Screening for ACEs in Emergency Rooms

I am an Emergency Room Case Manager. In my area I do not know of anyone who officially does the ACE. Having said that I have started doing it lately and documenting the positive's in my note. It is interesting as I work in an urban area where people are so used to Trauma that they do not even recognize they have experienced it until they answer the questions. Many health care professionals don't even recognize it in themselves.  Many are drawn to the field based on what they have gone through.   

Mass. is the state who best incorporates competencies into health care professional training. I am currently advocating around my state to implement the AVAhealth.org HealthCare Competencies for healthcare workers. I have been ask how it fits with other initiatives such as domestic violence. I answer that it is like with driving, first the slogan was don't drive drunk, then don't drive and text, then Don't Drive Distracted. Trauma Informed Care is the umbrella under which subsets like domestic violence fit.  I have been handing out the AVAhealth booklet along with Bessel Van der Kolk and Donna Jackson Nakazawa's book. Donna was kind enough to autograph several of them for me which went over well with the recipients. 

My next step is to visit the clergy in the Health Empowerment zones in my state. Bessel Van der Kolk highly recommends Drama as a path to resilience. To that audience I am taking a copy of Donna's book along with the play The Last days of Judas Iscariot which I think will resonate well with the post-incarceration population in the area. 

Feedback welcome.

Hi Donna,

Thank you for what you are doing and for your thoughtful answer to this question.  I couldn't agree more with your perspective about trauma informed care as the umbrella.  I've often used the language that TIC and ACEs connect the dots.  Please keep us updated on how your work progresses.

As a Volunteer EMT for 41 years I started using ACE survey in the past 8 months in the field. I only ask for the score , not the questions. Then attempt to connect the relevance of the score to my patients condition. I'm meeting with the mental health unit at Lake Shore Hospital attached to the ER for continuity of patient care. Still a work in progress. The Seneca Nation Health organization has started a program of Trauma Informed Care in the Addiction Treatment Department. My hopes are that everyone coming for medical attention be offered the ACE's Survey. Especially the Native American with ACE score of 4+ in as high as 80% of the population. My attempts are to bring awareness to the public and emergency medicine about ACEs.

Hi Leslie,

I'm developing open source web- and smartphone-based ACE screening tools, that will also be able to generate printer-friendly screening questionnaires (among others). I am really interested in learning more about the setting in which you would use the tools to see if the tools I develop could somehow help bring ACE screening all the way to the ER.

Feel free to send me a PM or comment here to get in touch.

Best,
Thomas

Hi Thomas,

Thanks for your response.  I asked this on behalf of someone else who is a volunteer EMT and has started informally using the  ACE questions.

Agreed with the informal questioning.  In my state there is a proposal this legislative session to have substance abuse counselors available 24/7 in the ER. The news ran the story in the section on far fetched legislative proposals citing the main reason that it is unlikely to pass is that even if we did have someone in the ER to counsel people the are not enough outpatient resources to refer them to. The same is true with mental health the Mental Health screeners in the ER essentially make sure they are not suicidal/homicidal and send people back out to the streets that are not suicidal/homicidal, telling them to follow up outpatient. Again there are not many outpatient resources. Even if there were many people who have experienced trauma or are substance abusers have had the executive function portion of their brain that helps them organize themselves compromised and will likely never follow up.     

Health systems many times don't want things documented that might expose them to liability. So for example if a person comes to the ER, we document ACE but they have no immediate need for hospitalization we discharge them and they cause harm to self or others then it exposes them to risk. For that reason it is less likely that Hospital systems will implement it.  

If they did implement it they would put it on the standardized form in the EMR that initial screeners fill out for discharge planning. They create alot of these templates for Physical Therapy, Occupational therapy etc. 

I do appreciate the efforts of all to bring the ACE questionaire into the vernacular. 

I do still document it informally, I have not received negative feedback at this point.  

Darn legal fears. I do tell my patients I only want their score. Not what they scored on. What gets me excited is the moment they realize they are not alone. Giving their score for the first time is an unconscious decision to become vulnerable. When I normalize the score using the NEAR@Home model, it starts the reframing of the events that have been kept secret. And now that they have shared the secrets indirectly threw the score, I tell them they have started the healing process. 

As I apply ACEs each time, I refine my approach. What drives me is that every patient I serve gets a chance to heal.

Diane, Your take on your states reaction to counselors in the ER and the lack of support is right on. In Dr. Felitti's words, let the public make the decision on what to do with this information. Patrick Kennedy's problem getting the Health Parity Act in place was the fear fellow Representatives had in public perception of their own life. Instead of waiting for government to catch up with science. I propose let the people push for what is needed.

The simplest explanation of "economy" is the movement of money. The new economy will not be the making of widgets. Or the development of new Apps. Or high Tech jobs. The new economy will be in social sciences. The CDC research has pointed the way and secrets that make us sick have to be known.

Agreed, that is why my advocacy efforts are focusing on the public, not the hospital system at this point. I am meeting with Church leaders and giving them 1-2 books depending on the audience, Childhood Disrupted by Donna Jackson Nakazawa (an author local to Maryland), and Bessel Vander Kolk's book.  I have also met with my local YMCA asking that their coaches go through Trauma Informed training such as through up2us.org.  I have met with the continuing education department at my community college who are very interested, I just need to find someone Masters Degree or above to teach. I would like them to teach a trauma/sports session in addition to one for health care workers.  I am also meeting with the Provost of a local Arts/ Theater college asking that they consider adding a Trauma Drama degree  NADTA.org . I am asking one of our State Delegates to help facilitate recognition of the Drama Therapist Certification.

I have met with two people from the Population Health community who were really not very interested. They like 'Big Data' efforts and to know how to get money.  My thought is that depending on the formal health care system to bring up the solutions for resilience is much like the Wikipedia vs. Microsofts Encarta venture. The product that flourished in the end was the one that the community of users contributed to freely out of internal motivations that were out of the domain of the economy. Trauma informed care, Resilience, Sanctuary develop out of an endorphin reward system generated by contributing to the good of the community, the dollar is less relevant (though we do need trained professionals to educate us). 

http://www.wnytrauma.org  Western New York Trauma Initiative is pushing through community groups bringing awareness in TIC.  University of Buffalo's Social Science Department has a degree program in TIC. A Masters student from UB travels WNY presenting work shops on TIC. At the age of 63, I am being mentored by Masters student. Old Dogs can learn new tricks.  The web site has a powerpoint for work shop type presentations. Take a look.

Thank you very much. That is a great resource. I'm 54 so I hear you about Old Dogs learning new tricks. I appreciate the story on the website by the judge. I am trying to get a meeting with our Substance abuse court judge. 

Leslie, in case you didn't see this, here is a link to a recent post on ACEs Connection about the Hague Protocol in the Netherlands about detecting child maltreatment on parental characteristics in the Emergency Room/Department.  I think you'll find it of interest. Elizabeth 

I work in Scotland, and we are just about to launch a project collecting ACE scores (amongst other measures) from patients admitted to hospital after an episode of self-harm. We will follow up 5 years+ to prospectively examine impact of ACE on outcomes after self-harm. 

I know this isn't ED, but related! Happy to share further info if that's of interest. 

Hi Michael, That sounds like a nice study.  

Evidently there is at least one software company that has a product to link patients with local resources. It is my hope that we can get this company and any other similar companies to put the ACEs scores into their software that we can use optionally. I have not seen the software yet nor do I have any financial ties with it. Their marketing sounds good though if it pans out.  https://www.healthify.us/healthcare-editorial/announcing-the-medi-community-resource-center

Does anyone know of a tool that helps screen for what treatment modality might me the most effective i.e. Trauma Drama, Music, Arts, Talk therapy?