Trauma informed care in a modern hospital setting

By: Tona Gillen in Clinical Practice, Opinion, Top Stories May 5, 2020 0

This article explores the relationship between physical trauma, psychological trauma and the integration of trauma informed care in a modern hospital setting.

Traumatic physical injury is the leading cause of death in the first four decades of life. It accounts for approximately 10 per cent of worldwide deaths (more than the number of deaths from malaria, tuberculosis and HIV combined) according to the World Health Organization (WHO) 2008. Injury prevention with patient education and trauma care policies aim to reduce both fatalities and permanent consequences among patient survivors.

For every injured child who dies, there are several thousand children who live with varying degrees of disability after the event. These disabilities may result in long periods of school absenteeism, loss of productive years of work and can have a significant impact on the patient’s mental health and quality of life.

At Queensland Children’s Hospital in Brisbane, a level 1 major trauma centre, approximately 900 children per annum are admitted for greater than 24 hours following a significant injury.

Paediatric patients are a heterogenous group, multi-faceted and complex, and they bring their own individual characteristics including their temperament, their strengths and their vulnerabilities to their hospital admission. A simple but important factor is the age of the patient – their chronological age may well differ from their developmental age and this may impact on their coping with separation from their family.

The younger the child, potentially the greater the separation anxiety. Other contributing factors of complexity include their family, their education, their community and their neighbourhood. The severity of the injury and their temperament (such as optimist or pessimist) will play a part in their ultimate recovery.

The optimist-pessimist spectrum represents a way in which we can classify how people direct their energy in any given circumstance. Optimistic people tend to see positives in almost all situations where as pessimists can experience anticipatory anxiety in certain situations; they may worry about potential ramifications that may not eventuate. This fear generates distress and this may impact both their physiological state (e.g. pulse, blood pressure) and psychological state (self-belief, levels of happiness or contentment).

Healthcare requires flexibility in the approach provided to children, from age appropriate information (about their injury and the hospital routine) in addition to simple strategies to help them manage their emotions. Giving them choices where possible (which hand for the IV cannula, medication in liquid or tablet form) helping them reframe the negative situation (teaching them about what to expect as their body heals, enabling a Skype call with their friends and class mates) and normalising their fears assists with making them feel emotionally safe.

A child may enter the healthcare system following an injury that necessitates a hospital admission. This may be due to a motor vehicle incident, a fall from a tree, a sporting collision, a house fire or a surfing incident. Take for example the case of Lucy.

Lucy is a six-year-old (the youngest of four children) living on a rural property. She often helps her father cut the grass by riding with him on their ride-on lawnmower. One day, she slipped from the ride-on lawnmower when they hit a rock on the paddock and Lucy’s hand was caught under the blades of the lawnmower. Her father immediately cut the ignition but the blades have caused some serious damage.

Lucy experiences the initial physical pain from the injuries sustained (deep and extensive lacerations) to her dominant hand. Following a triple zero call, there is activation of the emergency services and she is transported to hospital in a helicopter. Lucy notices the concerned, anxious or indeed the panic-stricken faces of her father, her mother, siblings and neighbours.

The pre-hospital services stabilise Lucy and transport her to the closest hospital or trauma centre. Lucy is greeted in the emergency room with bright lights and teams of healthcare professionals who she has never met before. For any child this is a confronting, if not a very frightening experience, despite the healthcare teams’ best efforts to provide them with reassurance.

This injury, which includes a crush injury to the forearm and a fracture of the humerus, results in an unplanned emergency admission, with care provided by trauma surgical teams, plastic, reconstructive and orthopedic surgical teams.

There is no time for Lucy and her family to prepare for this upheaval to their daily life, their normal routine. Lucy will require urgent surgical decontamination, followed by staged repair of her hand (multiple surgeries) and she will be admitted to the intensive care unit due to her extensive blood loss at the scene. When she has recovered sufficiently, Lucy will have intensive physiotherapy and occupational therapy, and this will be followed by many months of ongoing allied health intervention.

The hospital system is well equipped to deal with all manner of physical injuries, from trauma surgical specialists to sub-specialists to state-of-the-art equipment and highly trained personnel. A trauma team is one such multidisciplinary hospital team made up of healthcare professionals, who in response to a trauma call, rapidly form a team to work together to assess and treat the severely injured patient.

The primary aims of the trauma team are specifically to rapidly resuscitate and stabilise the patient, prioritise and determine the nature and extent of the injuries and prepare the patient for definitive care, in the operating theatre or in the intensive care unit. Clearly allocated roles and responsibilities are crucial for successful trauma team performance. Practice of these roles during simulated learning ensures that optimal care is delivered to the patient at all times. It is testament to the fact that patient morbidity and mortality is reduced when a competent trauma team uses a systematic approach (primary, secondary and later tertiary survey) to assess and manage the injured child.

Early childhood represents one of the most vulnerable periods in a child’s development and young children tend to struggle to make sense of their place in the world, across physical, social and psychological domains of functioning.

In the case of Lucy, physically there will be pain as she learns to re-use her hand to dress herself, to use her toothbrush, to use cutlery to eat and to use her pencils to write or draw. Socially Lucy has been separated from her home, her classmates in school, and from her three siblings and her beloved pet dog. Psychologically she may remember the expression on her parents' faces, the noise of the helicopter blades, the bright lights in ED and the many trips to the operating room. Given the severity of Lucy’s injury, it is likely that there will be a significant impact on her entire family’s physical, psychological and emotional reserve that will create disruption and distress on their family unit.

Regardless of the physical injury sustained, some children might experience the ‘hospitalisation’ as overwhelming or distressing (a psychological or emotional trauma) and this can impact negatively on the child’s brain. This is usually referred to as ‘acute psychological trauma’. According to the Psychiatric Annals (2005) psychological stress and emotional trauma can affect brain development, particularly if the adversity occurs during the critical period of nerve cell development (deemed to be under three years of age) when quality neural connections are laid down.

A physical injury or a psychological threat, whether real or perceived, will trigger the amygdala in the brain. The amygdala is said to the be the ‘threat detector’ (like a smoke detector in a house, it raises the alarm). The amygdala responds by sending signals to the pituitary gland in the hypothalamus, which stimulate the autonomic nervous system to release stress chemicals such as adrenaline and cortisol which is produced by the adrenal glands into the body.

Adrenaline (epinephrine) gets released immediately with the reflexive (fear) response that manifests as fight, flight or freeze. From a physiological perspective, the heart pumps faster with an increase in heart rate and blood pressure, extra blood is sent to the muscles (skeletal muscle vasodilation), more oxygen is available to the lungs (bronchodilation) and more glucose (energy) is available to the body in preparation for imminent danger.

If this response occurs often or on a regular basis the high glucose levels in addition to cortisol may lead to type II diabetes or hypertension, which can lead to cardiovascular disease. This response upsets the homeostasis of the body (the equilibrium) and it may extend to alter the acid base balance in the blood, and it can leave the child feeling anxious – in a ‘hyperarousal state’.

A healthy person requires both good physical health as well as optimal mental health to accelerate healing. Medical clinicians are well versed in accurate and detailed medical and surgical history taking. Taking a robust psychosocial history and the provision of psychosocial support has historically been left to social workers and occupational therapists.

Extensive research has been conducted into childhood adversity and its profound effects on children, and it would be remiss of healthcare professionals to ignore this evidence.

One such study conducted by Dr Vincent Felitti and Dr Robert Anda examined ‘Adverse Childhood Experience’ (ACE) at the Centre for Disease Control and Kaiser Permanente in the USA. This extensive study highlighted the fact that most people are familiar with ‘childhood adversity’. Their research focused specifically on 10 areas of ‘adversity’ that children may have been exposed to, usually in their homes.

This ranged from intentional injury (physical abuse) to psychological abuse from a finite list of possible causes. They nominated 10 ‘adverse childhood experiences’ including physical and sexual abuse, psychological abuse and neglect, household dysfunction including exposure to domestic violence, a house-hold member incarcerated, parental discord, divorce or abandonment or living with a family member who is mentally ill or one who is addicted to alcohol or other substances.

This 10-year ACE study was conducted in the late 1990s and included over 17,000 research participants who were asked about their own exposure to trauma during their childhood. Surprisingly, 67 per cent of all respondents reported exposure to at least one of the 10 categories of adverse childhood experiences. The responders tended to be upper and middle class, often college-educated people, mostly Caucasian but included all races and ethnicities, emphasising the fact that a significant proportion of society has been exposed to some adversity.

Exposure to adverse childhood experiences has been referred to as living in a toxic or harmful environment. When the exposure to adversity is ongoing, long term and repetitive it is referred to as ‘chronic trauma’ whereas when the adversity is strong, frequent and prolonged it is said to be ‘complex trauma or toxic trauma’.

Intergenerational trauma is another form of trauma where the trauma is passed down from one generation to the next, such as racial discrimination or impoverishment. Ongoing stress caused by negative events or experiences can damage the neuron development in the hippocampus, and the hippocampal-mediated learning and memory processes may be impaired.

Young children may have impaired neurodevelopment, whereas in older children stress or adversity may affect the prefrontal cortex in the frontal lobe of the brain. This part of the brain is responsible for executive functioning, and any disruption to this area may affect problem-solving skills, attention span, memory, language, spontaneity or inhibition, judgement, impulse control and cognitive behaviour. Knowing the implications of the adverse childhood experiences study it would be neglectful to ignore the impact on children that are hospitalised following injury.

The ACE study also highlighted the long-term destructive nature of exposure to adveristy in childhood, which can manifest in a variety of ways in adulthood, causing chronic medical diseases such as lung, cardiac, liver disease or cancer.

There may be social problems such as unemployment and subsequent urban poverty. There may be mental health issues such as depression, attempted suicide and illicit drug use, which may lead to crime and the inevitable contact with the justice system (including incarceration). All of these ramifications make this a public health issue that spans all areas of our community.

According to the WHO, childhood adversity encompasses all forms of child maltreatment, intentional injury (physical abuse), sexual, emotional abuse as well as neglect. While data is available, we know child abuse is massively underreported and therefore it is virtually impossible to know accurately how many children have been exposed to and impacted by such adversity.

In addition, there are other considerations that negatively impact the child such as childhood bullying or peer exclusion, grief and bereavement, previous significant injury or prolonged hospital stay, poverty or community adversities such as living in an at-risk area or a neighbourhood where violence or high levels of crime prevail.

Surviving a major disaster is also a risk factor for adversity. There may be more catastrophic events such as extreme weather events and natural disasters, including cyclones and floods, earthquakes and mudslides or the very recent devastating Australian bushfires that has challenged both our natural and personal resources. The full impact of children living though and surviving a pandemic is yet to be known in this generation.

Dr Bessel van der Kolk, a Dutch psychiatrist who has dedicated most of his professional life to treating complex post trauma stress disorder, together with his colleagues at the National Child Traumatic Stress Network (May 2005) proposed a new diagnosis called ‘Developmental Trauma Disorder’ (DTD).

This represents very early exposure to adversity with the developmental trauma disorder occurring between the moment of conception, and before the onset of conscious verbal thought at age two or three. It is sometimes referred to as “trauma in the first 1000 days” of life. A child’s brain is most plastic (neuroplasticity) from zero to three years of age. This is a critical period for nerve cell development. These early childhood experiences create the foundation for life long health, social relationships, academic success and self-regulation.

Self-regulation is often referred to as the capacity to control impulses such as aggression or anger outbursts. Dr van der Kolk described the sequelae of exposure to adversity in early childhood to many facets of dysregulation and post traumatic spectrum symptoms. One of the important factors with developmental trauma disorder was its intention to specifically note the impact of cumulative childhood trauma (multiple events or chronic or prolonged or repetitive) noting the differences from that following a single (one time) traumatic incident. As yet, the diagnosis of DTD has not been included in the Diagnostic Statistical Manual (DSM-V).

This ACE study and the work of Dr van der Kolk is a ‘game-changer’ by highlighting the lifelong ramifications of childhood adversity psychologically, physically and socially. The goal is that the entire healthcare workforce acts proactively and responds compassionately, while creating opportunities for trauma survivors to rebuild a sense of control and empowerment. This requires a paradigm shift from the traditional to modern thinking and practice.

Currently, at Queensland Children’s Hospital in Brisbane, the trauma nurse navigator together with the trauma social worker form the ‘family-support’ trauma service team. Both team members, while bringing a unique skillset to the team, use a trauma informed framework when treating any child that has been admitted following a severe injury.

Support and validation are offered in a courteous and professional manner. Keeping the child and their family informed and liaising with the multidisciplinary team enables continual updates as to their child’s progress. Using receptive body language, simplifying medical jargon and conveying trauma service availability to the family helps restore their sense of control. Written resources, early referrals to specialists and community services help meet their physical and emotional needs both during the hospital journey and after their discharge home.

Trauma informed care is a framework that is grounded in understanding, compassion and responsiveness to the impact of childhood adversity. As with any successful initiative it requires investment by the leadership team in the form of governance as well as a financial commitment. Fortunately, at our major trauma center, the organisational leadership team acknowledge and support the principles of trauma informed care and are keen to promote a culture of safety, empowerment and healing.

Standards of trauma informed care need to be incorporated into policies and programs to ensure that the principles of trauma informed care are followed every day. This also enables the opportunity for evaluating the effectiveness of the program through assessment, monitoring and tracking while identifying areas for ongoing improvement.

Realising that a significant proportion of our population are survivors of childhood adversity, prudence would dictate that each patient is treated from a trauma informed perspective. Carefully choosing the words spoken, coupled with open body language and good listening skills shows the person that they are valued and respected. In addition, it is important to provide a safe physical environment for the individual and their family to be sensitive to triggers of their trauma and not add any further trauma.

This may include open plan spaces (ward or play areas) privacy curtains and consideration of an appropriate chaperone. The provision of psychological safety is equally important and includes enabling choices through rapport building, dialogue and collaboration around medical treatment decisions.

It would seem incumbent on all services that deal with children, including healthcare and hospitals, to be pro-active and practice trauma informed care. Physical injury and psychological trauma are intricately entwined, and healthcare systems should enhance the delivery of services that are evidence-based and designed to address the cognitive, emotional, behavioural and physical issues associated with trauma.

There is hope for every person in the form of neuroplasticity – the brain's ability to form new neural connections throughout the lifespan. In addition to trauma informed targeted support, there is the opportunity for the trauma survivor to live a less burdensome life. We owe it to children like Lucy to improve their opportunity to adapt, change and live well with their trauma.

*Lucy is not the patients real name, all identifying features have been changed.

Tona Gillen is nurse manager, trauma, at Queensland Children’s Hospital.

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