Monica M. Bennett Ph.D.

Roden-Foreman, J. W., M. M. Bennett, E. E. Rainey, J. S. Garrett, M. B. Powers and A. M. Warren (2017). “Secondary traumatic stress in emergency medicine clinicians.” Cogn Behav Ther: 1-11.

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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.

Salisbury, D. B., S. J. Driver, M. Reynolds, M. Bennett, L. B. Petrey and A. M. Warren (2017). “Hospital-based health care after traumatic brain injury.” Arch Phys Med Rehabil 98(3): 425-433.

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OBJECTIVE: To investigate trends of hospital-based health care utilization after admission to a level I trauma center after acute traumatic brain injury (TBI). DESIGN: Retrospective review. SETTING: Large urban trauma hospital and a hospital council data registry consisting of 88 member institutions (>150 hospitals) covering 15,000 square miles. PARTICIPANTS: All patients (N=5291) admitted to a level I trauma center between January 1, 2006, and June 30, 2014, who experienced an acute TBI based on International Classification of Diseases, Ninth Revision coding. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Included the incidence and type of select hospital-based services received. Analyses were also categorized based on demographic and injury-related information. RESULTS: Of the 5291 patients with newly acquired TBI who were admitted, 512 died, leaving 4779 patients for inclusion in the final analysis. Additional health care utilization from January 1, 2006, and June 30, 2014, was recorded for 3158 patients (66%), totaling 12,307 encounters, with a median of 3 encounters (interquartile range, 1-5) and a maximum of 102 encounters. Most nonadmission urgent or procedural visits (96%) and inpatient encounters (93%) occurred in the first year. Of all the additional encounters, 9769 visits were nonadmission urgent or procedural visits (79%) with a median charge of $1955. The most common type of encounter was elective (46%), followed by medical emergency (29%). Of the remaining 2538 inpatient encounters (21%), the mean length of stay was 6 days with a median charge of $28,450. Medical emergency (39%) and elective admissions (33%) again were the most common encounter type. CONCLUSIONS: This analysis encompasses health care utilization across the range of TBI severity and numerous hospital systems, allowing for a more comprehensive and objective identification of reasons for readmission. This represents an initial step to developing a preventive intervention to manage secondary complications postinjury.

Ewing, M., G. A. Funk, A. M. Warren, N. Rapier, M. Reynolds, M. Bennett, C. Mastropieri and M. L. Foreman (2016). “Improving national trauma data bank(r) coding data reliability for traumatic injury using a prospective systems approach.” Health Informatics J 22(4): 1076-1082.

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Trauma centers manage an active Trauma Registry from which research, quality improvement, and epidemiologic information are extracted to ensure optimal care of the trauma patient. We evaluated coding procedures using the Relational Trauma Scoring System to determine the relative accuracy of the Relational Trauma Scoring System for coding diagnoses in comparison to the standard retrospective chart-based format. Charts from 150 patients admitted to a level I trauma service were abstracted using standard methods. These charts were then randomized and abstracted by trauma nurse clinicians with coding software aide. For charts scored pre-training, percent correct for the trauma nurse clinicians ranged from 52 to 64 percent, while the registrars scored 51 percent correct. After training, percentage correct for the trauma nurse clinicians increased to a range of 80-86 percent. Our research has demonstrated implementable changes that can significantly increase the accuracy of data from trauma centers.

Warren, A. M., A. L. Jones, M. Bennett, J. K. Solis, M. Reynolds, E. E. Rainey, G. Viere and M. L. Foreman (2016). “Prospective evaluation of posttraumatic stress disorder in injured patients with and without orthopaedic injury.” J Orthop Trauma 30(9): e305-311.

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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.

Warren, A. M., M. Reynolds, M. L. Foreman, M. M. Bennett, R. J. Weddle, J. D. Austin, K. Roden-Foreman and L. B. Petrey (2016). “Validation of a brief, two-question depression screen in trauma patients.” J Trauma Acute Care Surg 80(2): 318-323.

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BACKGROUND: Increasingly, depression following traumatic injury is recognized as a complication of injury. Unlike mandated screening for risky alcohol use in trauma centers, screening for psychological risks is not required by the American College of Surgeons’ Committee on Trauma. Limited resources and time constraints are commonly given reasons against routine screening. The purpose of this study was to determine if a two-item screen was as valid as an eight-question screen for depression. METHODS: A total of 421 patients were given the Patient Health Questionnaire 8 (PHQ-8) during initial hospitalization to assess depression in a prospective study at a Level I trauma center. A cutoff score of 10 or higher (possible range, 0-24) on the PHQ-8 is used as diagnostic for depression. The PHQ-2 (possible range, 0-6) is derived from the first two questions of the PHQ-8 and contains items assessing sad mood and loss of interest/pleasure during the previous 2 weeks. A cutoff score of 3 or higher was considered to be a positive screen result. Discriminatory ability of the PHQ-2 was calculated. RESULTS: The sample was predominantly male (65%) and white (67%). The majority (85%) sustained a blunt trauma, and the primary cause of injury was motor vehicle collision (37%), with a mean Injury Severity Score (ISS) of 11.6. A total of 142 patients (34%) were positive for depression on the PHQ-8. When comparing the PHQ-2 with the PHQ-8, a sensitivity of 76.1 and a specificity of 92.8 were found, as well as a positive predictive value of 84.4. CONCLUSION: The result of our study confirms that depression is a frequent condition (34%) among individuals who sustain physical injury. The PHQ-2 seems to have acceptable sensitivity and specificity to identify depression in this population. The use of a two-item screening questionnaire is a minimal addition to the evaluation of patients after injury, allowing for earlier intervention and better outcomes. LEVEL OF EVIDENCE: Diagnostic study, level IV; prognostic/epidemiologic study, level III.