Addressing Psychological Distress in Orthopaedic Trauma Patients

Background: Psychological outcomes of trauma play an integral role in the long-term recovery of patients. Previous studies show that almost half of patients with severe lower-extremity trauma screened positive for psychological distress, including moderate to severe depression and phobic anxiety. In trauma patients, post-traumatic stress disorder (PTSD) has been shown to be the strongest determinant of health outcomes and is more influential than injury severity, chronic medical conditions, age, sex, pre-injury function, and alcohol use. Higher levels of psychological distress have been linked with lower levels of physical function during early and late recovery following injury. Many psychological interventions are based on Bandura’s concept of self-efficacy. Self-efficacy is defined as one’s belief in one’s capacity to perform any activity and has been shown to mediate the relationship between pain intensity, depression, and disability. To ensure trauma care is patient-centered, all providers involved in the care of trauma patients must begin to attend to the psychological as well as the physical manifestations of injury at admission as well as during recovery. Methods: I conducted key stakeholder interviews with 15 providers and staff at UNC Health Care to identify the obstacles to developing a clinic-based mental health program for trauma patients. These interviews yielded 236 minutes of responses, which I systematically coded for kind, type, and direction of substantive comments. Results: Thirteen (87%) respondents stated there was a large burden of psychological distress in trauma patients, and a different 13 (87%) respondents noted that trauma patients’ psychological distress is poorly assessed, or not assessed at all, currently at UNC. Twelve (80%) respondents mentioned using a screening tool to improve assessment. Money (or cost) was most commonly mentioned (11 or 73%) as a barrier to creating new services. Respondents also recognized time, space, and personnel support as other major challenges. Systematic barriers included a fragmented health system, lack of primary care physician, lack of access to mental health care resources, and poor reimbursement for mental health care. Seven (47%) respondents emphasized the need for effective interventions, stressing a direct relationship between effectiveness and sustainability. Conclusions: There is a large unmet need for mental health services in trauma patients. These interviews reveal the strong agreement across all domains of clinical service on the size of the problem and the need to solve it: establishing mental and behavioral health services as a routine part of trauma patients’ care and recovery is essential, but at present it will take creative collaboration to initiate such services in the face of real obstacles of time, money, and space. Clinical Relevance: The global goal of this proposed intervention will be to improve health-related quality of life and lower the likelihood of injury-related disability in orthopaedic trauma patients by helping them to develop their self-efficacy and mitigate mental health sequelae. Cost is an obvious concern, as is determining efficacy and utility.Master of Public Healt

A Prospective Investigation to Develop Data-Driven Interventions and Improve Process Efficiency at a Level II Trauma Center

INTRODUCTION: The purpose of this investigation was to better understand process inefficiencies in a Level II trauma center through the identification and classification of flow disruptions. Data-driven interventions were systematically developed and introduced in an effort to reduce disruptions threatening the optimal delivery of trauma care. METHOD: Medical human factors researchers observed disruptions during resuscitation and imaging in 117 trauma cases. Data was classified using the human factors taxonomy Realizing Improved Patient Care through Human-centered Operating Room Design for Threat Window Analysis (RIPCHORD-TWA). Interdisciplinary subject matter experts (SMEs) utilized a human factors intervention matrix (HFIX) to generate targeted interventions designed to address the most detrimental disruptions. A multiple-baseline interrupted time-series (ITS) design was used to gauge the effectiveness of the interventions introduced. RESULTS: Significant differences were found in the frequency of disruptions between the pre-intervention (n=65 cases, 1137 disruptions) and post-intervention phases (n=52 cases, 939 disruptions). Results revealed significant improvements related to ineffective communication (x2 (1, n=2076) = 24.412, p=0.00, x2 (1, n=1031) = 9.504, p=0.002, x2 (1, n=1045) = 12.197, p=0.000); however, similar levels of improvement were not observed in the other targeted areas. CONCLUSION: This study provided a foundation for a data-driven approach to investigating precursor events and process inefficiencies in trauma care. Further, this approach allowed individuals on the front lines to generate specific interventions aimed at mitigating systemic weaknesses and inefficiencies frequently encountered in their work environment