Screening for Posttraumatic Stress Disorder in Civilians With Mangled Hand Injury: A Practice Enhancement Approach.

Posttraumatic stress disorder (PTSD) is a symptom cluster of intrusion, avoidance, negative alteration in cognition, and alteration in arousal and reactivity following trauma. PTSD occurs frequently after a physical trauma such as a severe hand injury. It is often not recognized and consequently untreated. Previous research has shown that 10%-40% of civilian trauma survivors experience PTSD in the first 12 months after injury. There is great urgency to identify patients in the early stage of recovery from trauma, as PTSD becomes more difficult to treat in its chronic form. Mangling hand injuries are particularly disabling because they are an integral part of our social body image. We wanted to investigate the degree of PTSD screening and the follow-up-referral procedures in all mangled hand cases at the hand clinic of a large Northwestern Trauma Center. A retrospective medical record review was conducted from January to December 2012 using an existing PTSD screen with data from the electronic medical records. We found that 40% of the patients with mangled hand injury were classified as "at risk" according to our PTSD screening but only 22% of those cases were referred to rehabilitation psychiatry for further evaluation and treatment. The low rate of referral for PTSD after mangled hand injury was alarming. On the basis of this, we instituted a new screening protocol for all patients with mangled hand injury using the 4-item Primary Care-PTSD screening tool and provided an informational brochure on PTSD. The investigation led to a positive change in the practice environment and workflow of the clinic. We have not conducted any follow-up study as yet, but our goal is to screen all patients with mangled hand injury and refer all patients for psychiatric therapy who have positively answered 3 of the 4 screening questions.