likely to develop PTSD. Simply asking patients whether they thought that they would die at the time of injury may prospectively identify PTSD risk.
Prognostic Level II.
The purpose was to describe the frequency of orthopaedic trauma and postsurgical complications associated with psychiatric diagnoses.
Query of TriNetx Analytics Network.
Participating hospitals.
...Those ≥18 years old with psychiatric illness and orthopaedic trauma.
Fractures and postoperative complications were described. A 1:1 propensity score matching function was used. Odds ratios compared intercohort complications.
A total of 11,266,415 patients were identified with a psychiatric diagnosis, including bipolar disorder (8.9%), schizophrenia (3.3%), major depression (12.4%), stress-related disorder (9.6%), anxiety disorder (64.5%), borderline personality disorder (1.1%), or antisocial personality (0.2%). Prevalence of 30.2% was found for a fracture and at least 1 psychiatric diagnosis. Antisocial personality disorder had the highest risk ratio relative to people without that mental disorder (relative risk RR = 5.09) of having 1 or more associated fracture, followed by depression (RR = 3.03), stress-related disorders (RR = 3.00), anxiety disorders (RR = 2.97), borderline personality disorder (RR = 2.92), bipolar disorder (RR = 2.80), and schizophrenia (RR = 2.69). Patients with at least 1 psychiatric comorbidity had greater risk of pulmonary embolism, superficial and deep surgical site infections, pneumonia, urinary tract infection, deep venous thrombosis, osteonecrosis, and complex regional pain syndrome by 1 month after fixation, when compared with patients without psychiatric disorder. By 1 year, they were also at an increased risk for stroke and myocardial infarction.
All psychiatric comorbidities were associated with increased RR of fracture and higher odds of complications compared with patients without psychiatric comorbidities. Providers should be aware of preexisting psychiatric diagnoses during treatment of acute injuries because of these risks.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Survivors of physical trauma, their home caregivers, and their medical providers all have an increased risk of developing psychological distress and trauma-related psychiatric disease. The purpose of ...this study was to describe the frequency and change over time of trauma society research presentations regarding mental health to identify opportunities for growth.
Archives from 2018 to 2020 from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association were reviewed. The studies that measured mental illness, psychosocial distress, and other psychosocial factors were assessed: for (1) the use of patient-reported outcome measures ; (2) the association of psychosocial variables with outcomes; and (3) the interventions investigated. Change over time was assessed using χ2 analysis.
Of 1,239 abstracts, 57 (4.6%) addressed at least 1 mental health-related factor. Mental health was more frequently studied over time (2018 3.2%; 2019 3.5%; 2020 7.7%; P = .003). The most frequently measured factors were post-traumatic stress disorder, quality of life, general mental health, and depression. Seventeen (29.8%) abstracts addressed substance abuse, most commonly opioid abuse. Seven (12.3%) abstracts measured mental health in caregivers or medical providers. Patient-reported outcome measures were used in 32 studies (56.1%). Two-thirds of studies reported findings suggesting that mental illness impairs trauma-related outcomes. Only 5 (8.8%) investigated interventions designed to reduce adverse outcomes.
Although academic discussion of mental health after trauma increased from 2018 to 2020, the topic remains a limited component of annual programs, patient-reported outcome measures remain underutilized, and intervention studies are rare.
INTRODUCTION:The purpose of this study is to assess the impact of Trauma Recovery Services (TRS), a program facilitating engagement and recovery on satisfaction after orthopaedic trauma.
METHODS:Two ...hundred ninety-four patients with surgically managed extremity fractures were prospectively surveyed. Satisfaction was assessed after 12 months using a 13-question telephone survey, rated on a Likert scale from 1 to 5 (with five being excellent). TRS resource utilization during and after hospitalization was recorded. Eighty-eight patients (30%) used TRS.
RESULTS:Overall satisfaction was high with a mean score of 4.32. Although no differences were observed between the control group and patients with TRS utilization in age, sex, race, insurance, smoking history, or employment status, TRS patients sustained more high-energy mechanisms (81% versus 56%) and had more associated psychiatric illness (33% versus 17%), both P < 0.01. Multivariable regression indicated general exposure to TRS to be an independent predictor of higher overall care ratings (B = 1.31; P = 0.03).
DISCUSSION:Utilization of TRS was the greatest predictor of better overall care ratings. This study builds on existing evidence demonstrating the positive impact of Trauma Survivor Network programming. We conclude that a hospital-wide program supporting patient education and engagement can effectively increase patient satisfaction after traumatic injury.
LEVEL OF EVIDENCE:Prognostic Level II
INTRODUCTION:Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is ...inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit.
METHODS:This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit.
RESULTS:Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001).
DISCUSSION:Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.
INTRODUCTIONRecidivism is common following injury. Interventions to enhance patient engagement may reduce trauma recidivism. Education, counseling, peer mentorship, and other resources are known as ...Trauma Recovery Services (TRS). The authors hypothesized that TRS use would reduce trauma recidivism.METHODSOver five years at a level 1 trauma center, 954 adults treated operatively for pelvic, spine, and femoral fractures were reviewed. Recidivism was defined as return to trauma center for new injury within 30-months. All patients were offered TRS. Multivariate logistic regression statistical analysis was used to identify predictors of recidivism.RESULTSThree hundred and ninety-seven of all patients (42 %) utilized TRS, including educational materials (n = 293), peer visits (n = 360), coaching (n = 284), posttraumatic stress disorder (PTSD) screening (n = 74), and other services. Within the entire sample, 136 patients (14 %) returned to the emergency department for an unrelated trauma event after mean 21 months. 13 % of TRS users became recidivists. Overall, 49 % of recidivists had history of pre-existing mental illness. High rates of TRS engagement between recidivists and non-recidivists were seen (75 %); however, non-recidivists were more likely to use multiple types of recovery services (49 % vs 34 %, p = 0.002), and were more likely to engage with trauma peer mentors (former trauma survivors) more than once (91 % vs 81 %, p = 0.03). After multivariable analysis, patients using multiple different recovery services had a lower risk of recidivism (p = 0.04, OR 0.42, 95 % CI 0.19-0.96).CONCLUSIONSMultifaceted engagement with recovery programming is associated with less recidivism following trauma. Future study of resultant reductions in healthcare costs are warranted.LEVEL OF EVIDENCELevel II; Prognostic.
Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe mucocutaneous hypersensitivity disorders characterized by sudden onset epidermal necrosis. Acute manifestations of ...SJS/TEN often include vulvovaginal erosions, ulcerations, vaginal discharge, bleeding, vaginal pain, dysuria, and urinary retention. If not treated, this can lead to complications such as vulvovaginal adhesions, vaginal stenosis or dryness, pain, dyspareunia, bleeding, and adenosis. Even with adequate treatment, there are lasting impacts including difficulty with vaginal exams and psychological distress. Early recognition and treatment of vulvovaginal involvement are crucial to preventing severe sequelae. Despite the potentially devastating consequences of genitourinary involvement of SJS/TEN, involvement of the mucocutaneous surfaces of the vulva and vagina is inconsistently documented, and protocols for treatment and follow-up are not well-established. The treatment of vulvovaginal involvement relies largely on expert opinion, and there is little data on the efficacy of suggested management. The goal of this review was to identify whether establishing a clinical pathway increased treatment of vulvovaginal SJS/TEN and to optimize our standardized protocol to prevent genitourinary sequelae.
Methods
We conducted a retrospective chart review of female patients with SJS/TEN at Harborview Medical Center, University of Washington from 2008 to 2021. Demographic and clinical data including gynecologic consultation, exam findings, treatment regimens, and outpatient follow-up were collected from the electronic medical record. We compared data before and after implementation of a clinical care pathway in 2017.
Results
We reviewed a total of 88 charts of women with possible SJS/TEN between 2008 and 2021. Of these 88 charts, 77 were found to have clear biopsy proven diagnosis of SJS/TEN. A total of 42 patients were found to have vulvovaginal involvement (55%) and gynecology was consulted in 43% of cases. 50% of patients (
n
= 21) with vulvovaginal involvement were recommended treatment with vaginal dilators and steroid ointment and 34% of patients with genital involvement received no treatment.
Between 2008 and May of 2017 (pre-protocol), we found 55 patients with SJS/TEN. 55% of patients (
n
= 29) had vulvovaginal involvement (
n
= 26 vulvar,
n
= 21 vaginal). Gynecology was only consulted in 26% (
n
= 14) of patients. Of the 21 females with vaginal involvement, only 38% (
n
= 8) had dilators/vaginal molds with steroid ointment recommended. Of the 26 females with vulvar involvement, 31% (
n
= 8) had no vulvar treatment recommendations with the remaining 69% having some documentation that ranged from gauze placement only (19%) to topical lidocaine, barrier cream, antibiotic or antifungal cream/ ointment, lubricant, or topical steroid ointment (50%). Menstrual suppression was recommended in 38% (
n
= 9) of menstruating females. An antifungal medication was only prescribed in 4% of patients.
Following implementation of the clinical pathway for the treatment of SJS/TEN in 2017, 22 females with SJS/TEN were identified. 72% (
n
= 16) had documented vulvovaginal involvement (
n
= 16 vulvar,
n
= 9 vaginal). Gynecology consultations took place in 86% (
n
= 19) of patients. We identified several improvements after implementation of the protocol. Gynecology consults overall increased from 26% pre-, to 86% post-protocol. For patients with vulvovaginal involvement, consultations were completed in 93% compared to 50% prior to protocol. Of note, the finding of vulvovaginal lesions increased from 53 to 72%. Dilator use with topical steroid ointment was consistently recommended, as was antifungal use and menstrual suppression.
Conclusion
Having a protocol in place for treatment of female patients with SJS/TEN increased the consistency of Gynecologic consultation and the documentation and treatment of vulvovaginal SJS/TEN. We identified the need to improve clinical follow-up after discharge from the hospital, which could be arranged as multidisciplinary visits and would be a good option to assess long-term outcomes (pain, sexual activity, etc.). With regards to future directions, we are in the process of assessing long-term data on quality of life and sexual functioning. The impact of treatment in the acute setting on the development of chronic sequelae needs to be established, as does the management of long-term sequelae like vaginal dryness, pain, dyspareunia. The role of local estrogen and vaginal laser still needs to be explored. Pelvic floor physical therapy might play a significant role in rehabilitation and has yet to be studied.
BackgroundThe primary goal of the present study is to describe the psychosocial support services provided at our institution and the evolution of such programming through time. This study will also ...report the demographics and injury patterns of patients using available resources.MethodsTrauma Recovery Services (TRS) is a social and psychological support program that provides services and resources to patients and families admitted to our hospital. It includes a number of different services such as emotional coaching from licensed counselors, educational materials, peer mentorship from trauma survivors, monthly support groups, post-traumatic stress disorder (PTSD) screening and programming for victims of crime. Patients using services were prospectively recorded by hired staff, volunteers and students who engaged in distributing programming. Demographics and injury characteristics were retrospectively gathered from patient’s medical records.ResultsFrom May of 2013 through December 2018, a total of 4977 discrete patients used TRS at an urban level 1 trauma center. During the study period, 31.4% of the 15 640 admitted adult trauma patients were exposed to TRS and this increased from 7.2% in 2013 to 60.1% in 2018. During the period of 5.5 years, 3317 patients had ‘direct contact’ (coaching and/or educational materials) and 1827 patients had at least one peer visit. The average number of peer visits was 2.7 per patient (range: 2–15). Of the 114 patients who attended support groups over 4 years, 55 (48%) attended more than one session, with an average of 3.9 visits (range: 2–10) per patient. After the establishment of PTSD screening and Victims of Crime Advocacy and Recovery Program (VOCARP) services in 2017, a total of 482 patients were screened for PTSD and 974 patients used VOCARP resources during the period of 2 years, with substantial growth from 2017 to 2018.ConclusionsHospital-provided resources aimed at educating patients, expanding support networks and bolstering resiliency were popular at our institution, with nearly 5000 discrete patients accessing services during a period of 5.5 years. Moving forward, greater investigation of program usage, development, and efficacy is necessary.Level of evidenceLevel II therapeutic.
PDF