Trauma professionals are keenly aware of the impact of traumatic injury on their patients. And they are particularly aware of the impact during their own phase of care. Prehospital providers know everything about the situation on scene and in their rig. Inpatient providers are experts in the trauma team activation process and other facets of inpatient care. Physiatrists excel at helping their patients overcome the immediate effects of injury.
But what happens later, three or six or more months down the road? A huge amount of data is collected during the acute care processes and maintained in local or national registries. But once the patient leaves the hospital, there is much less information available about long-term progress and outcomes.
The trauma group at the University of Pennsylvania examined longer-term physical, emotional, and social outcome information on their own patients over a two year period. They administered a set of test instruments and screens, including substance use, employment, living situation, PTSD, and PROMIS-29, a comprehensive evaluation of pain and seven health domains. This battery was given on admission, and then six months after discharge.
Here are the factoids:
- A total of 618 patients underwent the initial screen, and 129 (21%) completed the six-month followup
- Demographics of the pre- and post-followup groups were nearly identical
- The incidence of penetrating trauma was high, about 25%
- Half of patients had been previously hospitalized for an injury
- There were statistically significant decreases in the ability to participate in social roles and activities, and a significant increase in anxiety and depression
- PTSD was common, occurring in 28% of patients
- Patients reporting only occasional employment or unemployment increased from 45% to 68%
The authors concluded that effects of injury extend beyond the initial pain and disability, impacting several areas for at least six months post-injury. They suggest that there is a need for screening and intervention protocols for post-injury patients.
Bottom line: This is an intriguing paper that focuses attention beyond the areas where most clinicians are aware. It points out the longer lasting impact from trauma, which may have a significant effect on the rest of the patient’s life. Any issues relating to mental or emotional health, or employment and livelihood may have a far ranging impact on that person’s life.
The sample size is small, and the attrition between initial interview and six month followup resulted in an even smaller analysis group. However, the similar demographics imply that the sample is reasonably valid. The screening tools were selected appropriately, and the statistical analyses seem to be appropriate.
This abstract points out the need to look beyond discharge to really find out how our patients are doing. We will probably not like what we see, and it should prompt us to develop more robust screening to figure out who is in trouble. Ultimately, this should move us to incorporate screening and appropriate interventions into the bigger trauma care picture, just as the authors suggest.
Here are my questions for the authors and presenter:
- Are you confident that your data is representative of your patients given the steep attrition between admission and six month followup?
- Can your results be generalized to other non-urban trauma patients? The number of patients suffering penetrating trauma or previously hospitalized for injury is very high. Might this group of patients suffer a disproportionately higher likelihood of disturbances at six months?
- Although your screening test changes are statistically significant, are they clinically relevant? I have seen many numerically different results in other studies that have only questionable clinical significance (e.g. a decrease in ICU length length of stay of 0.4 days).
- Has your work prompted you to design and implement the type of screening and interventions you are presenting?
This is important work, and will serve to increase awareness of the non-anatomic issues we absolutely must address in order to get our patients back to being healthy again.
Reference: BEYOND PAIN AND DISABILITY: THE LASTING EFFECTS OF TRAUMA ON LIFE AFTER INJURY. EAST 35th ASA, oral abstract #7.