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1.  Traumatic Life Events Prior to Alcohol-Related Admission of Injured Acute Care Inpatients: A Brief Report 
Psychiatry  2015;78(4):367-371.
Approximately 30 million Americans present to acute care medical settings annually after incurring traumatic injuries. Posttraumatic stress disorder and depressive symptoms are endemic among injury survivors. Our paper is a replication and extension of a previous report documenting a pattern of multiple traumatic life events across patients admitted to Level I trauma centers for an alcohol-related injury.
This study is a secondary analysis of a nationwide 20-site randomized trial of an alcohol brief intervention with 660 traumatically injured inpatients. Pre-injury trauma history was assessed using the National Comorbidity Survey trauma history screen at the 6 month time point.
Most common traumatic events experienced by our population of alcohol positive trauma survivors were having had someone close unexpectedly die, followed by having seen someone badly beaten or injured. Of particular note, there is high reported prevalence of rape/sexual assault, and childhood abuse and neglect among physically injured trauma survivors. Additional trauma histories are increasingly common among alcohol-positive patients admitted for a traumatic injury.
Due to the high rate of experienced multiple traumatic events among acutely injured inpatients, the trauma history screen could be productively integrated into screening and brief intervention procedures developed for acute care settings.
PMCID: PMC4777601  PMID: 26745689
2.  Factors Associated with Follow-Up Attendance among Rape Victims Seen in Acute Medical Care 
Psychiatry  2015;78(1):89-101.
Rape is associated with Posttraumatic Stress Disorder and related comorbidities. Most victims do not obtain treatment for these conditions. Acute care medical settings are well-positioned to link patients to services; however, difficulty engaging victims and low attendance at provided follow-up appointments is well documented. Identifying factors associated with follow-up can inform engagement and linkage strategies.
Administrative, patient self-report, and provider observational data from Harborview Medical Center were combined for the analysis. Using logistic regression, we examined factors associated with follow-up health service utilization after seeking services for rape in the emergency department.
Of the 521 diverse female (n=476) and male (n=45) rape victims, 28% attended the recommended medical/counseling follow-up appointment. In the final (adjusted) logistic regression model, having a developmental or other disability (OR=0.40, 95% CI=0.21-0.77), having a current mental illness (OR=0.25, 95% CI=0.13-0.49), and being assaulted in public (OR=0.50, 95% CI=0.28-0.87) were uniquely associated with reduced odds of attending the follow-up. Having a prior mental health condition (OR= 3.02 95% CI=1.86-4.91), a completed SANE examination (OR=2.97, 95% CI=1.84-4.81), and social support available to help cope with the assault (OR=3.54, 95% CI=1.76-7.11) were associated with an increased odds of attending the follow-up.
Findings point to relevant characteristics ascertained at the acute care medical visit for rape that may be used to identify victims less likely to obtain posttraumatic medical and mental health services. Efforts to improve service linkage among these patients is warranted and may require alternative models to engage these patients to support posttraumatic recovery.
PMCID: PMC4777603  PMID: 26168030
3.  “You need to get them where they feel it”: Conflicting Perspectives on How to Maximize the Structure of Text-Message Psychological Interventions for Adolescents 
Mobile psychological interventions are of growing interest, particularly for populations with little access to traditional mental health services. Optimum structural components of these interventions are unknown. In this study, twenty-one adolescents (age 13-17) with past two week depressive symptoms were recruited from the emergency department to participate in a semi-structured interview, to inform development of a text-message-based depression prevention intervention. Teens expressed conflict about intervention structure. Although trust and reliability were essential to sustain engagement, teens disagreed about how to best maintain reliability; whether the program should be “pushed” or “pulled”; and what the ideal degree of human interaction would be. These findings highlight the challenges in automating psychological interventions that are normally delivered face-to-face. Data indicate a broad desire for developing tailoring methods for system design (duration, frequency, and level of interactivity). The paper closes with thoughts about potential solutions to these structural issues for mobile psychological interventions.
PMCID: PMC4669198  PMID: 26640419
4.  Psychiatric Symptoms and Acute Care Service Utilization over the Course of the Year Following Medical-Surgical Intensive Care Unit Admission: A Longitudinal Investigation 
Critical care medicine  2014;42(12):2473-2481.
To determine if the presence of in-hospital substantial acute stress symptoms, as well as substantial depressive or posttraumatic stress disorder (PTSD) symptoms at 3-months post-intensive care unit (ICU), are associated with increased acute care service utilization over the course of the year following medical-surgical ICU admission.
Longitudinal cohort study.
Academic medical center.
150 patients ≥ 18 years old admitted to medical-surgical ICUs for over 24 hours.
Measurements and Main Results
Participants were interviewed in-hospital to ascertain substantial acute stress symptoms using the PTSD Checklist-civilian version (PCL-C). Substantial depressive and PTSD symptoms were assessed using the Patient Health Questionnaire-9 and the PCL-C respectively at 3 months post-ICU. The number of rehospitalizations and emergency room (ER) visits were ascertained at 3 and 12 months post-ICU using the Cornell Services Index. After adjusting for participant and clinical characteristics, in-hospital substantial acute stress symptoms were independently associated with greater risk of an additional hospitalization (Relative Risk [RR]: 3.00, 95% Confidence Interval [CI]: 1.80, 4.99) over the year post-ICU. Substantial PTSD symptoms at 3 months post-ICU were independently associated with greater risk of an additional ER visit during the subsequent 9 months (RR: 2.29, 95%CI: 1.09, 4.84) even after adjusting for both rehospitalizations and ER visits between the index hospitalization and 3 months post-ICU.
Post-ICU psychiatric morbidity is associated with increased acute care service utilization during the year after a medical-surgical ICU admission. Early interventions for at-risk ICU survivors may improve longer-term outcomes and reduce subsequent acute care utilization.
PMCID: PMC4236258  PMID: 25083985
critical care; posttraumatic stress disorder; depression; patient readmission
5.  Correlates of Suicidal Ideation in Physically Injured Trauma Survivors 
Epidemiologic studies have documented that injury survivors are at increased risk for suicide. We evaluated 206 trauma survivors to examine demographic, clinical, and injury characteristics associated with suicidal ideation during hospitalization and across one-year. Results indicate that mental health functioning, depression symptoms, and history of mental health services were associated with suicidal ideation in the hospital; being a parent was a protective factor. Pre-injury posttraumatic stress disorder symptoms, assaultive injury mechanism, injury-related legal proceedings, and physical pain were significantly associated with suicidal ideation across one-year. Readily identifiable risk factors early after traumatic injury may inform hospital-based screening and intervention procedures.
PMCID: PMC4143496  PMID: 24612070
6.  A Nationwide Surveyof Trauma Center Information Technology Leverage Capacity for Mental Health Comorbidity Screening 
Despite evidence that electronic medical records (EMR) information technology innovations can enhance the quality of trauma center care, few investigations have systematically assessed United States (US) trauma center EMR capacity, particularly for screening of mental health comorbidities.
Study Design
Trauma programs at all US Level I and II trauma centers were contacted and asked to complete a survey regarding health information technology (IT) and EMR capacity.
Three hundred and ninety one of 525 (74%) US Level I and II trauma centers responded to the survey. More than 90% of trauma centers report the ability to create custom patient tracking lists in their EMR. Forty-seven percent of centers were interested in automating a blood alcohol content (BAC) screening process, while only 14% report successfully using their EMR to perform this task. Marked variation was observed across trauma center sites with regard to the types of EMR systems employed as well as rates of adoption and turnover of EMR systems.
Most US Level I and II trauma centers have installed EMR systems, however marked heterogeneity exists with regard to EMR type, available features, and turnover. A minority of centers have leveraged their EMR for screening of mental health comorbidities among trauma inpatients. Greater attention to effective EMR use is warranted from trauma accreditation organizations.
PMCID: PMC4160658  PMID: 25151344
7.  A Survey of Screening & Intervention for Comorbid Alcohol, Drugs, Suicidality, Depression & PTSD at Trauma Centers 
Comorbid mental health and substance use problems are endemic among injured trauma survivors. The American College of Surgeons has mandated alcohol screening and brief intervention at trauma centers and is anticipated to produce best practice policy guidelines recommendations for drug screening and posttraumatic stress disorder (PTSD). Few investigations, however, have examined screening and intervention procedures for the full spectrum of comorbid mental health and substance use conditions at United States (US) trauma centers.
Trauma programs at all US Level I and Level II trauma centers were contacted and asked to complete a survey describing screening and intervention procedures for alcohol and drug use problems, suicidality, depression, and PTSD.
Three hundred and ninety-one of 518 (75%) of US Level I and II trauma centers responded to the survey. Over 80% of Level I and II trauma centers reported routinely screening for alcohol and drugs. As anticipated by current American College of Surgeons policy, Level I centers were significantly more likely to provide alcohol intervention when compared to Level II centers. The frequencies of routine trauma center screening and intervention for suicidality, depression, and PTSD was markedly lower; only 7% of centers reported routinely screening for PTSD.
Alcohol screening and intervention occurs frequently at US trauma centers and appears to be responsive to American College of Surgeons policy mandates. Future orchestrated clinical investigation and policy could productively address screening and intervention procedures for comorbid PTSD, depression, and suicidality.
PMCID: PMC4256134  PMID: 24733143
8.  Parental Injury and Psychological Health of Children 
Pediatrics  2014;134(1):e88-e97.
To determine how parental injury affects the psychological health and functioning of injured as well as uninjured children.
We recruited 175 parent-child dyads treated at a regional trauma center in 4 groups: parent and child both injured in the same event, child-only injured, parent-only injured, and neither parent nor child met criteria for significant injury. The preinjury health and functioning of parents and children were assessed with follow-up at 5 and 12 months.
Parents who were injured themselves showed higher levels of impairment in activities of daily living, quality of life, and depression at both follow-up assessments than parents who were not injured. Children in dyads with both parent and child injured had the highest proportion of posttraumatic stress disorder (PTSD) symptoms at both 5 and 12 months. In addition, children with an injured parent but who were not injured themselves were more likely to report PTSD symptoms at 5 months.
There were bidirectional effects of parental and child injury on the outcomes of each other. Injuries to the parent negatively affected the health-related quality of life of the injured children, over and above the effect of the injury itself on the child. Of great concern is the effect of parental injury on risk of stress and PTSD among uninjured children in the home.
PMCID: PMC4531277  PMID: 24918226
injury; trauma; quality of life; PTSD
9.  Disseminating Alcohol Screening and Brief Intervention at Trauma Centers: A Policy Relevant Cluster Randomized Effectiveness Trial 
Addiction (Abingdon, England)  2014;109(5):754-765.
Background and aims
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have mechanisms to identify and intervene with problem drinkers. The aim of this investigation was to determine if a multilevel trauma center intervention targeting both providers and patients would lead to higher quality alcohol screening and brief intervention (SBI) when compared with trauma center mandate compliance without implementation enhancements.
Cluster randomized trial in which intervention site (site n =10, patient n =409) providers received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions; control sites (site n =10, patient n =469) implemented the mandate without study team training enhancements.
Trauma centers in the United States of America.
878 blood alcohol positive inpatients with and without traumatic brain injury (TBI).
MI skills of providers were assessed with fidelity coded standardized patient interviews. All patients were interviewed at baseline, and 6- and 12-months post-injury with the Alcohol Use Disorders Identification Test (AUDIT).
Intervention site providers consistently demonstrated enhanced MI skills compared with control providers. Intervention patients demonstrated an 8% reduction in AUDIT hazardous drinking relative to controls over the course of the year after injury (RR =0.88, 95%, CI =0.79, 0.98). Intervention patients were more likely to demonstrate improvements in alcohol use problems in the absence of TBI (p =0.002).
Trauma center providers can be trained to deliver higher quality alcohol screening and brief intervention than untrained providers, which is associated with modest reductions in alcohol use problems, particularly among patients without traumatic brain injury.
PMCID: PMC4014067  PMID: 24450612
Alcohol; Screening and Brief Intervention; Traumatic Injury; American College of Surgeons; Policy Mandate; Motivational Interviewing; Dissemination and Implementation Research
10.  Intersection of Stress, Social Disadvantage, and Life Course Processes: Reframing Trauma and Mental Health 
This paper describes the intersection of converging lines of research on the social structural, psychosocial, and physiological factors involved in the production of stress and implications for the field of mental health. Of particular interest are the stress sensitization consequences stemming from exposure to adversity over the life course. Contemporary stress sensitization theory provides important clinical utility in articulating mechanisms through which these multiple levels exert influence on mental health. Stress sensitization models (a) extend understanding of neurobiological and functional contexts within which extreme stressors operate and (b) make clear how these can influence psychologically traumatic outcomes. The value of interventions that are sensitive to current contexts as well as life course profiles of cumulative stress are illustrated through recent treatment innovations.
PMCID: PMC4343539  PMID: 25729337
Mental health; Neurobiology; Poverty; PTSD; Stress; Trauma
11.  World Health Organization Guidelines for Management of Acute Stress, PTSD, and Bereavement: Key Challenges on the Road Ahead 
PLoS Medicine  2014;11(12):e1001769.
Wietse Tol and colleagues discuss some of the key challenges for implementation of new WHO guidelines for stress-related mental health disorders in low- and middle-income countries.
Please see later in the article for the Editors' Summary
PMCID: PMC4267806  PMID: 25514024
12.  Acute Care Clinical Indicators Associated with Discharge Outcomes in Children with Severe Traumatic Brain Injury 
Critical care medicine  2014;42(10):2258-2266.
The relationship between acute care clinical indicators in the first severe Pediatric traumatic brain injury (TBI) Guidelines and outcomes have not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes.
Retrospective multicenter cohort study
Five regional pediatric trauma centers affiliated with academic medical centers.
Children under 17 years with severe TBI (admission Glasgow coma scale (GCS) score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated injury severity score ≥ 3) who received tracheal intubation for at-least 48 hours in the intensive care unit (ICU) between 2007 -2011 were examined.
Measurements and Main Results
Total percent adherence to the clinical indicators across all treatment locations (pre-hospital [PH], emergency department [ED], operating room [OR], and intensive care unit [ICU]) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow outcome scale (GOS) score.
Total adherence rate across all locations and all centers ranged from 68-78%. Clinical indicators of adherence were associated with survival (aHR 0.94; 95 % CI 0.91, 0.96). Three indicators were associated with survival: absence of PH hypoxia (aHR 0.20; 95% CI 0.08, 0.46), early ICU start of nutrition (aHR 0.06; 95% CI 0.01, 0.26), and ICU PaCO2 >30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (aHR 0.22; 95% CI 0.06, 0.8). Clinical indicators of adherence were associated with favorable GOS among survivors, (aHR 0.99; 95% CI 0.98, 0.99). Three indicators were associated with favorable discharge GOS: all OR CPP >40 mm Hg (aRR 0.64; 95% CI 0.55, 0.75), all ICU CPP > 40mm Hg (aRR 0.74; 95% CI 0.63, 0.87), and no surgery (any type; aRR 0.72; 95% CI 0.53, 0.97).
Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge GOS. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe TBI.
PMCID: PMC4167478  PMID: 25083982
pediatrics; trauma; brain injury; indicators; outcomes; injury
13.  In-Hospital Acute Stress Symptoms Are Associated with Impairment in Cognition 1 Year after Intensive Care Unit Admission 
Rationale: Prior studies have found that cognitive dysfunction is common in intensive care unit (ICU) survivors. Yet, relatively little is known about potentially modifiable risk factors for longer-term post-ICU cognitive impairment.
Objectives: To determine if in-hospital acute stress symptoms were associated with impaired 12-month cognitive functioning among ICU survivors.
Methods: We prospectively enrolled 150 nontrauma patients without cognitive impairment or a dementia diagnosis who were admitted to an ICU for more than 24 hours. Patients were interviewed before hospital discharge and again via telephone at 12 months post-ICU.
Measurements and Main Results: Demographics and clinical information were obtained through medical record reviews and in-person interviews. In-hospital acute stress symptoms were assessed with the Posttraumatic Stress Disorder Checklist-Civilian Version. Twelve-month post-ICU cognition was assessed with the modified Telephone Interview for Cognitive Status. Follow-up interviews were completed with 120 (80%) patients. Patients’ mean age at hospitalization was 48.2 years (SD, 13.7). In unadjusted analyses, a greater number of in-hospital acute stress symptoms was associated with significantly greater impairment in 12-month cognitive functioning (β, −0.1; 95% confidence interval, −0.2 to −0.004; P = 0.04). After adjusting for patient and clinical factors, in-hospital acute stress symptoms were independently associated with greater impairment in 12-month cognitive functioning (β, −0.1; 95% CI, −0.2 to −0.01; P = 0.03).
Conclusions: In-hospital acute stress symptoms may be a potentially modifiable risk factor for greater impairment in cognitive functioning post-ICU. Early interventions for at-risk ICU survivors may improve longer-term outcomes.
PMCID: PMC3960914  PMID: 23987665
critical care; acute stress symptoms; cognitive impairment
14.  The Development of a Population-Based Automated Screening Procedure for PTSD in Acutely Injured Hospitalized Trauma Survivors 
General hospital psychiatry  2013;35(5):485-491.
This investigation aimed to advance posttraumatic stress disorder (PTSD) risk prediction among hospitalized injury survivors by developing a population-based automated screening tool derived from data elements available in the electronic medical record (EMR).
Potential EMR derived PTSD risk factors with the greatest predictive utilities were identified for 878 randomly selected injured trauma survivors. Risk factors were assessed using logistic regression, sensitivity, specificity, predictive values, and receiver operator characteristic (ROC) curve analyses.
Ten EMR data elements contributed to the optimal PTSD risk prediction model including: ICD-9-CM PTSD diagnosis, other ICD-9-CM psychiatric diagnosis, other ICD-9-CM substance use diagnosis or positive blood alcohol on admission, tobacco use, female gender, non-White ethnicity, uninsured, public or veteran insurance status, E-code identified intentional injury, intensive care unit admission, and EMR documentation of any prior trauma center visits. The 10-item automated screen demonstrated good area under the ROC curve (0.72), sensitivity (0.71), and specificity (0.66).
Automated EMR screening can be used to efficiently and accurately triage injury survivors at risk for the development of PTSD. Automated EMR procedures could be combined with stepped care protocols to optimize the sustainable implementation of PTSD screening and intervention at trauma centers nationwide.
PMCID: PMC3784242  PMID: 23806535
PTSD; screening; injury; EMR; information technology
15.  National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury 
Neurosurgery  2013;73(5):746-752.
Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood.
To analyze sources of variability in the use of ICPM and CRANI.
Retrospective cross-sectional study of patients with moderate/severe pediatric TBI with the use of data submitted to the American College of Surgeons National Trauma Databank.
We analyzed data from 7140 children at 156 US hospitals during 7 continuous years. Of the children, 27.4% had ICPM, whereas 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than among children treated at adult-only trauma centers (relative risk = 0.80; 95% confidence interval 0.66-0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency toward performing these procedures.
Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.
PMCID: PMC4127400  PMID: 23863766
Decompressive craniectomy; Intracranial pressure monitoring
16.  A Longitudinal Investigation of Alcohol Use over the Course of the Year Following Medical-Surgical Intensive Care Unit Admission 
Psychosomatics  2013;54(4):307-316.
There have been no studies describing post-intensive care unit (ICU) alcohol use among medical-surgical ICU survivors.
To examine alcohol use and identify potentially modifiable risk factors, such as in-hospital probable acute stress disorder, for increased alcohol use following medical-surgical ICU admission.
This longitudinal investigation included 150 medical-surgical ICU survivors. In-hospital interviews obtained baseline characteristics including pre-ICU alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) and in-hospital probable acute stress disorder with the Posttraumatic Stress Disorder Checklist-civilian version. Clinical factors were obtained from medical records. Post-ICU alcohol use was ascertained via telephone interviews at 3 and 12 months post-discharge using the AUDIT. Mixed-model linear regression was used to examine potential risk factors for increased post-ICU alcohol use.
There was a significant decline in the mean AUDIT score from baseline (3.9, 95%Confidence Interval [95%CI]: 2.9, 5.0) to 3 months post-ICU (1.5, 95%CI: 1.0, 2.1) (P < 0.001 by one-way analysis of variance [ANOVA]), with a significant increase between 3 and 12 months post-ICU (2.7, 95%CI: 1.8, 3.5) (P < 0.001 by one-way ANOVA). After adjusting for patient and clinical factors, in-hospital probable acute stress disorder (beta: 3.0, 95%CI: 0.9, 5.0) and pre-ICU unhealthy alcohol use (beta: 5.4, 95%CI: 3.4, 7.4) were independently associated with increased post-ICU alcohol use.
Alcohol use decreases in the early aftermath of medical-surgical ICU admission and then increases significantly by one year post-ICU. Interventions for unhealthy alcohol use among medical-surgical ICU survivors that take into account comorbid psychiatric symptoms are needed.
PMCID: PMC3659187  PMID: 23414847
critical care; alcohol use disorders; acute stress disorder; outcome assessment (health care)
17.  Triage of Children with Moderate and Severe Traumatic Brain Injury to Trauma Centers 
Journal of Neurotrauma  2013;30(13):1129-1136.
Outcomes after pediatric traumatic brain injury (TBI) are related to pre-treatment factors including age, injury severity, and mechanism of injury, and may be positively affected by treatment at trauma centers relative to non-trauma centers. This study estimated the proportion of children with moderate to severe TBI who receive care at trauma centers, and examined factors associated with receipt of care at adult (ATC), pediatric (PTC), and adult/pediatric trauma centers (APTC), compared with care at non-trauma centers (NTC) using a nationally representative database. The Kids' Inpatient Database was used to identify hospitalizations for moderate to severe pediatric TBI. Pediatric inpatients ages 0 to 17 years with at least one diagnosis of TBI and a maximum head Abbreviated Injury Scale score of ≥3 were studied. Multinomial logistic regression was performed to examine factors predictive of the level and type of facility where care was received. A total of 16.7% of patients were hospitalized at NTC, 44.2% at Level I or II ATC, 17.9% at Level I or II PTC, and 21.2% at Level I or II APTC. Multiple regression analyses showed receipt of care at a trauma center was associated with age and polytrauma. We concluded that almost 84% of children with moderate to severe TBI currently receive care at a Level I or Level II trauma center. Children with trauma to multiple body regions in addition to more severe TBI are more likely to receive care a trauma center relative to a NTC.
PMCID: PMC3700462  PMID: 23343131
brain injury; pediatrics; trauma; trauma center
18.  A Longitudinal Investigation of Posttraumatic Stress and Depressive Symptoms over the Course of the Year Following Medical-Surgical Intensive Care Unit Admission 
General hospital psychiatry  2013;35(3):226-232.
To identify risk factors for posttraumatic stress disorder (PTSD) and depressive symptoms after medical-surgical intensive care unit (ICU) admission.
This longitudinal investigation included 150 medical-surgical ICU patients. We assessed acute stress and post-ICU PTSD symptoms with the PTSD Checklist-civilian version and post-ICU depressive symptoms with the Patient Health Questionnaire-9. Mixed-model linear regression ascertained associations between patient and clinical characteristics and repeated measures of post-ICU PTSD and depressive symptoms.
The prevalences of substantial PTSD and depressive symptoms were 16% and 31% at 3 months post-ICU and 15% and 17% at 12 months post-ICU, respectively. In-hospital substantial acute stress symptoms (beta: 16.9, 95%Confidence Interval [95%CI]: 11.4, 22.4) were independently associated with increased post-ICU PTSD symptoms. Lifetime history of major depression (beta: 2.2, 95%CI: 0.1, 4.2), greater prior trauma exposure (beta: 0.5, 95%CI: 0.2, 0.9) and in-hospital substantial acute stress symptoms (beta: 3.5, 95%CI: 0.8, 6.2) were independently associated with increased post-ICU depressive symptoms.
In-hospital acute stress symptoms may represent a modifiable risk factor for psychiatric morbidity in ICU survivors. Early interventions for at-risk ICU survivors may improve longer-term psychiatric outcomes.
PMCID: PMC3644338  PMID: 23369507
posttraumatic stress disorder; depression; critical care; intensive care; outcome assessment (health care)
19.  The effect of perceived person-job fit on employee attitudes towards change in trauma centers 
Health care management review  2013;38(2):115-124.
Employee attitudes towards change are critical for health care organizations implementing new procedures and practices. When employees are more positive about the change they are likely to behave in ways that support the change, whereas when employees are negative about the change they will resist the changes.
This study examines how perceived person-job (demands–abilities) fit influences attitudes towards change following an externally-mandated change. Specifically, we propose that perceived person-job fit moderates the negative relationship between individual job impact and attitudes towards change.
We examined this issue in a sample of Level I trauma centers facing a regulatory mandate to develop an alcohol screening and brief intervention (SBI) program. A survey of 200 providers within 20 trauma centers assessed perceived person-job fit, individual job impact, and attitudes towards change approximately one year after the mandate was enacted.
Providers who perceived a better fit between their abilities and the new job demands were more positive about the change. Further, the impact of the alcohol SBI program on attitudes towards change was mitigated by perceived fit, where the relationship between job impact and change attitudes was more negative for providers who perceived a worse fit as compared to those who perceived a better fit.
Practical Implications
Successful implementation of changes to work processes and procedures requires provider support of the change. Management can enhance this support by improving perceived person-job fit through ongoing training sessions that enhance providers’ abilities to implement the new procedures.
PMCID: PMC3370148  PMID: 22310485
Person-job fit; attitudes toward change; organizational change; trauma centers
20.  Ethnoracial Variations in Acute PTSD Symptoms Among Hospitalized Survivors of Traumatic Injury 
Journal of traumatic stress  2010;23(3):384-392.
Ethnoracial minority status contributes to an increased risk for posttraumatic stress disorder (PTSD) after trauma exposure, beyond other risk factors. A population-based sampling frame was used to examine the associations between ethnoracial groups and early PTSD symptoms while adjusting for relevant clinical and demographic characteristics. Acutely injured trauma center inpatients (N = 623) were screened with the PTSD Checklist. American Indian and African American patients reported the highest levels of posttraumatic stress and preinjury cumulative trauma burden. African American heritage was independently associated with an increased risk of higher acute PTSD symptom levels. Disparities in trauma history, PTSD symptoms, and event related factors emphasize the need for acute care services to incorporate culturally competent approaches for treating these diverse populations.
PMCID: PMC3947745  PMID: 20564368
21.  A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors 
Annals of surgery  2013;257(3):390-399.
To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury.
Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings.
The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined, care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at one-, three-, six-, nine-, and twelve-months after the index injury admission.
Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared to controls (group by time effect, CAPS, F(2, 185) = 5.50, P < 0.01; PCL-C, F(4, 185) = 5.45, P < 0.001). Clinically and statistically significant PTSD treatment effects were observed at the six-, nine-, and twelve-month post-injury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function (MOS SF-36 PCS main effect, F(1, 172) = 9.87, P < 0.01).
Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at United States trauma centers. (Trial Registration: identifier: NCT00270959)
PMCID: PMC3582367  PMID: 23222034
22.  Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) for Alcohol at Trauma Centers Study Design 
General hospital psychiatry  2012;35(2):174-180.
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high quality alcohol screening and brief intervention (SBI) services at trauma centers.
Twenty sites selected from all US Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma center-based alcohol SBI with blood alcohol positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed.
The investigation has successfully recruited provider, patient, and trauma center staff samples into the study and outcomes are being followed longitudinally.
When completed, the DO-SBIS trial will inform future American College of Surgeons’ policy targeting the sustained integration of high quality alcohol SBI at trauma centers nationwide.
PMCID: PMC3594343  PMID: 23273831
Acute care medical trauma centers; Injury; Alcohol; Screening and brief intervention; American College of Surgeons
23.  Substance Use and PTSD Symptoms in Trauma Center Patients Receiving Mandated Alcohol SBI 
In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of College policy targeting integrated substance abuse treatment at trauma centers.
PMCID: PMC3528356  PMID: 22999379
24.  Staying Connected: A Feasibility Study Linking American Indian and Alaska Native Trauma Survivors to their Tribal Communities 
Psychiatry  2011;74(4):349-361.
The objective of this investigation was to assess the feasibility of a culturally tailored care management intervention for physically injured American Indian/Alaska Native (AI/AN) patients. The intervention was initiated at a Level I trauma center and aimed to link AI/AN patients to their distant tribal communities. Thirty AI/AN patients were randomized to the intervention or to usual care. Assessments at baseline, 3 months, and 6 months included self-reported lifetime cumulative trauma burden, Native healing requests, and symptoms of posttraumatic stress, depression, and alcohol use. Generalized estimating equations ascertained differences between groups over time. Ninety-four percent of eligible patients participated; follow-up at 3 and 6 months was 83%. Participants had high numbers of lifetime traumas (mean = 5.1, standard deviation = 2.6). No differences between the intervention and control groups were observed in posttraumatic stress symptoms, depression symptoms, or alcohol use at baseline or follow-up time points. Among intervention patients, 60% either requested or participated in traditional Native healing practices and 75% reported that the intervention was helpful. This effectiveness trial demonstrated the feasibility of recruiting and randomizing injured AI/AN patients. Future efforts could integrate evidence-based interventions and traditional Native healing into stepped collaborative care treatment programs.
PMCID: PMC3795506  PMID: 22168295
25.  Variability in the Characteristics and Quality of Care for Injured Youth Treated at Trauma Centers 
The Journal of pediatrics  2011;159(6):1012-1016.
To survey US Level I trauma centers in order to assess the characteristics of child and adolescent psychosocial service delivery.
Study design
Trauma program staff at US Level I trauma centers were asked to complete a survey regarding the characteristics and quality of service delivery for youth. The presence of pediatric services and screening of injured youth for alcohol use problems and posttraumatic stress disorder (PTSD) symptoms were assessed.
150 of 202 (74%) of trauma centers responded to the survey. Substantial variability was observed in trauma center age cutoffs for pediatric and adolescent patients. Although the majority of sites endorsed having specialized pediatric, intensive care unit, and surgical services, marked differences were found in the reported percentage of youth receiving psychosocial services. Even though the majority of sites screened injured youth for alcohol use problems, variability was observed in the actual percentage of children and adolescents screened. Only 20% of sites endorsed specialized PTSD services.
Our investigation observed marked variability across trauma centers in the delivery of child and adolescent services. Future research could develop high quality pediatric psychosocial services in order to inform trauma center standards nationwide.
PMCID: PMC3202660  PMID: 21784440
Quality of Care; Children; Adolescents; Psychiatry; PTSD; Alcohol

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