MCHB Conference Webcasts
2005 EMSC Annual Grantee Meeting
April 12-13, 2005

Breakout Series

FLAURA WINSTON: Okay. So we actually were still working on some of the handouts, so you're going to get them passed out now. Thank you very much.

So, we've heard a lot in the research about how to prevent injuries and then what to do once children have been injured or have had some other emergency. And what I'm here to talk a little bit about is what to do to help the children beyond their physical treatment.

And so you have to understand a little bit about traumatic stress which is something that as a pediatrician I know I learned nothing about in all of my medical years. Whenever there is a life threat, either to the child or to someone the child knows, there develops fear, helplessness or horror. And if these two are together, there might be symptoms of traumatic stress, which could include avoidance intrusion and hyper-arousal. And in the handout you'll see a lot more about it.

So you might say of course, of course, yes. Almost everyone has some form of traumatic stress after an injury, after a pediatric injury. 88 percent other children and 83 percent of the parents have at least one traumatic stress symptom within the first month after injury.

But the interesting thing is that we do have, many of us, reresiliency. So it ends up that a significant minority, but remember, it's a minority, of children and their parents have persistent symptoms four to eight months later than the functioning, 16 percent of injured children 15 percent of their parents.

So in these days of limited resources and also the idea of do no harm, who do we deliver services to help them through this traumatic experience and who do we let just resolve on their own and how do we address this?

And so the two basic questions of this targeted issues grant were can we identify those who are at risk for the persistent symptoms and then can we prevent persistent symptoms through interventions early on.

So in the previous study, we developed an in-hospital base screener called the step that is available for any of you, it's in the handout there and it's really very quick and easy to use. Four questions of the child, four questions of the parent, and four things that are easily obtained from the chart. And this basically, if you have a negative step screener, there's a very little chance that the parent or the child will have traumatic stress, persistent traumatic stress. And it works very well with an injured population hospitalized.

So in this targeted issue study, we wanted to go the next level of saying whether or not the screening protocol would actually work in the ED based setting since many children or most children actually are released from the ED after their treatment and not  -- don't go on to hospitalization. We then wanted to develop systematic ways to follow up, to assure the traumatic stress was being addressed and then to develop some interventions that could be done to secondarily prevent persistent symptoms after the trauma.

So let's first look at the ED based screening protocol. So Dr. Joel Fine who also worked on this study with us helped us get this out in our emergency department of our children's hospital. In Philadelphia, there are a million children's hospital. What we found was 250 step screeners were actually delivered by 70 nurses. They said it was easy to use and the length was okay, but they felt a little uncomfortable as one of our questions was, did you think you were going to die? And that was for some of the nurses, a third of them, they felt a little uncomfortable with this.

So unfortunately, though, this simple screener that works well in a hospitalized setting does not work well in the ED because we see such a range of kids there. So we are in the process right now of revising it so it can be an ED based survey. We wanted that one magic bullet question. It does not exist, unfortunately, since so many things go into whether or not you develop the post-traumatic stress. The format was okay the nurses were okay with the screening. We want to review some of the wording so they are most comfortable with it.

Now some of the exciting things, I think, this is one part, was systematic follow-up. Now, how do we get this message out there that traumatic stress can be an issue. And one of the very first things we did, and you all just got this, was develop a brochure for pediatricians and a little easy quick reference card with Are You Okay? Ask children and the parents, the risk factors, understand it, offer anticipatory guidance and keep in touch. So that was one of the first things we did because we knew that pediatricians know very little about this as well as hospital based workers.

So we thought of how to get this information in their hand, but then also to develop some standardized methodology. And the goals were to find out how children and their parents are doing. Can't forget the parents. Provide information and anticipatory guidance and then monitor or refer as appropriate. That's what we see the goals of doctors.

So here is the training brochure. We tried to make it engaging, pretty colors and not -- a lot of white space, so not a lot of words. We know how little time people have.

But one of the interesting things that was suggested by the head of pediatric trauma surgery, Dr. Nance, was why don't we include a paragraph about this in the trauma discharge letter. So as a standardized protocol now, whenever the in-patient discharge letters are sent out, they include a paragraph that you know in the handout but it starts with, I would like to highlight the importance of addressing traumatic stress in all injured patients. And the trauma surgeon includes this in his letter as well as handouts for the parent to be given out, which is also given out in the hospital.

Doctors love this. This was something that the trauma surgeon found very easy to do, his nurse just put it in the letters, and the doctors who received it requested more information. So this seemed like a way to go. But we wanted to get fancier, and I'm not sure where this stands, but I think in hearing about the disaster preparedness information that was here, this might be something to consider. We have electronic medical records in our primary care setting, and so we created a trauma follow-up, best practice alert as well as a smart set that screened for traumatic stress and also assured that the injury prevention was taken care of as well as the pain was continuing to be addressed.

This was piloted in our primary care sites and what was determined was that the alerts came through wonderfully. Whenever a child was hospitalized or in the ED, an alert just showed up next time the child showed. I can show you any of this if you want to see it. That worked wonderfully. The screening -- the screener was there for them, but the doctors don't pay attention to the alerts. This is a problem we are finding more broadly and that the templates they felt were too long for the kids who they just assumed right up front didn't have traumatic stress.

So we are trying to think of how to deal with this in the future, but I do see this as a way to go with disaster preparedness, for example, in thinking about alerting the doctors and getting something right into their electronic medical record the next time the child is seen and have an action plan right there, a good dissemination path.

So now, what the doctors wanted most, they told us, is so what do we do once we screen them? Well, there's this handout, but what's if the handout wasn't enough and that's part of their reluctance to screen. So we looked at the NIMH model for secondary prevention interventions that has three levels I don't have time to go into. We have universal, selective and indicated. And we started to develop interventions for the universal and selective. The first you got is a handout. It's a parent handout we are about to in our now follow and targeted issue study, a parent handout on what you can do, and this is evidenced based information. What you can do to help your child cope after injury. The families love it, they find it very helpful, and we plan a randomized control trial to see how helpful it is.

The second is we have created a work book and manualized protocol for those who have identified risk, you know, they have a positive step screen or doctors are worried. We've developed -- we've looked at our longitudinal data as well as that of experts and realize the parents need to accurately assess their children as distinct from their own. A lot of parents see their children's have problems just because they do. Create a coping plan, teach them about how to deal with anxiety symptoms, like your heart's racing doesn't mean you're going to die. And how to deal with (the) avoidance of these scary situations.

The families absolutely love this. It's a two hour, one hour each session, intervention that does not require mental health provider. And again, in our next targeted issue grant, we plan a randomized trial to test us.

So in summary, what's really wonderful is in Trauma link we like to look at research to action. Identify the issue. And what we identified with MCHB money is that there are a significant minority of children and their parents who have traumatic stress symptoms and now, thanks to the funding, we are able to go around this research to action cycle to develop interventions that can ultimately, we hope, prevent the symptoms the children are going to develop in a persistent way.

Thank you very much.

I'm sorry. One other handout is a summary of our targeted issue grant in a way that is actually user friendly, what you can do depending on where you are in the EMS system. Thank you.