569 - Trauma-Informed Care on the Pediatric Ward: A Novel Application of ACEs/Trauma Screening and Intervention in the Inpatient Medical Setting

Publication Number: 569.6778

Maggie Kozman, University of California, Los Angeles David Geffen School of Medicine, Torrance, CA, United States; Paola Gomez, Harbor UCLA Medical Center, Torrance, CA, United States

Background: Adverse Childhood Events screening is routine in pediatric, and some adult, clinics. The broader trauma-informed care (TIC) framework has also been applied to outpatient settings and inpatient psychiatric units. However, no models exist in the literature for ACEs/trauma screening on an inpatient medical ward, where there is ample time during hospitalization for screening and expeditious multidisciplinary intervention.

Objective: Achieve universal TIC education for all Pediatric Ward staff. Screen hospitalized 0-20yo patients for ACEs/trauma to then mobilize patient-desired inpatient/outpatient resources, avoid re-traumatization, and bolster resilience factors. Develop a generalizable, adaptable model for ACEs/trauma screening and intervention on an inpatient medical ward.

Design/Methods: This is an ongoing single-site quality improvement study in the Pediatric Ward of a county safety-net hospital. Phase 1, Universal Education, utilized Becoming ACEs Aware in California (BAA) online module to provide foundational TIC training. Phase 2, Screening/Intervention, entailed creating the novel inpatient Trauma and Resilience Questionnaire (TRQ) and TIC Algorithm, screening with TRQ and Pediatric ACEs and Related Life-events Screener, mobilizing resources, adding destigmatized ICD-10 codes, and physician documentation. Patients were eligible if they had county network insurance (to allow review of post-discharge follow-up) and would remain admitted for at least 24h after screening (to allow adequate intervention time).

Results: All Pediatric residents, hospitalists, nurses, social workers, and Child Life Specialists, and 50% of subspecialists who attend on Ward teams, completed BAA. Over 15 months, rate of patients/caregivers answering ALWAYS to Patient Experience Survey asking if they were treated in a trauma-informed manner was 80%. High completion rates of requested consults/referrals were maintained. ICD-10 coding improved with PDSA cycles. Rate of documentation in Discharge Summary, PCPs’ preferred hand-off, remained below 43% despite PDSAs: repeat trainings, incentivization, electronic record-based interventions. Thus, rate of PCP follow-up on positive screens within 3 months was 0%; 12% of those screened were rescreened in clinic within 3 months.

Conclusion(s): Inpatient TIC/ACEs screening can effectively elicit trauma history causing distress in the often-triggering hospital setting and provide resources to support resilience factors. If hand-off to PCP can be improved, inpatient screening can offload time-constrained PCP visits and should be considered for MediCal reimbursement like outpatient screening.

Trauma and Resilience Questionnaire
Novel questionnaire created to screen for various types of trauma history, current distress during the hospitalization as a result of the trauma(s), resilience factors, and patient-/caregiver-desired inpatient and outpatient resources they can select from a menu, rather than providers paternalistically forcing already-overburdened services on patients/families who may already have adequate resilience factors and resources buffering their trauma.

Trauma-Informed Care Algorithm
Process Map of the inpatient TIC workflow created to guide the screening and intervention process, which was placed in the physician work rooms and on badge buddies to remind physicians of the intervention steps.

P-Chart of the Completion of Requested Consults/Referrals
Proportion of requested consults/referrals selected by patients/caregivers in the TRQ that were fulfilled during the hospitalization, with the monthly denominator n ranging from 1 to 6 total requests from all patients screened in each month.