Explore the vast range of titles available.

ObjectivesAssess 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.DesignRapid 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.SettingLevel 1 trauma centre at Harborview Hospital in Seattle Washington in April 2020.ParticipantsFrontline clinical providers serving as participant observers during performance of their clinical duties recorded observations and summaries of conversations with other providers and patients.ResultsWe 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.ConclusionsAlthough 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.

Injured survivors of individual and mass trauma are at risk for developing post-traumatic stress disorder (PTSD). Few investigations have assessed PTSD after injury in large samples across diverse acute care hospital settings. A total of 2931 injured trauma survivors aged 18-84 who were representative of 9983 in-patients were recruited from 69 hospitals across the USA. In-patient medical records were abstracted, and hospitalized patients were interviewed at 3 and 12 months after injury. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist (PCL) 12 months after injury. Approximately 23% of injury survivors had symptoms consistent with a diagnosis of PTSD 12 months after their hospitalization. Greater levels of early post-injury emotional distress and physical pain were associated with an increased risk of symptoms consistent with a PTSD diagnosis. Pre-injury, intensive care unit (ICU) admission [relative risk (RR) 1.17, 95% confidence interval (CI) 1.02-1.34], pre-injury depression (RR 1.33, 95% CI 1.15-1.54), benzodiazepine prescription (RR 1.46, 95% CI 1.17-1.84) and intentional injury (RR 1.32, 95% CI 1.04-1.67) were independently associated with an increased risk of symptoms consistent with a PTSD diagnosis. White injury survivors without insurance demonstrated approximately twice the rate of symptoms consistent with a diagnosis of PTSD when compared to white individuals with private insurance. By contrast, for Hispanic injury survivors PTSD rates were approximately equal between uninsured and privately insured individuals. Nationwide in the USA, more than 20% of injured trauma survivors have symptoms consistent with a diagnosis of PTSD 12 months after acute care in-patient hospitalization. Coordinated investigative and policy efforts could target mandates for high-quality PTSD screening and intervention in acute care medical settings.

BackgroundQuestions regarding the extent to which post-traumatic stress disorder (PTSD) is comorbid with alcohol and drug use are particularly germane in an era when the American College of Surgeons Committee on Trauma (ACS-COT) is considering policy requiring screening, intervention and/or referral services for patients presenting with psychological sequalae of traumatic injury. Literature review revealed few multisite trauma-center-based investigations that have assessed the association between PTSD symptoms and alcohol and drug use comorbidities in injured patients.MethodsThis investigation was a secondary analysis of baseline data collected prior to randomization in a 25-site trauma center pragmatic clinical trial. All 635 patients included in the investigation had elevated PTSD symptom levels at the time of trauma center admission. Self-report questionnaire screening, laboratory toxicology results, and electronic health record data were combined to assess the frequencies of alcohol, stimulant (i.e., amphetamine and cocaine), opioid and marijuana use comorbidities for injured patients. Logistic regression was used to assess the associations between demographic and injury characteristics and alcohol and drug use comorbidity.ResultsThe frequency of patients with one or more alcohol or substance use comorbidity was between 62% and 79%. Over 50% of patients were positive for one or more alcohol or cannabis comorbidity. Approximately 26% of patients were positive for stimulants and 10% for opioid comorbidity.DiscussionThis multisite investigation suggests that between 62% and 79% of hospitalized injury survivors with elevated PTSD symptoms have one or more alcohol or drug use comorbidity. Orchestrated ACS-COT policy and trauma center service delivery development should incorporate the key finding that a substantial majority of patients with high levels of psychological distress (eg, elevated PTSD symptoms) may have alcohol and drug use comorbidities.Level of evidenceLevel II (epidemiological investigation of untreated controls from a multisite randomized clinical trial)Trial registration numberNCT02655354.

ObjectivesNo large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors.MethodsThe investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds.ResultsThe investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference −3.72 (95% CI −7.33 to –0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference −1.29 (95% CI −4.89 to 2.31) ES=0.10, p=ns).ConclusionIn this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities.Level of evidenceLevel II, secondary analysis of randomized clinical trial data reporting a significant difference.Trial registration numberNCT02655354.

ObjectivesThe goal of the current study was to assess the effectiveness of a peer integrated collaborative care intervention for postinjury outcomes.MethodsInjury survivors ≥18 years of age were screened for post-traumatic stress disorder (PTSD) symptoms and severe postinjury concerns; screen-positive patients were randomized to the intervention versus enhanced usual care control conditions. The collaborative care intervention included peer support and care management. The intervention also included evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD. The COVID-19 pandemic interrupted recruitment between March and June 2020; in response to the COVID-19 pandemic, the peer component of the intervention went from in-person to virtual delivery. The primary outcomes were PTSD symptoms assessed with the Diagnostic and Statistical Manual of Mental Disorders fourth edition PTSD checklist, any severe postinjury concerns, and emergency department/inpatient utilization followed over the 12 months postinjury. Secondary outcomes included patient satisfaction with emotional healthcare.ResultsA total of 450 patients were randomized to the intervention (n=225) and control (n=225) conditions; 124 patients (28%) were recruited and completed all study assessments prior to the onset of the COVID-19 pandemic, while 326 patients (72%) were recruited after and/or had one or more study follow-ups occur postpandemic onset. Mixed model regression revealed no statistically significant comparisons for any of the primary outcomes. In exploratory models that examined the impact of COVID-19, significantly improved PTSD symptoms were present at 3 months pre-COVID-19 relative to post-COVID-19. Intervention patients consistently demonstrated higher satisfaction with emotional aspects of healthcare (F(5,1652)=2.87, p=0.01).ConclusionsThe intervention demonstrated no significant improvements in primary outcomes in the intent-to-treat sample. The peer integrated collaborative care intervention contributed to higher patient satisfaction with the emotional aspects of healthcare.Level of evidenceLevel II, randomized clinical trial.Trial registration number NCT03569878.

Objective: The goal of this study was to examine the longitudinal trajectories of posttraumatic stress disorder (PTSD) symptoms in a sample of acutely injured hospitalized civilian trauma survivors who participated in a randomized clinical trial. Prior longitudinal descriptive research has shown that there are distinct trajectories of PTSD symptoms over time in trauma survivors. Limited clinical trial research exists that describes the patterns of the trajectories as well as the risk factors that influence the trajectories for seriously injured trauma-exposed patients. Method: Semiparametric, group-based approach trajectory modeling was used to examine four group trajectories of a subset of data obtained from a previous longitudinal clinical trial. Trajectories examined included resilience, recovery, relapsing/remitting, and chronic symptom patterns. One hundred and ninety-four patients who participated in the randomized clinical trial were assessed at baseline in the days and weeks after injury and then randomized. The associations between previously identified PTSD risk factors and the four trajectories were examined. Results: The risk factors of ethnocultural minority status, psychiatric history, additional life stressors, and depressive symptoms, as well as intervention versus control group status, were found to significantly affect the probability of trajectory group membership for PTSD symptom severity. Conclusions: These findings suggest that there is a need for early PTSD interventions that anticipate differences in injured patients' PTSD trajectory profiles. Stepped care intervention procedures may optimally address the diverse PTSD trajectory patterns observed in injured trauma survivors through the tailoring of intervention timing and dosing.

BackgroundAccurate acute care medical utilization history is an important outcome for clinicians and investigators concerned with improving trauma center care. The objective of this study was to examine the accuracy of self-report emergency department (ED) utilization compared with utilization obtained from the Emergency Department Information Exchange (EDIE) in admitted trauma surgery patients with comorbid mental health and substance use problems.MethodsThis is a retrospective cohort study of 169 injured patients admitted to the University of Washington’s Harborview Level I Trauma Center. Patients had high levels of post-traumatic stress disorder and depressive symptoms, suicidal ideation and alcohol comorbidity. The investigation used EDIE, a novel health technology tool that collects information at the time a patient checks into any ED in Washington and other US states. Patterns of EDIE-documented visits were described, and the accuracy of injured patients’ self-report visits was compared with EDIE-recorded visits during the course of the 12 months prior to the index trauma center admission.ResultsOverall, 45% of the sample (n=76) inaccurately recalled their ED visits during the past year, with 36 participants (21%) reporting less ED visits than EDIE indicated and 40 (24%) reporting more ED visits than EDIE indicated. Patients with histories of alcohol use problems and major psychiatric illness were more likely to either under-report or over-report ED health service use.DiscussionNearly half of all patients were unable to accurately recall ED visits in the previous 12 months compared with EDIE, with almost one-quarter of patients demonstrating high levels of disagreement. The improved accuracy and ease of use when compared with self-report make EDIE an important tool for both clinical and pragmatic trial longitudinal outcome assessments. Orchestrated investigative and policy efforts could further examine the benefits of introducing EDIE and other information exchanges into routine acute care clinical workflows.Level of evidenceII/III.Trial registration numberClinicalTrials.gov NCT02274688.

Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreational-related concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parent-reported symptoms. Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3- to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, -6.6 to -0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, -7.7 to -0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes. Although both groups improved over time, youth receiving the collaborative care intervention had fewer symptoms and better quality of life over 1 year. Intervention delivery through telehealth broadens the reach of this treatment. ClinicalTrials.gov Identifier: NCT03034720.