DISCLOSURE INFORMATION

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1 The Forgotten Trauma Assessment: STEPP into Action. Frances T. Gill-Appiott, MSN, RN, CPNP AC/PC Nemours Alfred I. dupont Hospital for Children DISCLOSURE INFORMATION The Speaker has no disclosures. OBJECTIVES Discuss the rationale for including a subjective evaluation of pediatric trauma patients related to the risk of Post Traumatic Stress Disorder (PTSD). List 3 common mechanism of injuries related to positive psychological screens in trauma patients and their parents. 1

2 Pediatric Medical Traumatic Stress Described as a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences. Health Care Toolbox: Basics of Trauma-informed care, 2013 What is Post Traumatic Stress? Reactions: Intrusive thoughts Avoidance of reminders of the event Increased arousal (exaggerated startle) Worse functional outcomes Risk of unrecognized PTS Poorer health-related quality of life Increased use of health care services (Kassam-Adams, et al., 2009) 2

3 WHAT ARE WE MISSING? Nearly 9 million children seen in Emergency Departments annually after a traumatic event. Over 9,000 children die as a result of the injuries. Trauma remains the leading cause of death in children 19 years and younger. We are well trained! Subjective vs. Objective 3

4 Are YOU evaluating risk? National/International survey conducted of pediatric surgery and trauma nurses, nurse practitioners and physician assistants. Screening for PTSD risk was not general practice in the pediatric trauma population. Trauma physicians Trauma Nurse Practitioners/ PAs Trauma Nurses Social Workers Psychologists Physical Therapists Occupational Therapists Rehabilitation Therapists Building the Core STEPP Screening Tool for Early Predictors of Post Traumatic Stress Disorder: Validated screening tool Sensitivity: 0.88 children; 0.96 parents Helpful in identifying children and caregivers at risk for PTSD Certain mechanism of injury resulted in higher rates of positive evaluations. 4

5 Should we be selective? Certain mechanism of injury yield higher rates of positive STEPP evaluations. Limiting screening based on mechanism of injury, age or gender could result in delayed identification of PTSD risk. Mechanism of Injury Penetrating Sports injuries MVC Animal bite Assault Falls Bikes Other STEPP performed No STEPP performed Selecting the Population 8 yrs 18 yrs admitted to the trauma service. Any type of injury. Screening done within hours. May encounter delays. 5

6 The Child s Evaluation 4 questions: Global fears Parental separation after traumatic event Inclusion of additional victims Fears of impending death 4 questions: The Parent s Evaluation Child s behavioral history Direct visualization of the event Accompanying the child on hospital transport Feelings of hopelessness during incident ED Chart: Information from the Medical Record Heart rate upon arrival Age Sex Potential for extremity fracture 6

7 The STEPP Tool Instructions for Scoring Child STEPP: Sum of responses to questions Results: 4 or higher is POSITIVE. Parent STEPP: Sum of responses to questions Result: 3 or higher is POSITIVE. January December 2013 The Data 175 patients admitted to trauma service. 142 patients underwent STEPP evaluation 19% of eligible aged children not completed. 7

8 The Results CHILDREN 17.6% positive ADULT 25.3% positive 6.6% child was positive and parent was negative. 50% parent was positive and child was negative. Treatment of PTSD Trauma-Focused Cognitive Behavioral Therapy Psycho-education about trauma reactions Skill building for anxiety management Helping the child process and reframe maladaptive trauma-related appraisals Encouraging safe exposure to trauma-related triggers. Parents consistently involved in treatment. Role of Pediatric Clinicians Provide support and resources in health care setting. Screen for risks of PTSD and symptoms. Track symptoms Barriers to PTSD care by providers: Awareness of PTSD among injured children Training to increase knowledge of PTSD Time and other resources 8

9 Barriers Staffing Patient condition Parental presence What will YOU choose? ONLINE RESOURCES 9

10 The Original Article Winston, F.K., Kassam-Adams, N., Garcia-Espana, F., Ittenbach, R., Cnaan, A. (2003). Screening for Risk of Persistent Posttraumatic Stress in Injured Children and Their Parents. JAMA, August, Vol. 290(5), Thank you. Emily E. Murphy, MD Surgical Resident Christiana Care Medical Center Wilmington, DE Julia Price, PhD Staff Psychologist Nemours Wilmington, DE Questions? 10