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San Francisco Injury Center (SFIC) »  Psychiatric Disorder & Unintentional Injury

The Trauma Center as an Opportunity for Screening, Intervention, and Injury Prevention

Project Director/Lead Investigator: Rochelle Dicker, MD

Co-Investigators: Jennifer Alvidrez, PhD, Martha Shumway, PhD, Dahianna Lopez, RN   


Brief Summary of Project: The goals of this project are to examine the prevalence of psychiatric disorders in patients hospitalized as the result of unintentional injuries, and to examine whether psychiatric disorder is an independent risk factor for unintentional injury and subsequent injury recidivism. Project results will have implications for the development of injury preve

ntion programs specifically tailored for individuals with psychiatric disorders. In addition, this stud

y may have significant implications for provision of adequate mental health treatment and its role in injury prevention. Finally, we have added a pilot component looking at the rate of post-traumatic stress disorder in our subjects.

Specific Aims:
1. To carry out systematic psychiatric screening on victims of unintentional injury admitted to a trauma center.
2. To measure the prevalence of psychiatric disorders in the acutely injured trauma center population.
3. To prospectively identify the risk of unintentional injury recidivism associated with psychiatric disorders in the acutely injured trauma center population.
4. To perform a needs assessment for the target population including, but not limited to, mental health treatment, for the purpose of identifying an intervention targeted at preventing injury recidivism.
5. To complete baseline surveillance in preparation for a future study which will aim to implement and evaluate the identified intervention.
6. To begin to understand the magnitude of post-traumatic stress disorder in our population of trauma patients and look at differences in the rates of subjects with a prior history of mental illness.

Status: Since enrollment commenced in September 2008, we have screened a total of 2157 patients. Of the 1106 eligible patients, the positive response rate was 63% in patients who were able to be approached by research assistants prior to discharge (N = 220 enrolled).

Of the 1051 ineligible patients, there were 45 who we were not able to get consents from due to lack of cognitive capacity but were otherwise eligible for the study. There were 161 patients who were non-English speakers and for whom we did not have personnel trained to conduct an interview in their language. While we had 7-day staffing coverage at the beginning of 2009, we have since been operating short-staffed.

In March 2009 we added the "PTSD Checklist - Civilian Version (PCL-C)" questionnaire to the 6-month follow-up interview. Follow-up interviews are now complete. We have successfully conducted 138 of the 219 possible (one subject passed away). To facilitate successful follow-up, we have been collecting detailed contact information during the baseline interview so we may locate and contact participants. We offer subjects the option of having their interview over the phone or in person at the hospital. If they decide to come to the hospital, we provided free transportation in the form of taxi vouchers. We have extended the window of time to conduct follow-up interviews up to nine months after the baseline injury, with the target still at six, to allow for enough time to get in contact with participants. We were ultimately unable to reach 65 subjects. Sixteen subjects were unable to schedule a follow up interview time.

Chart reviews are scheduled to be completed by June 2011. They were originally planned to being in April 2009 but were pushed back due to a shortage in staff. We will be reviewing injury and mental health history one year before and one year after the index injury. The chart review, in combination with the follow up interview, will allow us to evaluate injury recidivism rate in our study population.

Mental Health Diagnoses

Results: Interviews took 35min ± 12. Chi squared analysis revealed no difference in mechanism in those with mental illness versus no mental illness. Men were significantly more likely to be found to have a mental health disorder but when substance abuse was excluded, no difference was found. Four-way diagnostic grouping reveled the incidence of mental illness detected. (Figure 1)

Sixty-six percent of the sample met criteria for at least one Axis I psychiatric disorder at baseline. From this pilot study we have concluded that preexisting mental illness is an independent risk factor for unintentional injury.

We have also begun to analyze our findings from the Camberwell Needs assessment. The table below represents our preliminary findings. We are in the process of further analysis and will be submitting an abstract to the American Public Health Association annual conference.

Table - Fin and Case Mgmt Needs by Dx

Success Stories: We presented our findings at the annual meeting of the American Association for the Surgery of Trauma conference in September 2010. The corresponding manuscript has been accepted and is in press in the Journal of Trauma.
We have found our study to be quite feasible with an acceptable enrollment rate. This has caught the attention of our colleagues at other trauma centers and has gained national attention, particularly after the early work was featured in the Journal of Trauma. The work generated the Resident Research Award at the annual Western Trauma Association meeting in 2008. In addition, we have taken the study a step further and have been able to identify people who have symptoms of PTSD or who are very interested in receiving services, and we have connected them with resources where they can get help.

Significance: This inpatient pilot screening program prospectively identifies preexisting mental illness as a risk factor for unintentional injury. Implementation of validated psychosocial and mental health screening instruments is feasible and efficient in the acute trauma setting. Administration of a validated mental health screening instrument and needs assessment can be achieved by training college-level research assistants. This system of screening can lead to identification and treatment of mental illness as a strategy for unintentional injury prevention.

Future: We anticipate finishing our chart review and recidivism analysis by July 2011. In addition, we will finish the Camberwell needs assessment analysis by July as well. The analysis of post-traumatic stress disorder will follow.

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