Acute Care Medical Hospitals

Hi Laneita, I am not sure exactly what you are looking for but let me share my experience.  First I would tell you the protocols and policy are the easy part, organizational and leadership support are essential challenges that are requisite for successful implementation.  To that question I am attaching a recently released Brief  by RWJF - Key Ingredients for Successful Trauma-Informed Care Implementation which is a good document for anyone interested in your questions.  For developing specific protocols, I will provide the  guidelines we used in the facility where I worked.  I worked in both acute care hospital and outpatient setting for 17 years and for 6 years was head of a Women's Health Department  (5 Ambulatory Care Clinics, and all hospital programs).  When we began to address trauma in the hx of our patients it essentially began with the same 'protocol' and policy in each setting.  Adversity and toxic stress cannot be addressed if it is not identified.  Thus the very basic protocol, similar to other medical condition  was; Step 1 to briefly educate the patient about new knowledge and understanding of how stress impacts health, use framing questions to begin the screening process "because adversity in childhood, or because violence in the home... or because we now understand how events in childhood impact adult health......followed by the specific screening questions....we are now asking all of our patients if they have experienced any of the following:  you can use the ACE screen,  a screen for Intimate partner violence, or other available tools depending on your focus and setting.   There are lots of examples out there including Kaisers intake screen which includes the ACE questions.   Step 2 is to address immediate medical concerns or conditions and if possible and indicated discuss potential impact that a hx of trauma or current adversity may have on their current health status.  Further, an additional check for safety is required as  many patients with a high ACE score  this may be an immediate concern - either the violence of others i.e. intimate partners, or toward self.  Step 3 is discussing what if any help, assistance or needs they may have beyond the scope of the care being immediately provided and would they like to discuss this with someone who has expertise in this area whether inside our hospital system or in the community;  It is not the role or responsibility of a provider or nurse in an acute care setting to "fix" ACEs or other adversities.  It is our responsibility to take a comprehensive history including all traumatic antecedents so that we can provide appropriate care.  Step 4 is outlining in protocol and policy the actual mechanisms for referral or MOU and assuring the patient is empowered to make that choice (and ensure the referral is a functional referral not just a card or phone number i.e. a warm hand-off).  Step 5 is including in protocols parameters for documentation.   This was the broad framework  we used to develop specific protocols and policy for all settings including acute care, ED, outpatient, long term care etc.  I have done numerous training's over  the years for providers, nurses, social workers, and allied health professionals and i am always curious about, and begin my  training with trying to understand what are the  "actual barriers" to developing and or integrating such protocols are. Most of  the individuals have developed protocols on many topics/conditions for their facilities but have both personal and professional barriers to broaching these topics which are sentinel to health.  I encourage you to try to actively identify what are perceived as the specific barriers as it is most often deeper and more complex than lack of protocols.  The RWJF brief addresses this well.

 

 

"sentinel to health"? Central to health? 

Otherwise great stuff ++

A sentinel health concern.

I think you and I have different dictionaries ;-) 

I am using it in usage as a “guard” a “warning or alarm” of health concerns. Roget’s Thesaurus… and I will consider alternative words in the future as my intent is not to confuse or misuse the language if awareness and education is a goal.



Thanks, Marcia

Thanks, Marcia, perhaps it's my fault for not speaking Americanese - - not using nouns as adjectives, or "horror",  verbs, unlike my North American correspondents ;-D

This is great material presented. I will examine the document a bit later on.  Until then, it would be helpful to see if the ACEs questions would ever include something about a serious medical condition in childhood (often necessitating invasive medical practices- which in themselves have traumatized the child or adult-- even worse within a "teaching hospital").  Has anyone examined this issue? It doesn't fall within the other ACEs questions...

Russell, I believe it is likely my lack of a cohesive education in my own life… I stopped breathing when I read your comment, in horror that I may have “used and incorrect usage of a word” ….a great fear of this child (now old) who finished only the 8th grade and then clawed my way back eventually to get my PhD. However, I know and am acutely aware of my gaps in formative language skills.



My thanks to you for pointing out this marginal usage and questionable value of using this verbiage. At least I did not use “bigly” like the U.S. President!



My darling niece is currently at University of Otago, Dunedin NZ. I will have to share with her my schooling from her peers in New Zealand.



Many thanks, Marcia

 I left the healthcare system 2 years ago and at that time we were not able to identify/locate existing validated protocols for Acute care settings for ACEs or other traumatic antecedents except for ED JCAHO requirements for Intimate Partner Violence screening.

Given the current acute care emphasis and metrics on preventing re-admission to the hospital, we used this opportunity to address the importance of both having a complete history, the known interplay of psycho-social factors and stress on health status, and discharge planning to address patient needs.    We had several basic goals in acute care.  Some were protocols regarding provider orientation and training.  Others identified  who would be responsible for taking a psycho-social history and assuring this was addressed in all phases of acute care from admission to discharge.   Because we had  hospitalists in acute care, and many hospitalists were locum tenens, we tried to include  material on trauma in all new employee orientation, CMEs at the hospital, and informal 'lunch and learns'.   We also tried to maintain an identified "champion" in each setting to build relationships in practice.  This was an ongoing struggle due to competing time and priorities. 

The actual specific screening in the acute care setting  was  completed by a medical social worker.  This was both a pragmatic and functional consideration.  As a member of the team, she/he was to share this information with others and advocate for appropriate care.  

Readily available clinical resources that supported knowledge and understanding for all staff was key to engagement .  The providers found the medical text chapter by Dr. Felitti and Dr. Anda to be particularly helpful and interesting.  I have attached it here.

Because the nature of acute care is to respond to acute, chronic and critical conditions, we are often limited in opportunities and appropriate frameworks for delivering even the most basic intervention as Dr. Felitti's describes:  “Asking, listening, and implicitly accepting are a powerful form of doing that appears to provide great relief to patients.”

If the patients condition allows, It is certainly within all of our capacities to have a brief discussion of what we have learned in recent decades about how what happens in childhood can impact adult health.  A few key points connecting this knowledge to patient health and the importance of having further discussion with their PCP may be the brief but powerful role a nurse, physician, or social worker may have in the acute care setting.  It will not "fix" everything, but it can enhance pt. health literacy and perhaps instill a seed of interest, and one point in the continuum of care. 

Primary care was always the focus of our follow-up for identified adversity not mental health.  Particularly with the current integrated medical home model.  

 

Two attachments:

Medical text chapter on ACEs

Resource from Child Traumatic Stress Network on Medical Trauma - Teens.

The Children's Hospital of Philadelphia and the National Child Traumatic Stress Network have a lot's of resources that may help you.   I forgot about these folks in Trauma Informed Acute Care for Pediatrics...they have a great site, toolbox, providers perspective, how to spread Trauma Informed practice throughout a healthcare system, after the ABCs, the DEFs (protocol for Distress, Emotional Support, remember the Family).  I think this site will be helpful to you.

https://www.healthcaretoolbox....hospital-system.html

Your niece has my profound sympathy -- a number of years ago I tried to get into a PhD here -- applied to all the universities but no go.

The University of Otago, particularly, was most rejecting of the idea (see the home page of my website for a link to it http://russwilson.coffeecup.com/

(OK, it's a bit dated now, but the proposal is largely still a worthwhile idea imho). That University is of the "behavioral and brain sciences" type -- snidely rejecting of applied / clinical research, especially in this area) -- although it doesn't even have the people to do the brain sciences stuff. If someone wants to do a PhD one really has to do an "academic" thesis -- but I believe there's real merit in working with some professor from the clinical area, familiar with the theories and practices of clinical work, and there's simply no one, especially in this area at UoO -- but Dunedin and its surrounds are beautiful and the climate is great imho -- coming from Queensland where it's too hot for me. Martin Dorahy at Canterbury, 5 hours away in Christchurch is the best potential supervisor in this area "locally". 

And don't my "criticism" of your use of words too much to heart -- I'm just an old codger, and your daughter may see things differently. And also don't forget, Kiwis speak differently, in some ways, to how Aussies do -- and I didn't come here till 2000, and have been to several places overseas since then, but happily settled in Dunedin. So, my own "education" (real world, as opposed to training) has also been somewhat "disjointed".

Must admit, apart from how you use your words, I'm loving the stuff you're writing!! :-)

See here for yet another attempt being made to introduce "TIC" into NZ through the Resilience film -- pity no one's prepared to share this "adverse childhood experiences report submitted to IIMHL"

http://us6.campaign-archive1.c...343&e=7ffb7a1097

"Tauranga woman ..."

Look up Nadine Burke Harris on Youtube and you can see what she, as a PCP, is doing within the medical community. She's a great speaker and has many videos of her presentations about this.