Interventions for acutely injured survivors of individual and mass trauma
by Expert 48043
Natural and human-made disasters entail the threat of physical injury. Injured trauma survivors initially receive care in the acute care medical setting. For example, the Centers for Disease Control report that within 48 h after the September 11, 2001 attack on the World Trade Center, 1 103 physically injured survivors were triaged through five acute care facilities in New York (Centers for Disease Control and Prevention, 2002). Injured survivors of mass disasters have been identified as a high-risk group that may require specialized early screening and evaluation procedures (United States Department of Defense et al., 2001; United States Department of Health and Human Services, 2003).
Trauma exposure when coupled with physical injury confers a higher risk for the development of post-traumatic stress disorder (PTSD) (Abenhaim et al., 1992; Green, 1993; Helzer et al., 1987; Hoge et al., 2004; Koren et al., 2005). Between 10%and 40% of hospitalized adolescent and adult injury survivors in the United States may go on to develop symptoms consistent with a diagnosis of PTSD (Holbrook et al., 2001; Marshall & Schell, 2002; Michaels et al., 1999b;Ursano et al., 1999; Zatzick et al., 2002a, 2002b, 2004c, 2006). Among injury survivors, PTSD is often complicated by comorbid, depressive symptoms (O’Donnell et al., 2004; Shalev et al., 1998; Zatzick et al., 2004c, 2006) and medically unexplained somatic complaints (Engel et al., 2000; Katon et al., 2001b; Zatzick et al., 2003).
In trauma-exposed populations in general, and injured trauma survivors in particular, multiple demographic, clinical, and injury-related risk factors for the development of PTSD have been identified (Brewin et al., 2000; Green, 1993; Holbrook et al., 1999; Kessler et al., 1999; March, 2003; Marshall & Schell, 2002; Mayou et al., 1993, 1997; Mellman et al., 2001; Michaels et al., 1999a; O’Donnell et al., 2003, 2004; Pynoos et al., 1999; Shalev et al., 1998a; Winston et al., 2003; Yehuda, 1999; Zatzick et al., 2002b, 2005b). In acutely injured patients, higher initial post-traumatic distress, higher initial emergency department heart rate, female gender, and greater preinjury trauma are among the most consistently identified predictors of persistent PTSD symptoms (Bryant et al., 2000; Holbrook et al., 2001; Marshall&Schell, 2002; Michaels et al., 1999a, 1999b O’Donnell et al., 2003; Winston et al., 2003; Zatzick et al., 2002b, Zatzick et al., 2005a).
A body of investigation substantiates an association between mass trauma exposure and the development of high-risk healthbehaviors such as substance abuse (Boscarino et al., 2006; Galea et al., 2002; Reijneveld et al., 2003, 2005; Vlahov et al., 2004a, 2004b). One controlled prospective study of disaster-exposed adolescents found that while emotional distress diminished over time, problems related to alcohol misuse endured chronically (Reijneveld et al., 2005).
In civilian and veteran trauma-exposed populations these high-risk behaviors appear to be linked to recurrent traumatic life events including an increased risk of recurrent physical injury and mortality (Hearst et al., 1986; Ramstad et al., 2004; Rivara et al., 1993).
In physically injured civilians (Holbrook et al., 1999; Michaels et al., 1999b; Zatzick et al., 1997a, 1997b, 2002a), refugees (Mollica et al., 1999), and veterans (Zatzick et al., 1997a, 1997b), PTSD makes an independent contribution to post-trauma functional limitations and diminished quality of life above and beyond the impact of injury severity and comorbid medical conditions. In a randomly selected cohort of survivors of intentional and unintentional injury, PTSD was the strongest independent predictor of a broad profile of functional impairment 1 year after inpatient surgical hospitalization (Zatzick et al., 2002a). PTSD is associated with increased costs to society; these costs appear to be in part secondary to increased healthcare costs (Greenberg et al., 1999; Kessler, 2000; Walker et al., 1999, 2003). Thus, early interventions for injured survivors of individual and mass traumatic life events that reduce the likelihood of developing enduring post-trauma disturbances may be essential components of public health efforts targeting injury control (Zatzick, 2003b).
Trauma centers provide care for injured civilians after individual and mass traumatic life events
Acute care centers in the United States provide health services after mass trauma (Herman et al.,2002; MacKenzie et al., 2003; Ursano, 2002). Recent consensus guidelines recommend early mental health screening and evaluation procedures for injured trauma survivors who require medical/ surgical attention, as this high-priority subgroup of patients is at risk for the development of PTSD (National Institute of Mental Health, 2002; United States Department of Health and Human Services, 2003).
The trauma care system is the service delivery sector in which injured patients receive treatment. A trauma care system is an organized and coordinated effort in a defined geographic area that is designated to deliver care to injured trauma victims (Bonnie et al., 1999). This care begins immediately after the injury and includes paramedic and ambulance service, emergency department triage, and inpatient surgical hospitalization. Trauma centers are acute care hospitals that are designed to treat emergent medical complications related to physical injury. Level I trauma centers are designated and equipped to care for the most severely injured patients, while levels II–IV centers are designed to treat less severely injured patients and to triage to level I facilities.
The major goals of trauma care systems have been to prevent fatalities, and to triage patients who are more severely injured to the most appropriate and cost-effective level of trauma care within a region (Bonnie et al., 1999). Guidelines for the operation of trauma care systems are only beginning to include comprehensive or even cursory approaches to the evaluation, referral, and treatment of injured patients with mental health problems (Committee on Trauma American College of Surgeons, 1990). In the United States, the American College of Surgeons Committee oversees verification/accreditation requirements for most of the country’s 1154 trauma centers (Committee on Trauma American College of Surgeons, 2006).
Refinements in routine acute care mental health evaluation procedures may serve Americans in the wake of mass trauma
Although PTSD screening measures exist, these instruments may be difficult to administer in mass casualty conditions (Zatzick et al., 2005a, 2005b). Routine acute care investigations are developing emergency department vital sign assessments that have the potential to be feasibly implemented with abbreviated symptom screens to predict PTSD after mass trauma (Bryant et al., 2000; Kassam-Adams et al., 2005; Shalev et al., 1998b; Winston et al., 2003; Zatzick et al., 2005a). Health services research in the acute care medical setting presents a unique opportunity to test and develop routine screening and intervention procedures that may also benefit injured survivors of mass trauma (Zatzick et al., 2004a, 2005b). In the United States 37 million individuals visit emergency departments each year after sustaining traumatic injuries and approximately 2.5 million Americans incur injuries so severe that they require inpatient hospitalization (Bonnie et al., 1999).
Efficacious interventions for PTSD
Efficacy research suggests that patients with PTSD symptoms may respond to psychotherapeutic and psychopharmacological treatments (Foa & Meadows, 1997; Shalev et al., 1996; Solomon et al., 1992). There is evidence that brief, early cognitive behavioral therapy (CBT) interventions can help curb the development of PTSD in injured trauma survivors (Bisson et al., 2004; Bryant, 2002; Bryant et al., 1998, 2003; Ehlers et al., 2003; Foa et al., 1995). Both selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants are efficacious treatments for PTSD (Brady et al., 2000; Davidson et al., 2001; Marshall et al., 2001; Solomonet al., 1992).
Guidelines based on this body of efficacy research have been formulated (Foa et al., 2000; Journal of Clinical Psychiatry Guidelines, 1999; Ursano et al., 2004). These clinical guidelines have yet to be translated to the real world treatment of physically injured trauma survivors within trauma care systems.
Challenges to acute care mental health service delivery
The acute care medical setting presents a series of challenges for the delivery of efficacious mental health interventions (Litz et al., 2002). Few investigations have successfully delivered efficacious PTSD interventions in the acute care setting (Zatzick et al., Submitted for publication). Single-session debriefing interventions can be robustly delivered to representative samples of acute care patients (Bisson et al., 1997; Mayou et al., 2000). Unfortunately, debriefing has not been shown to be efficacious in preventing PTSD (Rose &Bisson, 1998; Van Emmerik et al., 2002) and may actually be associated with poorer outcome among injured trauma survivors (Bisson et al., 1997; Mayou et al., 2000). Efficacy studies of psychotherapeutic and psychopharmacological interventions conducted under best practice conditions assume that well-developed clinical infrastructures exist for the delivery of treatments (Wells, 1999b). The acute care setting, however, poses a series of challenges to the delivery of efficacy-proven mental health interventions.
Acutely injured trauma survivors receive fragmented care that is not linked across inpatient, outpatient, and community service sectors. Currently, few resources exist for bridging acute care hospitalization to primary care and community services (Chesnut et al., 1999; Horowitz et al., 2001; Sabin, et al., 2006; Zatzick et al., 2003). Thus, the standardized regular appointments that constitute an implicit foundation of treatment delivery in efficacy trials may be difficult to implement, as injured patients move rapidly across surgical inpatient, primary care outpatient, and community health service delivery sectors in the days and weeks immediately following an injury. Furthermore, a substantial proportion of acute care patients are not connected to primary care providers (PCPs) (Sabin et al., 2006; Zatzick et al., 2003).
Currently, few patients treated in acute care receive comprehensive evaluation or evidence based mental health treatment. Although over 50% of trauma surgery inpatients suffer from high levels of post-traumatic distress, depression, and alcohol use disorders (Zatzick et al., 2004c), few symptomatic inpatients are detected (Cerda et al., 2000; Zatzick et al., 2000) or receive in-depth evaluation or referral (Danielsson et al., 1999; Gentilello et al., 1999a; Silver & McDuff, 1990; Zatzick et al., 2005b).
Symptomatic patients infrequently access mental health services after hospital discharge (Dunn et al., 2003; Jaycox et al., 2004; McCarthy et al., 2003; Sabin et al., 2006; Zatzick et al., 2001b). Thus, although evidence-based treatments for PTSD and related disorders exist, they are not routinely delivered as early interventions to injured trauma survivors in acute care.
The PhD/MD practitioners that deliver mental health interventions in efficacy trials are not representative of front-line acute care providers. Manuals for the operation of trauma centers clearly articulate roles for registered nurses, those with a Masters of Social Work, and trauma surgical providers, yet rarely mention PhD/MD mental health specialists (Committee on Trauma American College of Surgeons, 1990). Within trauma care systems, early interventions for PTSD and related conditions may ultimately be implemented by front-line acute care providers (Gentilello et al., 1995). Review of the relevant literature revealed no studies that have tested the effectiveness of early PTSD interventions delivered by front-line acute care providers.
Front-line acute care providers are receptive to implementing mental health interventions, yet perceived and structural barriers to implementation exist. Surveys/interviews with acute care providers suggest that mental health interventions are viewed as highly relevant to trauma center care (Danielsson et al., 1999; Schermer et al., 2003; Tellez & Mackersie, 1996).When surveyed, front-line acute care providers express openness to implementing mental health interventions; these providers also endorse a number of barriers to routine implementation including time pressures encountered in emergency settings and lack of training [e.g., “not knowing where to start” (Danielsson et al., 1999)].
Finally, longitudinal clinical investigations have consistently reported difficulties in engaging and retaining acutely traumatized patients in intervention protocols (Jack & Glied, 2002; Pitman et al., 2002; Roy-Byrne et al., 2004; Schelling et al., 2004; Schwarz & Kowalski, 1992; Weisaeth, 2001). Data on patients’ post-trauma concerns provide further insight into the observed difficulties in engaging trauma victims in early interventions. For acutely injured patients multiple physical, financial, social, medical, and legal post-trauma concerns exist that may limit the ability to focus exclusively on the psychological sequelae of the trauma (Zatzick et al., 2001a). Care management procedures that elicit and address patients’ most pressing post-trauma concerns have the potential to initially engage traumatized patients in shared patient–provider treatment planning (Zatzick et al., 2001a, 2004a).
Health services approaches to the problem of the development of early acute care intervention
Injured patients treated within trauma care systems are at high risk for developing PTSD. As is true for many Americans with psychiatric disorders, it appears that many injured patients who suffer from PTSD receive fragmented care and are not engaged in mental health services at strategic postinjury points (New Freedom Commission on Mental Health, 2003; Satcher, 1999). A literature review identified few early intervention trials targeting PTSD that have assessed symptomatic, functional, and utilization/cost outcomes for trauma survivors initially treated in acute care and followed through outpatient primary care visits and community rehabilitation.
Combined interventions have been developed as treatment strategies for chronically mentally ill, treatment-resistant, low-income, and primary care patients (Allness & Knoedler, 1998; Burns & Santos, 1995; Craske et al., 2002; Deci et al., 1995; Hoagwood et al., 2001;Katon&Gonzales, 1994;Katon et al., 1994, 1995, 1997, 1999, 2001a, 2001c, 2004; Roy-Byrne et al., 2001, 2003; Santos et al., 1995; Schoenwald & Hoagwood, 2001; Simon et al., 1995, 2002; Stein & Santos, 1998; Unutzer et al., 2001, 2002;Wells, 1999a; Wells et al., 2000). These treatments bring together efficacious psychotherapy and medication interventions with disease management strategies such as care management; the care management intervention component serves to bridge medical and mental health care (Von Korff et al., 1997;Wagner et al., 1996).
Just as combined interventions have incorporated PCP into the provision of mental health services, the introduction of early combined interventions within trauma care systems may serve to integrate acute care providers into post-traumatic mental healthcare delivery. Using randomized effectiveness designs rooted in the structure, process, and outcome model of intervention delivery (McGlynn et al., 1988), mental health services researchers have demonstrated that combined interventions can improve symptomatic outcomes for patients with depressive and anxiety disorders who are treated in primary care (Katon et al., 1995, 1997, 1999, 2001a, 2004; Roy-Byrne et al., 2001; Unutzer et al., 2002; Wells et al., 2000). Combined interventions in primary care settings have sought to find the optimal roles for PCP, practice nurses, and mental health specialists in the delivery of care for patients with psychiatric disorders and chronic conditions (Katon et al., 2001c).
Combined interventions hold promise for the delivery of mental health interventions in acute care as they can incorporate front-line trauma center providers into early mental health services delivery and can link trauma center care to outpatient services.
Clinical epidemiology as a foundation for a health services research approach to intervention development
This section is based on work published elsewhere (Engel & Katon, 1999; Engel et al., 2004). Clinical epidemiology is the science of making predictions about individual patients by describing events in populations (Fletcher et al., 1996). The methods used by clinical epidemiologists frame the care of the individual patient in the context of the larger population of patients that present for care in a specified health service delivery setting (Feinstein, 1987; Fletcher et al., 1996; Sackett et al., 1991;Walker- Barnes, 2003).
Acute care mental health services research programs aim to address the mental health needs of populations of injured patients presenting for treatment in the acute care medical setting. One manner in which the acute care research programs have operationalized a clinical epidemiological approach is through the use of population-based automated data systems. These provide clinical and demographic information on all patients treated within the health service delivery system so that characteristics of an individual patient or subgroup of patients included in an investigation can be compared to the population of patients presenting for care. For instance, preliminary investigations have used automated medical record data to gain insight into the processes of care underlying the detection of patients with mental health symptoms/diagnoses (Zatzick et al., 2000) and used the automated data systems to identify clinical populations to be targeted in a clinical trial (Zatzick et al., 2002b, 2006). Automated data systems also provide key data related to the policy-relevant outcome domains, such as emergency department and inpatient surgical utilization data documenting recurrent injury admissions (Gentilello et al., 1999a; Zatzick et al., 2004b).
Developing early combined interventions for injured trauma survivors treated in the acute care trauma center setting. The rationale and design of the pilot randomized effectiveness trial (Zatzick et al., 2001c) were strongly influenced by the results of the Gentilello et al. (1999a) intervention at the University of Washington’s Harborview level I trauma center (Harborview). Gentilello et al. (1999a) demonstrated that a PhD-level clinician based in a trauma center could deliver a brief motivational interviewing (MI) intervention from a surgical inpatient unit that reduced post-traumatic alcohol use and hospital admissions secondary to new injury (Gentilello et al., 1999a).
The pilot investigation sought to establish the feasibility of having three seasoned trauma center providers deliver a brief early intervention that aimed to reduce PTSD symptoms after the injury (i.e., secondary PTSD prevention) and high-risk behaviors such as postinjury alcohol consumption that were linked to injury recurrence (i.e., primary prevention of trauma/PTSD).
One interventionist was a trauma surgery nurse practitioner who had over a decade of experience as a front-line provider with the University of California at Davis trauma surgery service; two interventionists were MD consultation liaison psychiatrists. These providers were trained in a care management procedure that aimed to engage injured trauma survivors by providing readily accessible, continuous trauma support in the days and weeks following the injury. A key component of the trauma support intervention was eliciting and targeting for improvement each patient’s unique constellation of post-trauma concerns (Zatzick et al., 2001c). Interventionists also received training in brief interventions for PTSD and alcohol use (Gentilello et al., 1995; Litz, 2004).
In accordance with a population-based/clinical epidemiological approach, patients were randomly selected to participate from the population of patients admitted to the University of California at Davis trauma surgery service. Only severely brain injured and monolingual non-English-speaking patients were excluded from the investigation. Patients randomly selected for participation in the study had moderate levels of PTSD symptoms as well as substance-related comorbidities (Zatzick et al., 2001c).
The pilot investigation found that patients in the intervention group, when compared to controls, manifested significantly decreased PTSD symptom levels at 1 month (p<0.05) but not at 4 months after the injury (Zatzick et al., 2001c). The observed reduction and subsequent recurrence of trauma survivors’ PTSD and depressive symptoms followed the temporal “dosing” of the collaborative intervention. Examination of the interventionist’s logs revealed that patients were engaged in the early intervention and that 75% of patient–interventionist contact occurred between the hospital admission and the 1-month telephone follow-up interview. Interventionists successfully worked with other acute care providers to integrate the early intervention activities with other aspects of acute care treatment delivery (e.g., pain control, discharge planning).
However, the trauma-center-based interventionists frequently encountered difficulty transitioning the care of patients to the community.
A randomized effectiveness trial of the early combined intervention at Harborview
The Harborview randomized effectiveness trial of early combined intervention expanded on the pilot trial by developing an early combined intervention that included continuous masters-level case managers over the first 6 months postinjury, and evidence-based medication and psychotherapy for PTSD delivered by MD/PhD-level mental health specialists (Zatzick et al., 2004a). As with the University of California at Davis pilot, inclusion criteria for the Harborview pilot remained extremely broad. Patients screened into the study if they exhibited moderate levels of psychological distress in the surgical ward; patients with active alcohol and/or drug abuse were included in the study. The combined intervention components included: (1) care management targeting patient engagement and trauma center-to-community linkage; (2) medication and psychotheraphy targeting PTSD; and (3) motivational interviewing targeting alcohol consumption and injury recurrence.
Care management targeting patient engagement and trauma center-to-community linkage
The goal of the 6-month care management intervention was to engage injured trauma survivors in early intervention, and to link injured trauma survivors to appropriate primary care and community services. The care manager began treatment by meeting the injured patient at the bedside and by eliciting, tracking, and targeting for improvement each patient’s unique constellation of post-trauma concerns. The patient and care manager worked to formulate a comprehensive postinjury care plan.
In order to enhance engagement by encouraging spontaneous patient-initiated contact with the intervention team, the care manager pager was covered by team members 24 h per day, 7 days a week. The care manager aimed to ensure that injured patients were linked to appropriate outpatient primary care and community services. The procedures for collaboration with PCPs were informed by previous trials of consultation psychiatry interventions for depressive and anxiety disorders in primary care (Katon et al., 1995, 1999, 2001a; Roy-Byrne et al., 2001). First the care manager ascertained whether patients had a regular PCP with whom they could follow-up after discharge from the trauma center.
Over the initial weeks postinjury the care manager worked to obtain primary care services for any injured patient who did not have a regular provider. When patients had regular providers these practitioners were contacted by telephone to discuss the postinjury care plan. If necessary the care manager helped patients schedule primary care visits and provided reminders of scheduled appointments in order to facilitate attendance at office visits.
For the purposes of the trial a trauma center-to-community linkage team was developed. The Team included practitioners with expertise in the care of homeless patients, first generation Americans, pastoral care services, and gender-specific community PTSD services. Providers on the team assisted the care manager in obtaining community services for injured patients.
In the later months of the care management intervention (e.g., months 3–6), PCPs were again contacted by intervention team members in order to summarize postinjury care and ensure adequate care transfer. For patients started on psychotropic medication, in addition to phone conversations, a letter was sent to PCPs notifying them of the current doses and making recommendations for ongoing prescription and side-effect management. Patients with symptomatic recurrences received stepped-up, evidence-based care, and/or extension of case management through the 6–12months period postinjury.
Medication and psychotherapy targeting PTSD
At 3 months after the injury the care manager evaluated each intervention patient for PTSD with the Structured Clinical Interview for DSM (SCID) (First et al., 1997). Patients diagnosed with PTSD were referred to the team’s MD/PhD-level providers for the initiation of evidence-based medication and psychotherapy treatment. Team members shared information and deliberated (Charles et al., 1999; Emanuel & Emanuel, 1992; Zatzick et al., 2001c) with patients the importance of receiving guideline level treatments for PTSD symptoms. All patients were given their choice regarding treatment options and patients could receive medications, CBT, or both. The investigation’s expert CBT therapist, Amy Wagner, PhD, delivered an evidence-based protocol that derived from prior PTSD efficacy studies (Bryant et al., 1998, 2003; Foa et al., 1995; Wagner, 2003). The investigation’s psychiatrist performed an initial medication evaluation and initiated guideline-concordant pharmacological treatment (Zatzick & Roy-Byrne, 2003). Once the patient was stabilized on an initial course of pharmacotherapy, the psychiatrist would work with each patient’s primary care and community mental health providers to ensure guideline-level treatment was continued beyond the active study intervention phase.
Motivational interviewing (MI) targeting alcohol consumption and injury recurrence
The masters-level case manager had received prior training in the delivery of MI interventions (Johnston et al., 2002) by the investigation’s expert MI Supervisor, Chris Dunn, PhD. As with the previous MI intervention (Gentilello et al., 1999a), an initial 30-min MI intervention was delivered in the surgical ward to patients with current or past histories of alcohol abuse/dependence; MI booster sessions were delivered on an as-needed basis to patients with ongoing alcohol abuse and/or drinking behaviors that risked new injury. For receptive patients, the care manager linked patients to community alcohol services [e.g., Alcoholics Anonymous (AA)].
Results of the early combined intervention (Zatzick et al., 2004a)
Review of intervention logs revealed that the Case Management procedure effectively engaged 90% of intervention patients (Ghesquiere et al., 2004). Approximately 50% of intervention patients reported no regular source of primary care services at the time of the surgical ward interview; over 60% of these patients required that their care be coordinated for follow-up with a PCP or other community provider. Successful trauma center–PCP linkage by the care manager often required multiple attempts over the weeks and months postinjury.
Regression analyses revealed a significant treatment group by time interaction effect for PTSD The intervention effect coincided with the initiation of evidence-based medication and psychotherapy interventions for PTSD at the 3-month time point. Post-hoc analyses revealed that the significant treatment group by time interaction was due to treatment group differences in the adjusted rates of change in PTSD over the 12 months postinjury (p=0.02).
We previously reported that to further examine change over time we performed subgroup analyses of intervention and control group patients with PTSD 3 months postinjury and without PTSD 3 months postinjury (n = 74) (Zatzick et al., 2005c). At 6 months, 91% of control patients versus 69% of intervention patients in the subgroup with PTSD at 3 months still had PTSD (effect size = 0.6), and at 12 months 78% of controls versus 58% of intervention patients had PTSD (effect size = 0.4). The trajectories of PTSD decline in intervention and control patients in the with-PTSD subgroup were non converging. In the subgroup without PTSD at 3 months, 14% of controls and 14%of the intervention group had PTSD at 6 months, and 9% of the intervention group and 12% of controls had PTSD at 12 months (effect size = 0.1).
Regression analyses demonstrated a significant treatment group by time interaction effect for CIDI diagnosed, where CIDI stands for composite international diagnostic interview (Kessler et al., 1997) alcohol abuse/dependence (Zatzick et al., 2004a).The intervention appears to have produced maintenance of drinking reductions beyond the 6 months postinjury time point. The significant treatment group by time interaction was due to treatment group differences in the adjusted rates of change in alcohol abuse/dependence for the two groups over the 12 months postinjury (p<0.001) (Zatzick et al., 2004a). Intervention patients demonstrated decreased new injury admissions (5%) relative to controls (10%). These differences did not, however, achieve statistical significance (adjusted odds ratio = 0.43, 95%CI = 0.10, 1.96) (Zatzick et al., 2005c).
Looking to the future: how routine health services research in acute care medical settings may inform early intervention after mass trauma
Future investigations that refine routine acute care evaluation and treatment procedures have the potential to improve the quality of mental health care for Americans injured in the wake of mass trauma. For example, as discussed above, routine acute care prospective cohort studies have identified emergency department heart rate as a significant independent predictor of chronic PTSD symptoms. Brief PTSD screening instruments tailored for the acute care setting are now under development (Winston et al., 2003). However, pragmatically oriented, time-efficient acute care providers have been slow to adopt mental health screening procedures that extend beyond established routine vital sign and physical exam assessments (Danielsson et al., 1999; Gentilello et al., 1999b; Zatzick et al., 2005a). These tendencies can be expected to amplify under mass casualty conditions, leaving initial heart rate as potentially the most feasibly implemented acute care PTSD screen.
Recent investigation suggests that emergency department heart rate alone has only modest specificity (range 60%–65%) and sensitivity (range 49%– 63%) for the prediction of chronic PTSD symptoms. The exclusive use of a heart rate screen, with sensitivities between 49% and 63%, risks screening out a substantial proportion of patients who will go on to develop PTSD. Previous acute care reports have enhanced the predictive value of initial emergency department heart rate by combining heart rate cutoffs with other clinical characteristics (Bryant et al., 2000; Winston et al., 2003). Future population-based investigations could test heart rate cutoffs as a screening tool alone and in combination with other demographic, injury, and clinical characteristics readily available among acutely injured patients. Routine acute care studies of stepped care interventions, when combined with screening studies, could further inform care for injured patients after mass trauma. For example, postinjury care management interventions do not worsen PTSD symptoms and are an effective method of engaging injured trauma survivors in early intervention (Bordow & Porritt, 1979; Ursano et al., 2004; Zatzick et al., 2001a, 2004a).
Mental health professionals have been observed to converge on the scene of mass disasters. Rather than immediately preparing for early intervention targeting post-traumatic stress, newly arriving mental health professionals could be assigned as care managers to injured patients triaged through acute care settings. Reviews of initial emergency department heart rate data contained in acute care medical charts could inform triage efforts. Patients with higher heart rates and/or other demographic or clinical risk factors (e.g., multiple prior trauma exposures, female gender) could be identified for early care management contacts. Care manager problem solving around injured victims’ most pressing post-traumatic concerns would be used to first engage injured patients in an initial post event therapeutic alliance (Zatzick et al., 2001a, 2004a).
After initial engagement, patients with persistent symptoms could then be further evaluated and treated with evidence-based early interventions when indicated (Bryant et al., 1998, 2003; Litz, 2004; Litz et al., 2002; Ursano et al., 2004). In this way evaluation and treatment procedures developed during routine acute care practice conditions can continue to inform the care of injured survivors of mass trauma.