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Screening & Secondary Prevention of Traumatic Stress after Injury PowerPoint PPT Presentation


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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).

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Screening & Secondary Prevention of Traumatic Stress after Injury

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Screening secondary prevention of traumatic stress after injury l.jpg

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)


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Injury & traumatic stress

  • Life threat (self or others)

  • Fear, helplessness, horror

  • Symptoms

    • Avoidance

    • Intrusive thoughts

    • Hyperarousal


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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


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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?


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STEPP screener

  • Development sample

    • Traffic injured

    • Hospitalized

  • 12 items: child, parent, chart

    Child Parent

    Sens88%96%

    Spec48%53%

    PPV25%27%

    NPV95%99%

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


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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


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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


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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


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Primary MD training


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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


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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


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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


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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


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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


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Impact

Surveillance

In-Depth Study

Publish Research

Intervention

TraumaLink approach

Identify Issues

Research

to

Action

to

Impact


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