Evan Elizabeth Rainey

Psychological factors predicting outcome after traumatic injury: the role of resilience.

BACKGROUND Increasingly, studies have examined the psychological impact on individuals who survive a traumatic physical injury. The primary aim of this study was to determine the stability of resilience and its association with depressive symptoms. METHODS This study included 110 adults admitted to a Level I trauma center. Resilience and depression were measured at baseline and 12 months. Injury-related variables included Glasgow Coma Scale, Injury Severity Score, etiology of injury, and type of injury. RESULTS Analysis revealed that resilience remained stable over 12 months regardless of injury severity, etiology, or type. Negative correlations were found between baseline resilience and 12-month depression (P < .01), as well as Glasgow Coma Scale and depression (P = .001). CONCLUSIONS Injured individuals with low resilience are more likely to be depressed at 12 months. Assessing resilience at the time of injury may be useful in identifying those at risk for depression 1 year later.

The association between posttraumatic stress symptoms, depression, and length of hospital stay following traumatic injury

OBJECTIVE The present study examined the relationship between posttraumatic stress symptoms (PTSS) and depression symptoms with hospital outcome measures to explore how psychiatric factors relate to hospital length of stay (LOS). METHOD Participants were adults admitted to a large Level I Trauma Center for longer than 24h. Depression was assessed at hospitalization using the Patient Health Questionnaire (PHQ-8), and PTSS was measured by the Primary Care PTSD Screen (PC-PTSD). Hospital outcome information was collected from the hospitals trauma registry. Pearson correlations were performed. RESULTS 460 participants (mean age=44years, SD=16.8; 65.4% male) completed the study. Baseline PTSS and depression were significantly correlated with longer hospital LOS while controlling for demographics and injury severity (p=0.026; p=0.023). Both PTSS-positive and depression-positive groups had an average increased hospital LOS of two days. CONCLUSIONS A significant proportion of individuals who are admitted to the hospital following trauma may be at risk for depression and PTSS, which may then increase hospital LOS. As national attention turns to reducing healthcare costs, early screenings and interventions may aid in minimizing psychiatric symptoms in trauma patients, in turn reducing the cost and outcomes associated with total hospital LOS.

Secondary traumatic stress in emergency medicine clinicians

Abstract Previously called Secondary Traumatic Stress (STS), secondary exposure to trauma is now considered a valid DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD). Previous studies have found high rates of STS in clinicians who treat traumatically injured patients. However, little research has examined STS among Emergency Medicine (EM) physicians and advanced practice providers (APPs). The current study enrolled EM providers (N = 118) working in one of 10 hospitals to examine risk factors, protective factors, and the prevalence of STS in this understudied population. Most of the participants were physicians (72.9%), Caucasian (85.6%), and male (70.3%) with mean age of 39.7 (SD = 8.9). Overall, 12.7% of the sample screened positive for STS with clinical levels of intrusion, arousal, and avoidance symptom clusters, and 33.9% had at least one symptom cluster at clinical levels. Low resilience and a history of personal trauma were positively associated with positive STS screens and STS severity scores. Borderline significance suggested that female gender and spending ≥10% of one’s time with trauma patients could be additional risk factors. Findings suggest that resilience-building interventions may be beneficial.

Prospective Evaluation of Posttraumatic Stress Disorder in Injured Patients With and Without Orthopaedic Injury.

Objectives: The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type. Design: Prospective, longitudinal observational study. Setting: Level 1 Trauma Center. Patients/Participants: Two hundred fifty-nine participants admitted for at least 24 hours. Main Outcome Measurements: The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist–Civilian Version (PCL-C) measured PTS symptoms at 6 months. Results: In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012]. Conclusions: PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Discrepancy in caregiving expectations predicts problematic alcohol use among caregivers of trauma injury patients six months after ICU admission.

This prospective study examined the influence of caregiving variables on the development of problematic alcohol use among family members of patients admitted to an urban Level I trauma center. Data were collected from 124 caregivers 48 hrs after initial hospitalization of their family member. The final sample included 81 participants (24.6% male; Mage = 47.8) who completed their follow-up assessment at 6 months. Hierarchical linear and logistic regression analyses assessed increases in consumption and odds of a positive screen for problematic alcohol use in association with caregiver burden, actual time spent in the caregiving role, and caregiving differential (i.e., anticipated time spent caregiving at baseline in relation to actual time caregiving at 6 months). At 6 months, 24.7% of caregivers screened positive for problematic alcohol use. Results uniquely highlighted caregiving differential as a significant predictor of both increases in general alcohol consumption (&Dgr;R2 = .06, p < .01) and odds of screening positive for problematic alcohol use at 6 months (Odds Ratio = 1.05, 95% CI [1.02–1.09]). More specifically, our adjusted model found that providing 10% more time caregiving, relative to expectations at baseline, was associated with an increase in the probability of problematic alcohol use by 22% (95% CI: 8–37%) at 6 months. These results suggest that a discrepancy in expectations regarding anticipated time caregiving and actual time caregiving, rather than solely the amount of caregiving or perceived caregiver burden, may be an important predictor of caregiver alcohol use 6 months after a family member’s ICU hospitalization.

The effect of depressive symptoms on social support one year following traumatic injury

BACKGROUND Depression is a common mental health outcome after traumatic injury, negatively impacting physical outcomes and increasing the cost of care. Research shows that the presence and quality of support is a leading protective factor against depression post-injury; however, research is vague on the directional effects of both factors over the course of recovery. METHODS 130 patients admitted to a Level I Trauma Center were recruited to a prospective study examining overall outcomes one-year after injury. Effects of social support and depression at baseline and 12-months post-injury were examined using correlational and cross-lagged path model analyses. Additional follow-up analyses were conducted for depression on specific types of social support. RESULTS Findings replicated previous research suggesting depression and social support were inversely related. Initial depression at time of traumatic injury was predictive of social support 12-months after their injury, but initial social support levels did not significantly predict depression at 12-months. Additionally, initial depression significantly predicted attachment, social integration, reassurance of worth, and guidance 12-months later. LIMITATIONS Findings of the analyses are limited by lack of experimentation and inability to control for other related variables. CONCLUSIONS Findings of the present study support the notion that initial depression predicts poorer social support in recovery, in lieu of prevailing theory (i.e., initial support buffers against later depression) in a sample of trauma patients. These findings highlight the need for medical staff to target specific factors during inpatient stay, such as addressing depressive symptoms and preparing family members and caregivers prior to discharge.

Caregiver expectations of recovery among persons with spinal cord injury at three and six months post-injury: A brief report

Objective: Caregivers of patients with spinal cord injury (SCI) have increased risk of depression, anxiety, and diminished quality of life. Unmet expectations for recovery may contribute to poorer outcomes. Design: Prospective, longitudinal observation study. Settings: Trauma/Critical care ICU at baseline, telephone for follow-ups. Participants: Caregivers of patients with SCI (n = 13). Interventions: None. Outcome Measures: Expectations for recovery were assessed across four primary domains identified in a review of the literature including: pain severity, level of engagement in social/recreational activities, sleep quality, and ability to return to work/school. Caregivers’ forecasts of future recovery were compared to later perceived actual recovery. Results: At three months, 75% of caregivers had unmet expectations for social engagement recovery, 50% had unmet expectations for pain decrease, and 42% had unmet expectations for sleep improvement and resuming work. Rates of unmet expectations were similar at six months, with 70% of caregivers reporting unmet expectations for social engagement recovery, 50% with unmet expectations for pain decrease, and 40% with unmet expectations for sleep improvement. Conclusion: Unmet caregiver expectations for recovery could pose a risk for caregiver recovery and adjustment. Our results show that caregiver expectations merit further investigation for their link with caregiver mental health.

The role of depression and social support on readmission rates within one year of traumatic injury.

Objective: Hospital readmission rates have become a quality metric—particularly in trauma and acute care, where up to one third of individuals with traumatic injury return to the hospital. Thus, identifying predictors of readmission is a priority in an effort to reduce readmissions. Based on previous theoretical work, this study tests the utility of social support and depression in predicting readmissions up to one year after initial injury. Method: Data from 180 injured individuals admitted to a large, urban Level 1 trauma center were matched to a regional readmissions database. Logistic regression was used to assess whether social support levels or positive depression screens during initial trauma visit predicted unplanned (a) readmissions or (b) emergency/urgent outpatient visits. Results: Within the sample, there were 32 total readmissions and 50 total emergency outpatient encounters following initial injury. Depression continued to be a risk factor for emergency outpatient visits only (OR = 2.75). Patients with greater social integration (OR = 0.78), more guidance (advice or information; OR = 0.72) and more reliable alliance (OR = 0.72) as forms of social support were less likely to readmit. Conclusions: This study demonstrates the utility of screening for depression and social support in predicting readmission within one year after traumatic injury. Future efforts should continue emphasizing the impact of initial depression and the need for patients to have trusted individuals in their lives to whom they can turn during recovery; doing so may lower the probability that patients return to hospital.

1578: ENOXAPARIN PROPHYLAXIS DOSE ADJUSTED BY ANTI-XA TROUGH LEVELS IN CRITICALLY INJURED TRAUMA PATIENTS

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: The Brain Trauma Foundation guidelines recommend using phenytoin during the first seven days after a traumatic brain injury (TBI) for early post traumatic seizure (PTS) prophylaxis. Phenytoin requires close therapeutic monitoring and it has a high chance for potential side effects and medication interactions. Few small studies have suggested that levetiracetam may be a viable alternative to phenytoin with similar efficacy as phenytoin in preventing early PTS. While the trauma guidelines from 2016 still do not recommend levetiracetam, currently early PTS prophylaxis has already shifted from phenytoin to levetiracetam. Anecdotally, agitation has been seen in traumatic brain injury patients receiving levetiracetam. Methods: This was a retrospective observational study looking at TBI patients admitted to the trauma service at Scripps Mercy from 2010–2012, 2014–2016 for early PTS prophylaxis. The primary objective was to determine the incidence of agitation caused by levetiracetam in patients with a TBI. Patients were split into two groups, trauma intensive care unit (ICU) and trauma floor, depending on how severe a patient’s TBI was and then further stratified depending on the medication used for early PTS prophylaxis. Patients less than 18 years of age, with no RASS score recorded, hospital stay of less than 1 day, history of psychiatric disorder, positive drug screen or detectable alcohol level upon admission were excluded from the study. Patient’s agitation was assessed using RASS score and nurse recorded assessment in conjunction with concurrent use of benzodiazepines (midazolam, lorazepam) and antipsychotics (haloperidol, quetiapine). Results: After the inclusion and exclusion criteria were applied there were 82 patients in the levetiracetam arm and 19 patients in the phenytoin arm. There was no statistically significant difference seen in both the ICU and floor groups between patients who received levetiracetam versus phenytoin regarding the number of patients agitated and the percent of patients’ who required a safe unit. There was also no statistically significant difference seen in both the ICU and floor groups between patients who received levetiracetam versus phenytoin regarding the amount of haloperidol, quetiapine, benzodiazepines, opioids, and propofol used. Conclusions: There was no significant difference seen in the amount of agitation or the amount of medications used to treat agitation between patients in trauma ICU and trauma floor receiving levetiracetam versus phenytoin.

Examining the relationship between obesity and mental health outcomes among individuals admitted to a level I trauma centre: Obesity and mental health post-injury

The increased incidence of obesity in the general population translates into clinicians caring for an increased number of trauma patients with obesity. Previous research has documented the unique anatomical and physiological challenges that clinicians face when caring for trauma patients with obesity; however, little is known about psychological challenges that trauma patients with obesity may also experience in the months following injury. The aim of this study is to determine the relationship between obesity and (i) mental health, (ii) demographic and injury‐related variables and (iii) quality‐of‐life outcomes among trauma patients between hospitalization and 3‐months post‐injury. This is a prospective, longitudinal study conducted between March 2012 and May 2014 at a single, level I trauma centre in the southwest United States. Inclusion criteria for this convenience sample consisted of patients who were admitted to the trauma or orthopaedic trauma service ≥24 h, medically stable, spoke English or Spanish and ≥18 years of age. In total, 455 eligible patients were consented and enrolled; 343 (70.87%) completed 3‐month follow‐up. The objective of this study is to investigate the relationship between obesity and mental health among trauma patients in the months following injury. Demographic and injury‐related data were also collected; patients’ height and weight were used to determine body mass index. Health outcomes were assessed during initial hospitalization and at 3‐month follow‐up and included depression, post‐traumatic stress symptoms, pain and return to work. Prior to data collection, it was hypothesized that obesity would have a negative effect on mental health outcomes among patients 3 months post‐injury. The final sample consisted of 343 participants; average age was 46.4 ± 17.3 years; majority male (n = 213, 63%) and Caucasian (n = 231, 69%). Patients with obesity had higher odds of screening positive for depression (odds ratio [OR] = 2.36, P = 0.02) and overweight patients had lower odds of returning to work (OR = 0.31, P = 0.01) 3 months post‐injury compared to patients of normal weight (65% vs. 40%). No other significant differences were found. Results of the current study are novel in that they identify psychological challenges that overweight and trauma patients with obesity may experience. These results demonstrate the need for mental health professionals to be involved in follow‐up care to extending in the months following injury.