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Routine versus ad hoc screening for acute stress following injury: who would benefit and what are the… Bell, Nathaniel; Sobolev, Boris; Anderson, Stephen; Hewko, Robert; Simons, Richard K May 5, 2014

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RESEARCH Open AccessRoutine versus ad hoc screening for acute stressfollowing injury: who would benefit and what arethe opportunities for preventionNathaniel Bell1,4, Boris Sobolev2, Stephen Anderson3, Robert Hewko3 and Richard K Simons1*AbstractBackground: Screening for acute stress is not part of routine trauma care owing in part to high variability of acutestress symptoms in identifying later onset of posttraumatic stress disorder (PTSD). The objective of this pilot studywas to assess the sensitivity, specificity, and power to predict onset of PTSD symptoms at 1 and 4 months using aroutine screening program in comparison to current ad hoc referral practice.Methods: Prospective cross-sectional observational study of a sample of hospitalized trauma patients over afour-month period from a level-I hospital in Canada. Baseline assessments of acute stress (ASD) and subsyndromalASD (SASD) were measured using the Stanford Acute Stress Reaction Questionnaire (SASRQ). In-hospital psychiatricconsultations were identified from patient discharge summaries. PTSD symptoms were measured using the PTSDChecklist-Specific (PCL-S). Post-discharge health status and health services utilization surveys were also collected.Results: Routine screening using the ASD (0.43) and SASD (0.64) diagnoses were more sensitive to PTSD symptoms atone month in comparison to ad hoc referral (0.14) and also at four months (0.17, 0.33 versus 0.17). Ad hoc referral hadgreater positive predictive power in identifying PTSD caseness at 1 month (0.50) in comparison to the ASD (0.46) andSASD (0.43) diagnoses and also at 4 months (0.67 versus 0.25 and 0.29).Conclusions: Ad hoc psychiatric referral process for acute stress is a more conservative approach than employingroutine screening for identifying persons who are at risk of psychological morbidity following injury. Despite knownlimitations of available measures, routine patient screening would increase identification of trauma survivors at risk ofmental health sequelae and better position trauma centers to respond to the circumstances that affect mental healthduring recovery.Keywords: Trauma systems, Traumatic stress/PTSD, ScreeningBackgroundThe potential to identify trauma survivors at risk fordeveloping PTSD and thereby enable short- and long-termmental health intervention early on was a core drivingmechanism in introducing acute stress disorder (ASD) intothe Diagnostic and Statistical Manual of Mental Disorders(DSM-IV) taxonomy in 1994 [1]. An estimated ten toforty percent of civilian injury survivors go on to displaysymptoms consistent with PTSD, [2-6] of which theprobability of remission has been estimated at 18% to38% [7,8]. However, the ASD diagnosis has been criticizedowing to marked variability in predicting later onset ofPTSD and was not recommended to be retained in theDSM-V as a predictor of subsequent PTSD [9]. Whilechanges to the diagnosis have been made in the recentrelease of the DSM-V, there remains little evidence that theASD diagnosis is accurately predicting longer-term PTSD.These critiques have implications for how cliniciansidentify and manage psychological health after injury. InCanada, early screening for acute stress is not part ofroutine trauma care. Although it is well established thatearly identification of individuals at risk for PTSD isimportant for minimizing psychological morbidity, [10,11]trauma centers currently rely on ad hoc referral practices* Correspondence: richard.simons@vch.ca1Department of Surgery, University of British Columbia, 855 West 10thAvenue, Vancouver, British Columbia V5Z 1 M9, CanadaFull list of author information is available at the end of the article© 2014 Bell et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited.Bell et al. Journal of Trauma Management & Outcomes 2014, 8:5http://www.traumamanagement.org/content/8/1/5for identifying those individuals who display symptoms ofacute stress. It is not clear whether current practices arean appropriate substitute to administering what are essen-tially very low-cost and easily administered self-reportedsurveys of acute stress. In addition, there has been a lackof literature evaluating the clinical utility of routinescreening for identifying ongoing life stressors that mayimpact mental health. This is a significant limitationbecause persons with mental health illnesses often do notreceive treatment, [12] are less likely to see health carespecialists [13] and experience emotional disabilities oftenin parallel with substantial physical, social, and economicdisadvantages [14,15].We conducted a prospective observational pilot studywith adult injury survivors treated at Vancouver GeneralHospital, British Columbia, Canada to assess whetherroutine screening for acute stress improved identificationof patients who later went on to display PTSD symptomscompared with identification using ad hoc psychiatricreferral practices currently in place. These evaluations werecontextualized against patient self-reported experiencesand expectations for recovery in effort to outline futuresurveillance and intervention opportunities for minimizingpsychiatric morbidity after injury.MethodsThis prospective cross-sectional observational pilotstudy targeted all residents of British Columbia and theYukon ages 19 and older who were referred or admitteddirectly to Trauma Services, Vancouver General Hospitalfollowing injury. Patients were recruited over a consecu-tive enrollment period between June and November, 2011.Excluded were persons who had a hospital stay < 24 hoursand those with a Glasgow Coma Scale < 15 at discharge.All patients actively consented to participate while inhospital. Interviews took place on the ward and on theday prior to discharge whenever possible to ensureminimal impact on patient care. Follow-up interviewswere conducted 1 and 4 months after the initial interview.After each interview participants were asked if theyconsented to further follow-up. The follow-up period of 1and 4 months was selected based on recommendationsfrom the literature [16]. This study was registered andapproved by the UBC Behavioral Research Ethics Boardand the Vancouver Coastal Health Research Institute,which represents Vancouver General Hospital.Acute stress surveyEach patient completed a self-reported assessment ofacute stress using the Stanford Acute Stress ReactionQuestionnaire (SASRQ) [17]. The SASRQ is a 30-itemclosed-ended self-report questionnaire used to assesssymptoms of ASD following a traumatic event [5,18,19].The SASRQ uses DSM-IV criteria for diagnosing ASD.The SASRQ includes measures of acute dissociation(Cluster B; 10 items), re-experiencing (Cluster C; 6 items),avoidance (Cluster D; 6 items), anxiety and hyper-arousal(Cluster E; 6 items), and impairment in functioning(Cluster F; 2 items). Respondents were asked to report thefrequency with which they experienced each item using afive-point Likert scale, spanning from: (0) have/didnot experience, (1) very rarely experienced, (2) rarelyexperienced, (3) sometimes experienced, (4) oftenexperienced, and (5) very often experienced. The diagnos-tic cutoff for ASD requires each person to assign a valueof 3 or higher to at least three of the ten dissociativecriteria, and a score of three or higher for at least one ofsymptom clusters C, D, E, and F. The criteria for SASDonly requires meeting the diagnostic cut-off for symptomclusters C, D, and E. Positive SASD events were derivedfrom the original SASRQ response score scores.PTSD surveyPTSD symptoms at one and four months were identifiedusing the PCL-S (Specific) [20]. The PCL-S is a self-report measure developed by the US National Center forPTSD containing the 17 DSM-IV symptoms of PTSD.At each interview, participants were asked how oftenthey have been bothered by each symptom in the pastmonth. Responses were provided using a 5-point Likertscale, spanning from: (1) not at all, (2) a little bit, (3)moderately, (4) quite a bit, or (5) extremely. The PCL-Sis scored by using a summation of the individual 17symptoms. A cut-off score of 44 was used to identifypositive PTSD symptoms. This score was chosen based ona previous sensitivity analysis using Clinician AdministeredPTSD Scale (CAPS) scores with 40 motor vehicle andsexual assault survivors [21].Behavior, service utilization, and socio-economic surveyDuring the baseline interview participants were asked torespond to their current employment status, level ofeducational attainment, living arrangement, housingtenure and if they had sought treatment for anxiety ordepression in the past year. At follow-up, participantswere asked if they had a post-discharge consultationwith a health care provider about their health as a resultof their injury, whether they were taking medication forstress, or had consulted a medical professional aboutanxiety or depression as a result of their injury. At theconclusion of each interview participants were askedwhether they felt as emotionally or physically healthy asthey were before injury, and if not, whether these experi-ences had been expected. All participants were asked toopenly comment on these experiences as well as anybarriers that they had experienced in attempting to ac-cess health care services.Bell et al. Journal of Trauma Management & Outcomes 2014, 8:5 Page 2 of 7http://www.traumamanagement.org/content/8/1/5Statistical analysisThe principle outcome measures for this study were abaseline diagnosis of ASD and SASD using routine and adhoc screening, as well the sensitivity and specificity ofthese practices in predicting PTSD symptomatology at 1and 4 months. Psychiatric referrals and consultations wereidentified from reviewing hospital discharge summaries.Differences between means of continuous variables wereexamined using a 2-tailed independent samples t test, anddifferences in proportions of categorical variables were ex-amined using a χ2 test. To account for potential type-I er-rors in the subgroup analysis all goodness of fit testswere reported using a continuity-adjusted χ2. All statisticalanalyses were generated using SAS software, Version 9.2for Windows [22].ResultsA total of 91 of 120 eligible patients we approachedconsented to participate in this pilot study, for an overallopt-in consent rate of 76%. The study participation rateat one month was 61% (n = 56) and 47% (n = 43) afterfour months. Six participants were lost to follow-up atmonth 1, but returned a survey at month 4. Theseresponse scores were included in the analyses as there wasno socio-demographic, health status, or injury-relateddifferences between those who partially or fully partici-pated in follow-up. Socio-demographic, health status,and injury-related characteristics of all eligible patientscategorized by consent, participation, and loss to follow-upstatus are shown in Table 1.A total of 34 of the 91 participants (37%) scored posi-tive for SASD and 22 participants (24%) scored positivefor ASD using the SASRQ questionnaire during thebaseline (in-hospital) assessment. Median hospital lengthof stay prior to completing the SASRQ was 7 days. Allparticipants were screened for ASD within the timerange required for an ASD diagnosis (2 – 31) days. Atotal of 8 of the 91 participants (9%) received a referralfor a psychiatric consultation prior to discharge fromTrauma Services. All eight participants had positive SASDscores and five reported positive ASD scores.At one month, 14 of the 56 participants (25%) scoredpositive for PTSD symptoms based on the PCL-S assess-ment. At four months 12 of the 43 participants (28%)submitted positive PTSD assessment scores. Five ofthe 14 participants (36%) who reported positive PTSDscores at 1 month were lost to follow-up.To assess the optimal predictive value of the ASD diag-nosis we conducted a sensitivity, specificity, and power topredict test using individual ASD symptoms and differentgroupings for each symptom cluster. Tables 2 and 3 showthe sensitivity, specificity, and power to predict PTSDsymptoms at 1 and 4 months using various diagnosticgroupings. Overall, employing different symptom group-ings did not substantially improve either the sensitivity orpredictive power of the ASD diagnosis. At month 1, theindividual symptom clusters were more sensitive predic-tors than either the ASD or subsyndromal ASD diagnosis,but had lower predictive power. In contrast, at month 4the individual symptom clusters were more sensitiveTable 1 Characteristics of the 120 patients who were eligible for enrollment by their consent to participate andby retentionVariable Consenters(n = 91)Non-consenters(n = 29)p value Partial/full participation(n = 63)Lost to follow-up(n = 28)p valueSocio-demographicsMean (SD) age (years) 45 (19) 37 (16) 0.05 45 (18) 45 (19) 0.87Male 63 (69) 21 (84) 0.23 45 (72) 18 (62) 0.44Having no high school diploma 11 (12) – – 6 (10) 5 (18) 0.45Unememployed at time of injury 15 (16) – – 9 (14) 6 (21) 0.66Currently living alone 27 (30) – – 13 (21) 14 (48) 0.02Living in rented housing 61 (67) – – 39 (63) 22 (76) 0.32Health statusTreated for anxiety or depression in the last year 17 (19) – – 12 (20) 5 (17) 1.00Scored positive for ASD 22 (24) – – 13 (21) 9 (31) 0.43Scored positive for SASD 34 (37) – – 21 (34) 13 (45) 0.44Injury-relatedPositive blood alcohol (BAC) result 13 (16) 1 (29) 0.28 8 (15) 5 (20) 0.80Positive toxicology result 9 (11) 9 (37) 0.01 6 (11) 3 (12) 1.00Mean (SD) injury severity score (ISS) 22 (13) 22 (10) 0.98 23 (13) 20 (12) 0.33Intentional injury 14 (17) 4 (17) 1.00 4 (7) 10 (37) < 0.001Values reported are counts (% of group total) unless otherwise stated.Bell et al. Journal of Trauma Management & Outcomes 2014, 8:5 Page 3 of 7http://www.traumamanagement.org/content/8/1/5predictors than either the ASD or subsyndromal ASD diag-nosis and resulted in stronger predictive power, on average,in identifying participants who scored positive for PTSDsymptoms. In both time periods, ad hoc referral practiceswere less sensitive than routine screening for identifyingindividuals who went on to display PTSD symptoms, butresulted in greater positive predictive power for identifyingpersons who exhibited PTSD symptoms.Characteristics of participants by response scores tothe PCL-S self-assessment test at month 1 and month 4are shown in Table 4. At month 1, persons who scoredpositive for PTSD could be differentiated from respon-dents who were symptom negative when contrasted bygender (43% male vs 78% male, p 0.03) and by injuryseverity (ISS 15 vs ISS 24 p 0.03). No differences in healthbehavior, expectations, or health service utilization wereobserved. By month four, persons who scored positive forPTSD symptoms experienced more barriers accessing care(42% vs 10%, p 0.05), having unexpected physical andemotional pain (91% vs 42%; p 0.02), and displayed greatermedication use for stress or anxiety (42% vs 6%, p 0.02).There was an indication that participants who scoredpositive for PTSD symptoms at month 4 were primarilyself-coping as only half of the patient population hadreported discussing concerns about stress with their healthcare provider. When asked why, participants reported thatthey did not know with whom to talk with about theirstress or how to approach their physician about problemsthey were experiencing. Differences were also observedwith regards to satisfaction with current level of socialsupport, with 33% of persons who displayed PTSDsymptoms reporting they did not have adequate socialsupport compared to 7% of persons without PTSDsymptoms (p 0.04). When asked to comment on barriersexperienced accessing care, participants listed a lack ofextended health insurance and lack of income as theleading cause contributing to failure to see or consultwith a health care provider about stress or anxiety.DiscussionBoth routine screening and ad hoc referral for acutestress resulted in marked variability in predicting lateronset of PTSD symptoms at 1 and 4 months after injury.It is possible that this variability may be attributed to thedesign of the SASRQ, the study retention and participa-tion rate, or the opt-in as opposed to opt-out study design.The variability may also be due to a transient stressresponse that remitted within the first month after injurygiven the reduction in sensitivity, specificity, and power topredict PTSD between months 1 and 4. Although thesefinding suggest that the ASD diagnosis or its symptomsare not the ideal clinical detection tools for predictinglater onset of PTSD or other stressors, the initial evidencesuggests it is more efficient than current practice.The sensitivity, specificity, and power to predict PTSDusing the SASRQ questionnaire did produce rates thatconform with the current literature. In a recent systemreview of thirteen adult injury-related acute stressstudies, the ASD diagnosis resulted in a mean sensitivityof 0.50 (0.29 – 0.89), specificity of 0.89 (0.56 – 0.97), andpower to predict PTSD of 0.54 (0.25 – 0.82) usingvarious questionnaires over periods ranging from 2 toTable 2 Sensitivity, specificity, and power to predict 9PTSD cases at month one using the ASD symptomatologyDSM-IV ASD criteria Sensitivity Specificity PPV NPVASD symptoms using routinescreeningB. Dissociation 0.78 0.43 0.31 0.86C. Re-experiencing/Intrusion 0.78 0.67 0.44 0.90D. Avoidance 0.78 0.48 0.33 0.87E. Anxiety/Hyperarousal 0.93 0.19 0.28 0.89F. Impairment 0.86 0.17 0.26 0.78Subsyndromal ASD usingroutine screeningC + D + E 0.64 0.71 0.43 0.86ASD diagnosis using routinescreeningB + C + D + E + F + 2 day 0.43 0.83 0.46 0.81Ad hoc referral practiceConsultation with psychiatry 0.14 0.95 0.50 0.77PPV: positive predictive value; NPV: negative predictive value.The accuracy of PTSD classification characterized by ad hoc referral withpsychiatry was measured in reference to the participants SASRQ response score.Table 3 Sensitivity, specificity, and power to predict 10PTSD cases at month four using the ASD symptomatologyDSM-IV ASD criteria Sensitivity Specificity PPV NPVASD symptoms using routinescreeningB. Dissociation 0.75 0.39 0.32 0.80C. Re-experiencing/Intrusion 0.50 0.58 0.32 0.75D. Avoidance 0.58 0.55 0.33 0.77E. Anxiety/Hyperarousal 0.92 0.13 0.29 0.80F. Impairment 0.83 0.13 0.27 0.67Subsyndromal ASD usingroutine screeningC + D + E 0.33 0.68 0.29 0.72ASD diagnosis using routinescreeningB + C + D + E + F + 2 day 0.17 0.81 0.25 0.71Ad hoc referral practiceConsultation with psychiatry 0.17 0.97 0.67 0.75PPV: positive predictive value; NPV: negative predictive value.The accuracy of PTSD classification characterized by ad hoc referral withpsychiatry was measured in reference to the participants SASRQ response score.Bell et al. Journal of Trauma Management & Outcomes 2014, 8:5 Page 4 of 7http://www.traumamanagement.org/content/8/1/524 months after injury [9]. In comparison to ad hocclinical referral practices, routine screening improvedthe identification of patients whose acute stress per-sisted within the first month after injury. Although adhoc referral resulted in greater predictive power after4 months, this improvement came at the expense ofidentifying fewer individuals with acute stress. Whencontrasted against the context of patient experiences,these preliminary results suggest routine as opposed toad hoc screening for acute stress is a more sensitive ap-proach for identifying populations who would benefitfrom interventions.Our estimation of acute stress under current practicemay be conservative due to the reliance on patientdischarge summary notes to identify in-hospital referralswith psychiatric services. As the level of accuracy in thenumber of psychiatric referrals that are recorded inpatient discharge summaries is unknown, this study doesprovide a reference point from which to gauge futureassessments. However, it may be that current practicesover estimate incidence of acute stress as all personswith a previous mental health history are automaticallyidentified in the patient registry and flagged for a consultafter admission to Trauma Services. In this study, five ofthe eight individuals who were consulted by psychiatryprior to discharge met this criterion.Research has shown an estimated 13 to 25% ofunintentional and intentional injury survivors displaysymptoms of acute stress following injury [23-25]. Theprevalence of acute stress identified in this study fromroutine screening confirms with the current literaturewhereas the ad hoc referral underestimates the fre-quency that patients experience this type of stressresponse. However, using the ASD diagnosis as a meansto reduce the risk of PTSD remains a challenge due tolimitations of screening, the lack of capacity to providecare, and the inconclusive evidence on the effectivenessof treatment [11]. In addition, it has been shown thattherapies to minimize PTSD other than cognitive behaviortherapy, such as behavioral activation, cognitive restruc-turing, counseling, relaxation therapy, stepped collabora-tive care, or structured writing interventions are largelyineffective [26]. While there remains a need to abstainfrom providing a clinical diagnosis of PTSD in absence ofcapacity to provide care, this reservation is not sufficientgrounds to avoid routine screening for acute stress as itwould detract from the capacity to understand broadercontexts associated with recovery and how best toTable 4 Characteristics of participants by response scores to the PCL-S PTSD self-assessment test at month 1 and month 4Variable Symptom+ (n = 14)month 1Symptom - (n = 42)month 1pvalueSymptom+ (n = 12)month 4Symptom - (n = 31)month 4p valueSocio-demographic factorsMean (SD) age (years) 45 (20) 46 (19) 0.81 45 (15) 49 (20) 0.50Male 6 (42) 33 (78) 0.03 8 (67) 22 (71) 1.00Having no high school diploma 3 (21) 3 (7) 0.32 2 (17) 3 (10) 0.91Unemployed at time of injury 2 (14) 6 (14) 1.00 2 (17) 4 (13) 1.00Currently living alone 3 (21) 10 (24) 1.00 1 (8) 5 (16) 0.86Living in rented housing 10 (71) 24 (57) 0.53 6 (50) 18 (58) 0.89Health status factorsTreated for anxiety or depression in thelast year3 (21) 8 (19) 1.00 4 (33) 3 (10) 0.17Has consulted with GP/care provider 6 (54) 11 (38) 0.55 10 (91) 11 (42) 0.02Currently taking medication for stress 7 (50) 15 (36) 0.53 5 (42) 3 (10) 0.05Feel as healthy as prior to injury 3 (21) 8 (19) 1.00 4 (33) 3 (10) 0.17Had not expected pain to still bepresent12 (85) 33 (78) 0.85 9 (75) 27 (87) 0.61Has experienced barriers obtaining care 1 (7) 2 (5) 1.00 5 (42) 2 (6) 0.02Injury-related factorsPositive blood alcohol (BAC) uponadmission1 (8) 6 (16) 0.86 2 (18) 3 (11) 0.92Positive toxicology result uponadmission1 (8) 5 (13) 1.00 1 (9) 2 (7) 1.00Mean (SD) Injury severity score (ISS) 15 (14) 24 (12) 0.03 18 (14) 24 (12) 0.24Cause of injury was intentional 2 (17) 2 (5) 0.48 2 (17) 1 (3) 0.41Values reported are counts (% of group total) unless otherwise stated.Bell et al. Journal of Trauma Management & Outcomes 2014, 8:5 Page 5 of 7http://www.traumamanagement.org/content/8/1/5anticipate and respond to patient needs prior to and afterdischarge.Our preliminary findings suggest that the definitivestudy should test whether an improved discharge manage-ment program improves patient outcomes. Our initial re-sults suggest that patients lack knowledge of resourcesavailable during recovery, are dissatisfied with their levelof social support to help them manage their health,under-utilizing health care services as a result of either in-sufficient knowledge or financial resources, and that psy-chological stressors are largely unexpected. Some of theseexperiences could be prevented through improving dis-charge practices. For example, in British Columbia all in-dividuals are eligible to apply for temporary premiumhealth care assistance to reduce the financial impact ofobtaining extended health care (e.g. physiotherapy, coun-seling) in the event that they do not qualify for premiumassistance or would exhaust their health insurance tomaintain preventative health care treatment. Only oneparticipant was knowledgeable of this insurance assistanceprogram, suggesting that greater patient advocacy canbe incorporated into routine practice. In addition, pre-vious studies have initiated supportive self-managementprograms to increase the effectiveness of treatment fordepression [27]. A supportive self-management pro-gram targeted at survivors who exhibit acute or long-term symptoms of stress could be tested to determinewhether post-discharge care management that empha-sizes coaching and behavior change can foster self-efficacy with respect to their emotional health.We developed a systematic enrollment program to iden-tify participants for follow-up based on daily coordinationbetween the trauma nurse coordinator and the researchteam. Following rounds, the trauma nurse coordinator pro-vided a list of all patients to be discharged in the afternoonor who were likely to be discharged on the following day.There were few occasions where more than two individualswere discharged on a single day, thereby making it feasiblethat one individual could conduct the initial enrollmentinterview. An underlining benefit of this approach isthat the coordinator serves as a focal point for dailytrauma operations and is in a strong position to bro-ker additional support from clinical staff and surgicalresidents as to the benefits of improved patient follow-up.Limitations of this approach were that persons dischargedon weekends were missed. For the definitive study,enlisting surgical residents to coordinate baseline inter-views during weekends could help minimize this source ofpotential bias. A retrospective review of trauma registryrecords found no difference between consenters and pa-tients who were missed with respect to age, sex, injury in-tent, BAC, or toxicology result.Importantly, this pilot study is hindered by the limitationof a sample of 91 individuals. This limitation prohibited amore robust analysis of covariates attributed to retentionand psychological morbidity, both of which could helpidentify whether targeted as opposed to universal screeningwould be more beneficial. While participants who main-tained follow-up throughout the entire study period hadsimilar health and socio-economic backgrounds, there weredifferences among those who withdrew from follow-upfrom those who maintained full or partial participation.These differences may lead to participation bias andstrategies to minimize their impact will need to beaddressed. It should be noted that the study was com-pleted prior DSM-V and used a survey that was developedusing the DSM-IV criteria.ConclusionThis pilot study suggests there are opportunities toenhance current discharge practices in trauma care byactively screening for ASD symptomatology. This wouldrepresent a practice change in trauma care, but it is nomeans certain other trauma centers are able or willingto take on additional screening. To our knowledge, thisshift in care has not yet been undertaken elsewhere inCanadian trauma centers. Thus far, representatives ofour Quality Council have encouraged continued screeningfor acute stress and have supported its inclusion aspart of standard care practice. As such, we have proposeda quaternary discharge survey whereby acute stress assess-ments would become part of routine patient handoverprior to discharge. The proposal was framed such thatfuture surveys would be undertaken by our surgical resi-dents, under the rationale that this practice emphasizesthe ‘Health Advocacy’ component of the Royal College ofPhysicians and Surgeons of Canada CanMEDS PhysicianCompetency Framework – traditionally one of theleast supported CanMEDS roles. Further research intothe epidemiology of acute stress and assessment ofpatient outcomes is required to assess whether this is anoptimal structural framework for minimizing psychologicalmorbidity after injury.Competing interestsThere are no competing interests among any of the authors.Authors’ contributionsConception and design: NB and RKS. Acquisition of data: NB. Analysis andinterpretation of data: NB, RKS, BS, SA, RH. Drafting of manuscript: NB, RKS,BS, SA. Study supervision: RKS and BS. All authors read and approved thefinal manuscript.AcknowledgementsThe authors would like to thank Tracey Taulu, Kara George, Lori Quinn, LoisBudd, Court Babcock, and Margret Little from Vancouver General Hospital.The authors would also like to acknowledge the support of the BC TraumaRegistry and to Drs. Lynne Moore and Dirk Stengel for reviewing thismanuscript and their helpful comments and suggestions. Funding for NBwas supported by a postdoctoral fellowship awarded from the CanadianInstitutes of Health Research (CIHR).Bell et al. Journal of Trauma Management & Outcomes 2014, 8:5 Page 6 of 7http://www.traumamanagement.org/content/8/1/5Author details1Department of Surgery, University of British Columbia, 855 West 10thAvenue, Vancouver, British Columbia V5Z 1 M9, Canada. 2School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver, British Columbia V6T 1Z3, Canada. 3Department of Psychiatry,University of British Columbia, 855 West 10th Avenue, Vancouver, BritishColumbia V5Z 1 M9, Canada. 4College of Nursing, University of SouthCarolina, 1601 Greene Street, Columbia, SC 29208, USA.Received: 15 November 2012 Accepted: 29 April 2014Published: 5 May 2014References1. Bryant RA, Creamer M, O’Donnell ML, Silove D, McFarlane AC: A multisitestudy of the capacity of acute stress disorder diagnosis to predictposttraumatic stress disorder. J Clin Psychiatry 2008, 69:923–929.2. Shalev AY, Tuvia P, Canetti L, Schreiber S: Predictors of PTSD in injurytrauma survivors: a prospective study. 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