Trauma

Jan. 17, 2024

The American College of Surgeons (ACS) now requires Level I trauma centers to screen patients for at-risk mental health, adding to previous substance misuse screening requirements.

The ACS guideline says the goal is to ensure identification of at-risk patients, intervention and treatment referral. The intent is to go beyond the injury to care for the whole patient, involving other medical disciplines in the patient's care, as appropriate.

Leanne Y. Lexvold, L.I.C.S.W., M.S.W., a social worker at Mayo Clinic in Minnesota, indicates the ACS has long acknowledged that trauma centers need mental health resources for patients. This new guideline formalizes the ACS' recognition of this need.

"There's a heightened awareness of how traumatic events can affect mental health," says Lexvold. "It's great ACS is seeing this and raising the bar; validating mental health is important in the medical field."

Sarah R. McCarthy, Ph.D., M.P.H., L.P., director of pediatric psychology at Mayo Clinic in Minnesota, applauds ACS' new guideline's emphasis on long-term trauma impact, including factors that may worsen injury healing, and treatment along with screening. She says she also is glad to see ACS' guideline is flexible and understanding of the wide range of patients seen at a hospital for traumatic injury.

Mental health screening provides an early identification framework to minimize impact, per Dr. McCarthy, and offers opportunity for psychoeducation.

"We're educating patients especially on PTSD and when to seek resources," says Lexvold. "We want to make patients aware of things to be concerned about, if they occur."

What screening encompasses

Key elements in the ACS' new mental health screening include:

• Target patient group. The screening guideline applies to patients who experience acute injury or trauma, activating a trauma team, notes Dr. McCarthy. Lexvold says no demographic is affected more than others.

  Though adult patients may be screened directly, only children age 8 and older may complete screening forms alone without a supervising adult who can read to the child, as needed.

• Opportunity to choose. The ACS does not dictate a mental health screening tool, which Dr. McCarthy applauds. This allows each trauma center to determine the best option for its setting.

  For trauma centers desiring consult on screeners, however, she suggests speaking to Mayo Clinic Trauma Center professionals about the center's selected tool, Injured Trauma Survivor Screen. Mayo Clinic activated a new mental health assessment trigger for patients experiencing traumatic injury about one year ago, adding it to audit questions or a lab draw for substance misuse screening.

• Dual focus. The ACS' required screening is now twofold:

  • Substance misuse: In its screening guideline release, the ACS indicates alcohol and substance misuse problems are common in patients seen for traumatic injury, and numbers are growing. Patients screening positive for substance misuse would be given a short intervention while inpatients or a specialist referral.
  • Post-injury depression and PTSD: A 2019 Journal of Trauma and Acute Care Surgery publication indicated that at year one post-injury, approximately 21% of patients had developed PTSD and 6% had developed depression.

  "The ACS is being very forward thinking, as PTSD occurs in a significant number of trauma survivors," says Dr. McCarthy. "PTSD can significantly affect someone's life."

  She says PTSD screening covers various domains, including how the patient felt when the traumatic event was happening; immediately afterward, such as feeling disconnected or in a daze; further into post-trauma, including reexperiencing aspects of the trauma in pictures or sounds; and avoidance, such as not wanting to think about the trauma or experiencing jumpiness, worry or insomnia.

• Action orientation. The ACS' emphasis also extends to what can be done to help the patient, pending screening results.

  "The ACS guideline talks about screening and referral," says Dr. McCarthy. "It's not just screening without doing anything. We have good PTSD treatments, but post-injury patients must get to us. We have to know who needs these treatments."

  Lexvold explains that social workers at Mayo Clinic in Minnesota attempt to see all patients admitted under yellow or red trauma criteria.

  "The better we understand a patient's situation, the better we can help in the hospital and at discharge with providing interventions they need," she says.

• Appropriate timing. Dr. McCarthy feels it is inappropriate to ask mental health and substance use screening questions immediately when a patient has presented with traumatic injury. Goals for the patient at that juncture involve only assessment and stabilization. If the patient is admitted, mental health professionals can seek an appropriate screening time or administer posthospital screening, ideally at intervals such as one week, one month and three months.

Local trauma center screening and intervention insights

Though recognizing the ACS is not requiring screening for non-Level I trauma centers, Dr. McCarthy suggests how local Level II, III and IV trauma centers may implement screening and treating mental health conditions, along with the substance misuse screener:

• Set up a screening system. This does not need to be done by a psychologist. Social workers are well equipped for this task, especially as they can connect patients with mental health professionals.
• Analyze your resources. Determine how many patients with traumatic injury present to your center and resources you have available for systematically screening these patients, as well as services to respond to issues identified.

When asked if mental health and substance misuse are worse since the COVID-19 pandemic, Dr. McCarthy indicates it revealed an existing problem.

"In general, the pandemic laid bare the U.S. mental health crisis and how underresourced we are," she says. "Clinicians should recognize there's a connection between traumatic events and mental health sequelae."

For more information

Best practice guidelines: Screening and intervention for mental health disorders and substance abuse and misuse in the acute trauma patient. American College of Surgeons.

deRoon-Cassini TA, et al. Screening and treating hospitalized trauma survivors for posttraumatic stress disorder and depression. Journal of Trauma and Acute Care Surgery. 2019;87:440.

Refer a patient to Mayo Clinic.