It’s often easy to see the scars borne by people who suffer severe burns. But a significant number also battle injuries that lie within. Without treatment, psychological trauma can delay burn patients’ recovery and cause torment that aggravates their physical injuries.
The UCHealth University of Colorado Hospital Burn Center on the Anschutz Medical Campus is among the nation’s leaders in routinely screening patients for symptoms of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) and providing treatment with medications, psychotherapy and social support.
That’s no small group. The Burn Center began screening ASD and PTSD and educating patients about the conditions in July 2016. Over the next six months, the center screened more than 400 patients in the inpatient and outpatient settings; 20 percent (80 patients) screened positive at least once. Nearly 90 percent of the positive results occurred on the first or second screening.
Another part of wound care
The early identification is important, said Kelly Tuohy, a charge nurse with the center who led the screening initiative as a credentialing project for UEXCEL, the professional development ladder for UCH nurses.
Tuohy noted that ASD is defined by symptoms like reliving the trauma, sleeplessness and heightened arousal. The signs must be present for a minimum of three days to a maximum of 30 days in the first month after the traumatic event. Patients with PTSD experience these and other symptoms beyond 30 days – often for far longer. The longer the stress persists, the greater the burden it imposes on patients trying to return to their families, friends and jobs.
“ASD is an early indicator of PTSD,” Tuohy said. “If we catch it in screenings earlier, we can intervene earlier.”
A recommendation from the American Burn Association (ABA) during its reverification visit to the Burn Center in 2014 spurred work on the project, Tuohy said.
“The ABA told us we needed better screening tools for PTSD,” Tuohy said. “Prior to that time we had none.” As a direct-care nurse with years of experience treating burn patients, Tuohy said she readily understood how severely ASD and PTSD can scramble treatment.
“These patients’ coping mechanisms are challenged,” she said. “We see them not eating, getting out of bed, avoiding interactions with others and having nightmares, anger and anxiety. All of it interferes with them recovering and regaining function.”
Finding the signs
Tuohy’s work to address these challenges included reviewing literature and selecting the most valid screening tools for ASD and PTSD; working with the Epic team to embed the screening tools in the electronic health record; organizing education and training for nurses who are responsible for the weekly bedside screenings; helping to develop educational materials for patients and caregivers; and collaborating with clinical pharmacists and mental health professionals to develop focused treatments for patients, based on their symptoms.
The effort is all about moving patient care forward, said Dr. Anne Wagner, medical director for the Burn Center. “The ABA has been urging verified centers to do this screening,” she noted. “We knew we needed to start, and now we are way ahead. We are among the first centers that are not just getting the screening numbers but also using them to treat our patients.”
Wagner and Tuohy were among a half-dozen Burn Center providers who created a poster presentation of the ASD/PTSD screening data for the ABA’s 2017 annual meeting. Tuohy said the response from attendees reinforced her feeling that relatively few burn centers have implemented screening procedures, despite medical literature that indicates that the incidence of PTSD in burn patients runs as high as 45 percent.
“There was an overwhelming feeling that centers are not using screening for their patients,” Tuohy said.
No single source
The approaches to helping patients vary because stress disorders stem from many sources, said Tyler Branagan, a clinical psychologist at UCH who treats some of those in the Burn Center that screen positively for ASD or PTSD. For example, Branagan said, the stress response might result from painful wound care rather than the immediate injury. Some patients may deal with addiction, difficult social challenges, family discord and other sources of stress and trauma that are independent of the burn injury. It’s part of his job to try to gently summon that information from patients.
“What happened to the patient before and after the injury affects what happens going forward,” Branagan said. “A confluence of things can affect care.”
Branagan said he uses a variety of techniques to help patients manage their stress symptoms, including talk therapy, mindfulness and meditation exercises, and deep breathing. It’s most important, he added, to decrease patients’ sense of isolation.
“Being part of a connective social environment and feeling like one is a strong, included member of a group is a protective factor against stress,” Branagan said.
The Burn Center provides several ways for patients to make those connections, including the Burn Survivor Support Group, SOAR (Survivors Offering Assistance in Recovery), and volunteer/therapy dogs. Tuohy also recommends “PTSD Coach,” a free app developed by Veterans Affairs that offers a variety of information and tools for coping with and reducing stress.
The fundamental idea is to recognize that even the nationally recognized medical care that Burn Center providers deliver to patients with severe burns, frostbite, road rash and other injuries might not meet all their needs, Tuohy added.
“Many people in our patient population struggle with resiliency and have difficulty coming up with positive behavioral strategies to help with their coping,” she said. “We’re trying to treat the whole being as opposed to singly treating the burn or other injury.”
In the days ahead, Tuohy said the Burn Center plans to review data to determine if scores for patients who screen positive trended down, an indication that treatment and education efforts have had a positive effect. Another goal is to make sure as many patients as possible screened as inpatients continue to receive the screenings when they move to outpatient care. Wagner said the Burn Center plans to address that by hiring an additional advanced practice provider to head its outpatient clinic.
“Doing that will help us to streamline the screening process for our patients,” she said.
As the Burn Center gathers more data from its screenings, Wagner also hopes to apply it to research. The psychological components of the care present research challenges, she conceded, “but we’re still trying. We want to study what we are doing to see if it has improved patient outcomes.”