Trauma

Most adults with functional motor disorders (FMDs) report a history of psychological or physical trauma 6 months before the onset of symptoms, a retrospective study of 482 individuals suggests. Those challenges prevent more than half of those patients – most of whom are women – from working, the researchers found.

“This finding points to the huge socioeconomical burden of FMD and emphasizes the need for better diagnostic procedure and active management,” wrote Béatrice Garcin, MD, of Sorbonne Université, Paris, and associates.

FMDs are a common presentation of functional neurologic disorders, but clinical characteristics of FMDs are not well understood because large series of consecutive patients are limited, Dr. Garcin and associates said.

In the study, published in the Journal of Psychosomatic Research, the investigators reviewed data from consecutive patients with FMD who were seen at a single hospital in France between 2008 and 2016. Half of the patients had functional motor weakness (241) and half had functional movement disorders (241). All of the patients had been referred for transcranial magnetic stimulation (TMS) as treatment for FMD.

The median age of the patients was 40 years, the median age at the onset of symptoms was 35.5 years, and 74% were women. The most common clinical presentations were tremor and dystonia (83.4%), and no demographic differences were observed between patients with functional motor weakness and functional movement disorders. Symptoms were bilateral in about half of the patients (51.7%), with left- and right-sided symptoms in 28.2% and 20.1%, respectively.

More than 80% of the patients reported a history of trauma within 6 months of the onset of their symptoms, mainly psychological trauma (50.6%). Another 20.1% reported a physical trauma, and 8.7% reported trauma from surgical procedures.

In addition, about two-thirds (66.4%) had psychiatric comorbidities; 52.7% of these were mood disorders: 49.3% depression and 3.3% bipolar disorder. “However, these results about psychiatric comorbidities should be taken with caution,” the researchers emphasized. “The proportion of trauma and psychiatric comorbidities might be significantly underestimated, and psychiatric diagnosis may lack precision because of the absence of systematic psychiatric interviews and psychiatric questionnaires in the present study.”

No significant differences appeared between the motor weakness and movement disorders groups in terms of occupation, level of education, medical somatic history, symptom onset, psychiatric comorbidities, or self-reported history of trauma. Patients in the motor weakness group were significantly younger at the time of TMS treatment and had a shorter disease duration prior to that treatment. No differences were noted between the groups with regard to clinical FMD phenotypes.

The study findings were limited by several factors, including the potential selection bias because of enrollment at a neurology referral center, lack of a control group, and underrepresentation of children and older adults, the researchers noted. Also, symptom severity was not assessed and could not be compared among phenotypes or demographic groups.

However, the results contribute to the characterization of FMD patients. “Future studies are needed to clarify the characteristics of FMD patients and the consequences of their symptoms on disability and work status,” they said.

The study received no outside funding. Lead author Dr. Garcin had no disclosures.

Most adults with functional motor disorders (FMDs) report a history of psychological or physical trauma 6 months before the onset of symptoms, a retrospective study of 482 individuals suggests. Those challenges prevent more than half of those patients – most of whom are women – from working, the researchers found.

“This finding points to the huge socioeconomical burden of FMD and emphasizes the need for better diagnostic procedure and active management,” wrote Béatrice Garcin, MD, of Sorbonne Université, Paris, and associates.

FMDs are a common presentation of functional neurologic disorders, but clinical characteristics of FMDs are not well understood because large series of consecutive patients are limited, Dr. Garcin and associates said.

In the study, published in the Journal of Psychosomatic Research, the investigators reviewed data from consecutive patients with FMD who were seen at a single hospital in France between 2008 and 2016. Half of the patients had functional motor weakness (241) and half had functional movement disorders (241). All of the patients had been referred for transcranial magnetic stimulation (TMS) as treatment for FMD.

The median age of the patients was 40 years, the median age at the onset of symptoms was 35.5 years, and 74% were women. The most common clinical presentations were tremor and dystonia (83.4%), and no demographic differences were observed between patients with functional motor weakness and functional movement disorders. Symptoms were bilateral in about half of the patients (51.7%), with left- and right-sided symptoms in 28.2% and 20.1%, respectively.

More than 80% of the patients reported a history of trauma within 6 months of the onset of their symptoms, mainly psychological trauma (50.6%). Another 20.1% reported a physical trauma, and 8.7% reported trauma from surgical procedures.

In addition, about two-thirds (66.4%) had psychiatric comorbidities; 52.7% of these were mood disorders: 49.3% depression and 3.3% bipolar disorder. “However, these results about psychiatric comorbidities should be taken with caution,” the researchers emphasized. “The proportion of trauma and psychiatric comorbidities might be significantly underestimated, and psychiatric diagnosis may lack precision because of the absence of systematic psychiatric interviews and psychiatric questionnaires in the present study.”

No significant differences appeared between the motor weakness and movement disorders groups in terms of occupation, level of education, medical somatic history, symptom onset, psychiatric comorbidities, or self-reported history of trauma. Patients in the motor weakness group were significantly younger at the time of TMS treatment and had a shorter disease duration prior to that treatment. No differences were noted between the groups with regard to clinical FMD phenotypes.

The study findings were limited by several factors, including the potential selection bias because of enrollment at a neurology referral center, lack of a control group, and underrepresentation of children and older adults, the researchers noted. Also, symptom severity was not assessed and could not be compared among phenotypes or demographic groups.

However, the results contribute to the characterization of FMD patients. “Future studies are needed to clarify the characteristics of FMD patients and the consequences of their symptoms on disability and work status,” they said.

The study received no outside funding. Lead author Dr. Garcin had no disclosures.

Most adults with functional motor disorders (FMDs) report a history of psychological or physical trauma 6 months before the onset of symptoms, a retrospective study of 482 individuals suggests. Those challenges prevent more than half of those patients – most of whom are women – from working, the researchers found.

“This finding points to the huge socioeconomical burden of FMD and emphasizes the need for better diagnostic procedure and active management,” wrote Béatrice Garcin, MD, of Sorbonne Université, Paris, and associates.

FMDs are a common presentation of functional neurologic disorders, but clinical characteristics of FMDs are not well understood because large series of consecutive patients are limited, Dr. Garcin and associates said.

In the study, published in the Journal of Psychosomatic Research, the investigators reviewed data from consecutive patients with FMD who were seen at a single hospital in France between 2008 and 2016. Half of the patients had functional motor weakness (241) and half had functional movement disorders (241). All of the patients had been referred for transcranial magnetic stimulation (TMS) as treatment for FMD.

The median age of the patients was 40 years, the median age at the onset of symptoms was 35.5 years, and 74% were women. The most common clinical presentations were tremor and dystonia (83.4%), and no demographic differences were observed between patients with functional motor weakness and functional movement disorders. Symptoms were bilateral in about half of the patients (51.7%), with left- and right-sided symptoms in 28.2% and 20.1%, respectively.

More than 80% of the patients reported a history of trauma within 6 months of the onset of their symptoms, mainly psychological trauma (50.6%). Another 20.1% reported a physical trauma, and 8.7% reported trauma from surgical procedures.

In addition, about two-thirds (66.4%) had psychiatric comorbidities; 52.7% of these were mood disorders: 49.3% depression and 3.3% bipolar disorder. “However, these results about psychiatric comorbidities should be taken with caution,” the researchers emphasized. “The proportion of trauma and psychiatric comorbidities might be significantly underestimated, and psychiatric diagnosis may lack precision because of the absence of systematic psychiatric interviews and psychiatric questionnaires in the present study.”

No significant differences appeared between the motor weakness and movement disorders groups in terms of occupation, level of education, medical somatic history, symptom onset, psychiatric comorbidities, or self-reported history of trauma. Patients in the motor weakness group were significantly younger at the time of TMS treatment and had a shorter disease duration prior to that treatment. No differences were noted between the groups with regard to clinical FMD phenotypes.

The study findings were limited by several factors, including the potential selection bias because of enrollment at a neurology referral center, lack of a control group, and underrepresentation of children and older adults, the researchers noted. Also, symptom severity was not assessed and could not be compared among phenotypes or demographic groups.

However, the results contribute to the characterization of FMD patients. “Future studies are needed to clarify the characteristics of FMD patients and the consequences of their symptoms on disability and work status,” they said.

The study received no outside funding. Lead author Dr. Garcin had no disclosures.

Vocational rehabilitation (VR) interventions are offered through Compensated Work Therapy (CWT) as part of clinical care in the Veterans Health Administration (VHA) to improve employment and quality of life outcomes for veterans with life-altering disabilities.^1–5 CWT vocational services range from assessment, vocational counseling, and treatment plan development to job placement, coaching, and follow-along support.¹ However, many veterans receive care in community-based clinics that are not staffed with a VR specialist (VRS) to provide these services.^6–8 Telehealth may increase patient access to VR, especially for rural veterans and those with travel barriers, but it is not known whether veterans and VRS would find this to be a satisfactory service delivery method.^8,9 This paper examines veteran and VRS provider perspectives on VR provided by telehealth (VRtele) as part of a VHA clinical demonstration project. To our knowledge, this is the first report of using real-time, clinic-based VRtele.

Methods

The Rural Veterans Supported Employment Telerehabilitation Initiative (RVSETI) was conducted as a field-initiated demonstration project at 2 US Department of Veterans Affairs (VA) medical centers (VAMCs) in Florida between 2014 and 2016: James A. Haley Veterans’ Hospital & Clinics (Tampa) and Malcom Randall VAMC (Gainesville). This retrospective evaluation of its first year did not require institutional review board approval as it was determined to be a quality improvement project by the local research service.

The patient population for the project was veterans with disabilities who were referred by clinical consults to the CWT service, a recovery-oriented vocational program. During the project years, veterans were offered the option of receiving VR services, such as supported employment, community-based employment services, or vocational assistance, through VRtele rather than traditional face-to-face meetings. The specific interventions delivered included patient orientation, interview assessment, treatment plan development, referral activities, vocational counseling, assessment of workplace for accommodation needs, vocational case management, and other employment supports. VR staff participating in the project included 2 VR supervisors, 1 supported employment mentor trainer, and 5 VRSs.

Each clinic was set up for VRtele, and codes were added to the electronic health record (EHR) to ensure proper documentation. Participating VRSs completed teleconferencing training, including a skills assessment using the equipment for real-time, high-quality video streaming over an encrypted network to provide services in a patient’s home or other remote locations. VRS staff provided veterans with instructions on using a VA-provided tablet or their own device and assisted them with establishing connectivity with the network. Video equipment included speakers, camera, and headphones connected to the desktop computer or laptop of the VRS. A patient’s first VRtelesession was conducted in person at the VAMC to assure veterans were able to use the technology and to identify and resolve any problems.

Demographic data, primary diagnosis, VR usage data, and zip codes of participating veterans were extracted from the EHR. Veterans completed a 2-part satisfaction survey administered 90 days after enrollment and at discharge. Part 1 was composed of 15 items, most with a 5-point Likert scale (higher ratings indicated greater satisfaction), on various aspects of the VRtele experience, such as audio and video quality and wait times.¹⁰ Part 2 addressed VR services and the VRS and consisted of 8 Likert scale items with the option to add a comment for each and 2 open-ended items that asked the participant to list what they liked best and least about VRtele.

Semistructured, in-person 30- to 60-minute interviews were conducted with VRSs at the initiation of VRteleand audio-recorded with permission. An interview guide consisting of 14 questions was used to obtain data on caseload, VRtele set up, use of teleconferencing equipment, and veteran access to VR services.

After ≥ 2 months of VRtele use, researchers observed a session with each participant to obtain qualitative data from all participants on their VRtele experience. Using an observation form with open notes, data were collected on the use of the videoconferencing technology, the quality of the VRtele session, and reactions of veterans and their VRS. Following the observation session, both the VRS and the participating veteran were interviewed separately using a 9-question interview form to obtain data on the use of the technology in general and for VR. Interviews were audio-recorded with the permission of the VRS and veteran and transcribed for analysis.

Analyses

Descriptive statistics were used for EHR data and satisfaction surveys. For qualitative analysis, each transcript was read in full by 2 researchers to get an overview of the data, and a rapid analysis approach was used to identify central themes focused on how technology was used and the experiences of the participants.^11,12 Relevant text for each topic was tabulated, and a summary table was created that highlighted overlapping ideas discussed by the interviewees as well as differences.

Results

Of the 22 veterans who participated in the project, 11 completed satisfaction surveys and 4 participated in qualitative interviews. The rural and nonrural groups did not differ demographically or by diagnosis, which was predominantly mental health related. Only 1 veteran in each group owned a tablet; the majority of both groups required VA-issued devices: 80% (n = 8) rural and 91.7% (n = 11) nonrural. The number of VRtele sessions for the groups also was similar, 53 for rural and 60 for nonrural, as was the mean (SD) number of sessions per veteran: 5.3 (SD, 3.2) rural and 5.0 (SD, 2.5) urban. Overall, 63 miles per session were saved, mostly for rural veterans, and the number of mean (SD) miles saved per veteran was greater for rural than nonrural veterans: 379.2 (243.0) and 256.1 (275.9), respectively. One veteran who moved to a different state during the program continued VRtele at the new location. In a qualitative sampling of 5 VRtele sessions, all the VRSs used office desktop computers.

Level of satisfaction with aspects of VRtele related to the technology rated was consistently > 4 on the Likert scale. The lowest mean (SD) ratings were 4.2 (1.0) for audio quality and 4.4 (0.5) for video quality, and the highest rating was given for equipment operation explanation and privacy was respected, 4.9 (0.3) for both. All questions related to satisfaction with services were also rated high: The mean (SD) lowest ratings were 4.3 (1.0) given to both vocational needs 4.3 (1.0) and tasks effectively helped achieve goals 4.3 (0.7). The highest mean (SD) ratings were 4.6 (0.5) given to VR program service explained and 4.7 (0.5) for appointment timeliness.

Qualitative Results

At first, some VRSs thought the teleconferencing system might be difficult or awkward to use, but they found it easier to set up than expected and seamless to use. VRS staff reported being surprised at how well it worked despite some issues that occurred with loading the software. Once loaded, however, the connection worked well, one VRS noting that following step-by-step instructions solved the problem. Some VRSs indicated they did not invite all the veterans on their caseload to participate in VRtele due to concerns with the patient’s familiarity with technology, but one VRS stated, “I haven’t had anybody that failed to do a [session] that I couldn’t get them up and running within a few minutes.”

When working in the community, VRSs reported using laptops for VRtele but found that these devices were unreliable due to lack of internet access and were slow to start; several VRSs thought tablets would have been more helpful. Some veterans reported technical glitches, lack of comfort with technology, or a problem with sound due to a tablet’s protective case blocking the speakers. To solve the sound issue, a veteran used headphones. This veteran also explained that the log-on process required a new password every time, so he would keep a pen and paper ready to write it down. Because signing in and setting up takes a little time, this veteran and his VRS agreed to start connecting 5 minutes before their meeting time to allow for that set- up time.

Initially, some VRSs expressed concern that transitioning to VRtele would affect the quality of interactions with the veterans. However, VRSs also identified strengths of VRtele, including flexibility, saved time, and increased interaction. One VRS discussed a veteran’s adaptation by saying, “I think he feels even more involved in his plan [and] enjoys the increased interaction.” Veterans reported enjoying using tablets and identified the main strength of VRtele as being able to talk face-to-face with the VRS. Echoing the VRSs, veterans reported teleconferencing saved time by avoiding travel and enabled spontaneous meetings. One of the veterans summed up the benefits of using VRtele: “I’d rather just connect. It’s going to take us 40 to 50 minutes [to meet in person] when we can just connect right here and it takes 15 to 20. We don’t have to go through the driving.… So this right here, doing it ahead of time and having the appointment, it’s a lot easier.”

In their interviews, VRSs talked about enjoying VRtele. A VRS explained: “It makes it a lot easier. It makes me feel less guilty. This way [veterans] don’t have to use their gas money, use their time. I know [the veteran] had something else he needed to do today.” Thus, both veterans and VRSs were satisfied with their VRtele experiences.

Discussion

This first report on the perspective of providers and veterans using VRtele suggests that it is a viable option for service delivery and that is highly satisfactory for serving veterans with disabilities, many of whom live in rural areas or have travel barriers. These findings are consistent with data on telerehabilitation for veterans with cognitive, physical, and mental disabilities.^13-22 Further, the data support the notion of using VRtele to facilitate long-term VR follow-up for persons with disabilities, as illustrated by successful continuation of vocational services after a veteran moved out of state.²³

Similar to other reports, our experience highlighted 2 factors that affect successful VRtele: (1) Troubleshooting technology barriers for both VR providers and clients; and (2) supportive leadership to facilitate implementation.^24-26These areas have been improved with recent telehealth VHA initiatives and upgrades. After the conclusion of this project evaluation, the program was expanded, and local facilities may now receive mentored support to implement similar programs.²⁷ This ongoing telerehabilitation program uses the recently upgraded VHA telehealth platform that enables encrypted sessions to be provided to any mobile or online device, and veterans simply click on a link to connect rather than waiting for a session-specific password.²⁸ By using virtual medical rooms accessed by cameras on tablets, smartphones, or computers, veterans and VR providers now have an easier time scheduling and attending online appointments.²⁹ Improved access to VRtele is important as VHA began providing the majority of appointments via video telemedicine in Spring of 2020 due to the COVID-19 pandemic. The accelerated use of telehealth due to the COVID crisis makes these findings highly relevant to the current practice environment.

Changes to technology and increased usage of VA Video Connect may indicate that the barriers identified from the earlier process described here have been diminished or eliminated. More evaluation is needed to assess whether system upgrades have increased ease of use and access for veterans with disabilities.

Conclusions

Encouragingly, this clinical demonstration project showed that both providers and clients recognize the benefits of VRtele. Patient satisfaction and decreased travel costs were clear advantages to using VRtele for this small group of veterans who had barriers to care due to travel or disability barriers. As this program evaluation was limited by a small sample, absence of a comparison group, and lack of outcome data (eg, employment rates, hours, wages, retention), future research is needed on implementation and outcomes of VRtele.

Acknowledgments
The authors thank Lynn Dirk, MAMC, for substantial editorial assistance. This material was based on work supported by Rural Veterans Supported Employment TeleRehabilitation Initiative (RVSETI), funded by the VA Office of Rural Health (Project # N08-FY14Q3-S2-P01222) and by support of the VA Health Services Research and Development Service. This work was presented in part at the 114th Annual Meeting of the American Anthropological Association at Denver, Colorado, November 21, 2015; a field-based Health Services Research and Development Service meeting, US Department of Veterans Affairs at Washington, DC, September 12, 2016; and the 2016 Annual Conference of the American Congress for Rehabilitation Medicine at Chicago, Illinois, October-November 2016.

Vocational rehabilitation (VR) interventions are offered through Compensated Work Therapy (CWT) as part of clinical care in the Veterans Health Administration (VHA) to improve employment and quality of life outcomes for veterans with life-altering disabilities.^1–5 CWT vocational services range from assessment, vocational counseling, and treatment plan development to job placement, coaching, and follow-along support.¹ However, many veterans receive care in community-based clinics that are not staffed with a VR specialist (VRS) to provide these services.^6–8 Telehealth may increase patient access to VR, especially for rural veterans and those with travel barriers, but it is not known whether veterans and VRS would find this to be a satisfactory service delivery method.^8,9 This paper examines veteran and VRS provider perspectives on VR provided by telehealth (VRtele) as part of a VHA clinical demonstration project. To our knowledge, this is the first report of using real-time, clinic-based VRtele.

Methods

The Rural Veterans Supported Employment Telerehabilitation Initiative (RVSETI) was conducted as a field-initiated demonstration project at 2 US Department of Veterans Affairs (VA) medical centers (VAMCs) in Florida between 2014 and 2016: James A. Haley Veterans’ Hospital & Clinics (Tampa) and Malcom Randall VAMC (Gainesville). This retrospective evaluation of its first year did not require institutional review board approval as it was determined to be a quality improvement project by the local research service.

The patient population for the project was veterans with disabilities who were referred by clinical consults to the CWT service, a recovery-oriented vocational program. During the project years, veterans were offered the option of receiving VR services, such as supported employment, community-based employment services, or vocational assistance, through VRtele rather than traditional face-to-face meetings. The specific interventions delivered included patient orientation, interview assessment, treatment plan development, referral activities, vocational counseling, assessment of workplace for accommodation needs, vocational case management, and other employment supports. VR staff participating in the project included 2 VR supervisors, 1 supported employment mentor trainer, and 5 VRSs.

Each clinic was set up for VRtele, and codes were added to the electronic health record (EHR) to ensure proper documentation. Participating VRSs completed teleconferencing training, including a skills assessment using the equipment for real-time, high-quality video streaming over an encrypted network to provide services in a patient’s home or other remote locations. VRS staff provided veterans with instructions on using a VA-provided tablet or their own device and assisted them with establishing connectivity with the network. Video equipment included speakers, camera, and headphones connected to the desktop computer or laptop of the VRS. A patient’s first VRtelesession was conducted in person at the VAMC to assure veterans were able to use the technology and to identify and resolve any problems.

Demographic data, primary diagnosis, VR usage data, and zip codes of participating veterans were extracted from the EHR. Veterans completed a 2-part satisfaction survey administered 90 days after enrollment and at discharge. Part 1 was composed of 15 items, most with a 5-point Likert scale (higher ratings indicated greater satisfaction), on various aspects of the VRtele experience, such as audio and video quality and wait times.¹⁰ Part 2 addressed VR services and the VRS and consisted of 8 Likert scale items with the option to add a comment for each and 2 open-ended items that asked the participant to list what they liked best and least about VRtele.

Semistructured, in-person 30- to 60-minute interviews were conducted with VRSs at the initiation of VRteleand audio-recorded with permission. An interview guide consisting of 14 questions was used to obtain data on caseload, VRtele set up, use of teleconferencing equipment, and veteran access to VR services.

After ≥ 2 months of VRtele use, researchers observed a session with each participant to obtain qualitative data from all participants on their VRtele experience. Using an observation form with open notes, data were collected on the use of the videoconferencing technology, the quality of the VRtele session, and reactions of veterans and their VRS. Following the observation session, both the VRS and the participating veteran were interviewed separately using a 9-question interview form to obtain data on the use of the technology in general and for VR. Interviews were audio-recorded with the permission of the VRS and veteran and transcribed for analysis.

Analyses

Descriptive statistics were used for EHR data and satisfaction surveys. For qualitative analysis, each transcript was read in full by 2 researchers to get an overview of the data, and a rapid analysis approach was used to identify central themes focused on how technology was used and the experiences of the participants.^11,12 Relevant text for each topic was tabulated, and a summary table was created that highlighted overlapping ideas discussed by the interviewees as well as differences.

Results

Of the 22 veterans who participated in the project, 11 completed satisfaction surveys and 4 participated in qualitative interviews. The rural and nonrural groups did not differ demographically or by diagnosis, which was predominantly mental health related. Only 1 veteran in each group owned a tablet; the majority of both groups required VA-issued devices: 80% (n = 8) rural and 91.7% (n = 11) nonrural. The number of VRtele sessions for the groups also was similar, 53 for rural and 60 for nonrural, as was the mean (SD) number of sessions per veteran: 5.3 (SD, 3.2) rural and 5.0 (SD, 2.5) urban. Overall, 63 miles per session were saved, mostly for rural veterans, and the number of mean (SD) miles saved per veteran was greater for rural than nonrural veterans: 379.2 (243.0) and 256.1 (275.9), respectively. One veteran who moved to a different state during the program continued VRtele at the new location. In a qualitative sampling of 5 VRtele sessions, all the VRSs used office desktop computers.

Level of satisfaction with aspects of VRtele related to the technology rated was consistently > 4 on the Likert scale. The lowest mean (SD) ratings were 4.2 (1.0) for audio quality and 4.4 (0.5) for video quality, and the highest rating was given for equipment operation explanation and privacy was respected, 4.9 (0.3) for both. All questions related to satisfaction with services were also rated high: The mean (SD) lowest ratings were 4.3 (1.0) given to both vocational needs 4.3 (1.0) and tasks effectively helped achieve goals 4.3 (0.7). The highest mean (SD) ratings were 4.6 (0.5) given to VR program service explained and 4.7 (0.5) for appointment timeliness.

Qualitative Results

At first, some VRSs thought the teleconferencing system might be difficult or awkward to use, but they found it easier to set up than expected and seamless to use. VRS staff reported being surprised at how well it worked despite some issues that occurred with loading the software. Once loaded, however, the connection worked well, one VRS noting that following step-by-step instructions solved the problem. Some VRSs indicated they did not invite all the veterans on their caseload to participate in VRtele due to concerns with the patient’s familiarity with technology, but one VRS stated, “I haven’t had anybody that failed to do a [session] that I couldn’t get them up and running within a few minutes.”

When working in the community, VRSs reported using laptops for VRtele but found that these devices were unreliable due to lack of internet access and were slow to start; several VRSs thought tablets would have been more helpful. Some veterans reported technical glitches, lack of comfort with technology, or a problem with sound due to a tablet’s protective case blocking the speakers. To solve the sound issue, a veteran used headphones. This veteran also explained that the log-on process required a new password every time, so he would keep a pen and paper ready to write it down. Because signing in and setting up takes a little time, this veteran and his VRS agreed to start connecting 5 minutes before their meeting time to allow for that set- up time.

Initially, some VRSs expressed concern that transitioning to VRtele would affect the quality of interactions with the veterans. However, VRSs also identified strengths of VRtele, including flexibility, saved time, and increased interaction. One VRS discussed a veteran’s adaptation by saying, “I think he feels even more involved in his plan [and] enjoys the increased interaction.” Veterans reported enjoying using tablets and identified the main strength of VRtele as being able to talk face-to-face with the VRS. Echoing the VRSs, veterans reported teleconferencing saved time by avoiding travel and enabled spontaneous meetings. One of the veterans summed up the benefits of using VRtele: “I’d rather just connect. It’s going to take us 40 to 50 minutes [to meet in person] when we can just connect right here and it takes 15 to 20. We don’t have to go through the driving.… So this right here, doing it ahead of time and having the appointment, it’s a lot easier.”

In their interviews, VRSs talked about enjoying VRtele. A VRS explained: “It makes it a lot easier. It makes me feel less guilty. This way [veterans] don’t have to use their gas money, use their time. I know [the veteran] had something else he needed to do today.” Thus, both veterans and VRSs were satisfied with their VRtele experiences.

Discussion

This first report on the perspective of providers and veterans using VRtele suggests that it is a viable option for service delivery and that is highly satisfactory for serving veterans with disabilities, many of whom live in rural areas or have travel barriers. These findings are consistent with data on telerehabilitation for veterans with cognitive, physical, and mental disabilities.^13-22 Further, the data support the notion of using VRtele to facilitate long-term VR follow-up for persons with disabilities, as illustrated by successful continuation of vocational services after a veteran moved out of state.²³

Similar to other reports, our experience highlighted 2 factors that affect successful VRtele: (1) Troubleshooting technology barriers for both VR providers and clients; and (2) supportive leadership to facilitate implementation.^24-26These areas have been improved with recent telehealth VHA initiatives and upgrades. After the conclusion of this project evaluation, the program was expanded, and local facilities may now receive mentored support to implement similar programs.²⁷ This ongoing telerehabilitation program uses the recently upgraded VHA telehealth platform that enables encrypted sessions to be provided to any mobile or online device, and veterans simply click on a link to connect rather than waiting for a session-specific password.²⁸ By using virtual medical rooms accessed by cameras on tablets, smartphones, or computers, veterans and VR providers now have an easier time scheduling and attending online appointments.²⁹ Improved access to VRtele is important as VHA began providing the majority of appointments via video telemedicine in Spring of 2020 due to the COVID-19 pandemic. The accelerated use of telehealth due to the COVID crisis makes these findings highly relevant to the current practice environment.

Changes to technology and increased usage of VA Video Connect may indicate that the barriers identified from the earlier process described here have been diminished or eliminated. More evaluation is needed to assess whether system upgrades have increased ease of use and access for veterans with disabilities.

Conclusions

Encouragingly, this clinical demonstration project showed that both providers and clients recognize the benefits of VRtele. Patient satisfaction and decreased travel costs were clear advantages to using VRtele for this small group of veterans who had barriers to care due to travel or disability barriers. As this program evaluation was limited by a small sample, absence of a comparison group, and lack of outcome data (eg, employment rates, hours, wages, retention), future research is needed on implementation and outcomes of VRtele.

Acknowledgments
The authors thank Lynn Dirk, MAMC, for substantial editorial assistance. This material was based on work supported by Rural Veterans Supported Employment TeleRehabilitation Initiative (RVSETI), funded by the VA Office of Rural Health (Project # N08-FY14Q3-S2-P01222) and by support of the VA Health Services Research and Development Service. This work was presented in part at the 114th Annual Meeting of the American Anthropological Association at Denver, Colorado, November 21, 2015; a field-based Health Services Research and Development Service meeting, US Department of Veterans Affairs at Washington, DC, September 12, 2016; and the 2016 Annual Conference of the American Congress for Rehabilitation Medicine at Chicago, Illinois, October-November 2016.

Vocational rehabilitation (VR) interventions are offered through Compensated Work Therapy (CWT) as part of clinical care in the Veterans Health Administration (VHA) to improve employment and quality of life outcomes for veterans with life-altering disabilities.^1–5 CWT vocational services range from assessment, vocational counseling, and treatment plan development to job placement, coaching, and follow-along support.¹ However, many veterans receive care in community-based clinics that are not staffed with a VR specialist (VRS) to provide these services.^6–8 Telehealth may increase patient access to VR, especially for rural veterans and those with travel barriers, but it is not known whether veterans and VRS would find this to be a satisfactory service delivery method.^8,9 This paper examines veteran and VRS provider perspectives on VR provided by telehealth (VRtele) as part of a VHA clinical demonstration project. To our knowledge, this is the first report of using real-time, clinic-based VRtele.

Methods

The Rural Veterans Supported Employment Telerehabilitation Initiative (RVSETI) was conducted as a field-initiated demonstration project at 2 US Department of Veterans Affairs (VA) medical centers (VAMCs) in Florida between 2014 and 2016: James A. Haley Veterans’ Hospital & Clinics (Tampa) and Malcom Randall VAMC (Gainesville). This retrospective evaluation of its first year did not require institutional review board approval as it was determined to be a quality improvement project by the local research service.

The patient population for the project was veterans with disabilities who were referred by clinical consults to the CWT service, a recovery-oriented vocational program. During the project years, veterans were offered the option of receiving VR services, such as supported employment, community-based employment services, or vocational assistance, through VRtele rather than traditional face-to-face meetings. The specific interventions delivered included patient orientation, interview assessment, treatment plan development, referral activities, vocational counseling, assessment of workplace for accommodation needs, vocational case management, and other employment supports. VR staff participating in the project included 2 VR supervisors, 1 supported employment mentor trainer, and 5 VRSs.

Each clinic was set up for VRtele, and codes were added to the electronic health record (EHR) to ensure proper documentation. Participating VRSs completed teleconferencing training, including a skills assessment using the equipment for real-time, high-quality video streaming over an encrypted network to provide services in a patient’s home or other remote locations. VRS staff provided veterans with instructions on using a VA-provided tablet or their own device and assisted them with establishing connectivity with the network. Video equipment included speakers, camera, and headphones connected to the desktop computer or laptop of the VRS. A patient’s first VRtelesession was conducted in person at the VAMC to assure veterans were able to use the technology and to identify and resolve any problems.

Demographic data, primary diagnosis, VR usage data, and zip codes of participating veterans were extracted from the EHR. Veterans completed a 2-part satisfaction survey administered 90 days after enrollment and at discharge. Part 1 was composed of 15 items, most with a 5-point Likert scale (higher ratings indicated greater satisfaction), on various aspects of the VRtele experience, such as audio and video quality and wait times.¹⁰ Part 2 addressed VR services and the VRS and consisted of 8 Likert scale items with the option to add a comment for each and 2 open-ended items that asked the participant to list what they liked best and least about VRtele.

Semistructured, in-person 30- to 60-minute interviews were conducted with VRSs at the initiation of VRteleand audio-recorded with permission. An interview guide consisting of 14 questions was used to obtain data on caseload, VRtele set up, use of teleconferencing equipment, and veteran access to VR services.

After ≥ 2 months of VRtele use, researchers observed a session with each participant to obtain qualitative data from all participants on their VRtele experience. Using an observation form with open notes, data were collected on the use of the videoconferencing technology, the quality of the VRtele session, and reactions of veterans and their VRS. Following the observation session, both the VRS and the participating veteran were interviewed separately using a 9-question interview form to obtain data on the use of the technology in general and for VR. Interviews were audio-recorded with the permission of the VRS and veteran and transcribed for analysis.

Analyses

Descriptive statistics were used for EHR data and satisfaction surveys. For qualitative analysis, each transcript was read in full by 2 researchers to get an overview of the data, and a rapid analysis approach was used to identify central themes focused on how technology was used and the experiences of the participants.^11,12 Relevant text for each topic was tabulated, and a summary table was created that highlighted overlapping ideas discussed by the interviewees as well as differences.

Results

Of the 22 veterans who participated in the project, 11 completed satisfaction surveys and 4 participated in qualitative interviews. The rural and nonrural groups did not differ demographically or by diagnosis, which was predominantly mental health related. Only 1 veteran in each group owned a tablet; the majority of both groups required VA-issued devices: 80% (n = 8) rural and 91.7% (n = 11) nonrural. The number of VRtele sessions for the groups also was similar, 53 for rural and 60 for nonrural, as was the mean (SD) number of sessions per veteran: 5.3 (SD, 3.2) rural and 5.0 (SD, 2.5) urban. Overall, 63 miles per session were saved, mostly for rural veterans, and the number of mean (SD) miles saved per veteran was greater for rural than nonrural veterans: 379.2 (243.0) and 256.1 (275.9), respectively. One veteran who moved to a different state during the program continued VRtele at the new location. In a qualitative sampling of 5 VRtele sessions, all the VRSs used office desktop computers.

Level of satisfaction with aspects of VRtele related to the technology rated was consistently > 4 on the Likert scale. The lowest mean (SD) ratings were 4.2 (1.0) for audio quality and 4.4 (0.5) for video quality, and the highest rating was given for equipment operation explanation and privacy was respected, 4.9 (0.3) for both. All questions related to satisfaction with services were also rated high: The mean (SD) lowest ratings were 4.3 (1.0) given to both vocational needs 4.3 (1.0) and tasks effectively helped achieve goals 4.3 (0.7). The highest mean (SD) ratings were 4.6 (0.5) given to VR program service explained and 4.7 (0.5) for appointment timeliness.

Qualitative Results

At first, some VRSs thought the teleconferencing system might be difficult or awkward to use, but they found it easier to set up than expected and seamless to use. VRS staff reported being surprised at how well it worked despite some issues that occurred with loading the software. Once loaded, however, the connection worked well, one VRS noting that following step-by-step instructions solved the problem. Some VRSs indicated they did not invite all the veterans on their caseload to participate in VRtele due to concerns with the patient’s familiarity with technology, but one VRS stated, “I haven’t had anybody that failed to do a [session] that I couldn’t get them up and running within a few minutes.”

When working in the community, VRSs reported using laptops for VRtele but found that these devices were unreliable due to lack of internet access and were slow to start; several VRSs thought tablets would have been more helpful. Some veterans reported technical glitches, lack of comfort with technology, or a problem with sound due to a tablet’s protective case blocking the speakers. To solve the sound issue, a veteran used headphones. This veteran also explained that the log-on process required a new password every time, so he would keep a pen and paper ready to write it down. Because signing in and setting up takes a little time, this veteran and his VRS agreed to start connecting 5 minutes before their meeting time to allow for that set- up time.

Initially, some VRSs expressed concern that transitioning to VRtele would affect the quality of interactions with the veterans. However, VRSs also identified strengths of VRtele, including flexibility, saved time, and increased interaction. One VRS discussed a veteran’s adaptation by saying, “I think he feels even more involved in his plan [and] enjoys the increased interaction.” Veterans reported enjoying using tablets and identified the main strength of VRtele as being able to talk face-to-face with the VRS. Echoing the VRSs, veterans reported teleconferencing saved time by avoiding travel and enabled spontaneous meetings. One of the veterans summed up the benefits of using VRtele: “I’d rather just connect. It’s going to take us 40 to 50 minutes [to meet in person] when we can just connect right here and it takes 15 to 20. We don’t have to go through the driving.… So this right here, doing it ahead of time and having the appointment, it’s a lot easier.”

In their interviews, VRSs talked about enjoying VRtele. A VRS explained: “It makes it a lot easier. It makes me feel less guilty. This way [veterans] don’t have to use their gas money, use their time. I know [the veteran] had something else he needed to do today.” Thus, both veterans and VRSs were satisfied with their VRtele experiences.

Discussion

This first report on the perspective of providers and veterans using VRtele suggests that it is a viable option for service delivery and that is highly satisfactory for serving veterans with disabilities, many of whom live in rural areas or have travel barriers. These findings are consistent with data on telerehabilitation for veterans with cognitive, physical, and mental disabilities.^13-22 Further, the data support the notion of using VRtele to facilitate long-term VR follow-up for persons with disabilities, as illustrated by successful continuation of vocational services after a veteran moved out of state.²³

Similar to other reports, our experience highlighted 2 factors that affect successful VRtele: (1) Troubleshooting technology barriers for both VR providers and clients; and (2) supportive leadership to facilitate implementation.^24-26These areas have been improved with recent telehealth VHA initiatives and upgrades. After the conclusion of this project evaluation, the program was expanded, and local facilities may now receive mentored support to implement similar programs.²⁷ This ongoing telerehabilitation program uses the recently upgraded VHA telehealth platform that enables encrypted sessions to be provided to any mobile or online device, and veterans simply click on a link to connect rather than waiting for a session-specific password.²⁸ By using virtual medical rooms accessed by cameras on tablets, smartphones, or computers, veterans and VR providers now have an easier time scheduling and attending online appointments.²⁹ Improved access to VRtele is important as VHA began providing the majority of appointments via video telemedicine in Spring of 2020 due to the COVID-19 pandemic. The accelerated use of telehealth due to the COVID crisis makes these findings highly relevant to the current practice environment.

Changes to technology and increased usage of VA Video Connect may indicate that the barriers identified from the earlier process described here have been diminished or eliminated. More evaluation is needed to assess whether system upgrades have increased ease of use and access for veterans with disabilities.

Conclusions

Encouragingly, this clinical demonstration project showed that both providers and clients recognize the benefits of VRtele. Patient satisfaction and decreased travel costs were clear advantages to using VRtele for this small group of veterans who had barriers to care due to travel or disability barriers. As this program evaluation was limited by a small sample, absence of a comparison group, and lack of outcome data (eg, employment rates, hours, wages, retention), future research is needed on implementation and outcomes of VRtele.

Acknowledgments
The authors thank Lynn Dirk, MAMC, for substantial editorial assistance. This material was based on work supported by Rural Veterans Supported Employment TeleRehabilitation Initiative (RVSETI), funded by the VA Office of Rural Health (Project # N08-FY14Q3-S2-P01222) and by support of the VA Health Services Research and Development Service. This work was presented in part at the 114th Annual Meeting of the American Anthropological Association at Denver, Colorado, November 21, 2015; a field-based Health Services Research and Development Service meeting, US Department of Veterans Affairs at Washington, DC, September 12, 2016; and the 2016 Annual Conference of the American Congress for Rehabilitation Medicine at Chicago, Illinois, October-November 2016.

A large study of adolescent soccer players in Michigan revealed key differences in concussion injury metrics among males and females, underscoring a need to develop sex-specific approaches to managing injury in the sport.

Sport-related concussion (SRC) is a specific concern in young female athletes, study authors Abigail C. Bretzin, PhD, and colleagues noted in their paper, which appears in JAMA Network Open. Previous surveillance studies on SRC at the high school and college level have reported higher rates of injury risk and longer recovery outcomes in female soccer athletes. Taking a deeper dive into these trends, the investigators explored whether sex-associated differences existed in SRC, addressing the mechanics, management, and recovery from SRC.

“This is an area that is remarkably underresearched,” William Stewart, MBChB, PhD, the study’s corresponding author, said in an interview. Prior studies of males and females have shown that female axons are thinner, with fewer microtubules or internal scaffolding than male axons. This potentially increases risk of shear injury in females. Limited research has also cited differences in concussion risk across the menstrual cycle in female athletes.
 

Reporting system targets four injury areas

The investigators conducted a high school injury surveillance project in 43,741 male and 39,637 female soccer athletes participating in the Michigan High School Athletic Association (MHSAA) Head Injury Reporting System. The study included students from 9th to 12th grade, spanning from the beginning of academic year 2016-2017 to the end of academic year 2018-2019. Since 2015, the state has mandated high schools to submit data to MHSAA.

MHSAA captures data on four categories: person-to-person contact, person-to-object contact, person-to-playing surface contact, or uncertain about cause of the event. Study outcomes included details regarding injury mechanism, immediate management, and return-to-play time for each documented SRC.

Investigators reported notable differences among male and female players. Documented SRC risk was 1.88 times higher among adolescent girls than boys across all academic years (RR, 1.88; 95% CI, 1.69-2.09; P < .001). They also cited inconsistencies in distribution of injury mechanisms among the sexes. Females were most likely to suffer injury from equipment contact such as heading a ball (41.9%), whereas male players commonly sustained SRC from contact with another player (48.4%). The authors suggested that “female soccer athletes have lower neck strength and girth, compared with male athletes, with these variables inversely associated with linear and rotational head acceleration after soccer ball heading.”

Boys had greater odds of immediate removal from play and but also returned to the sport 2 days sooner than girls. “The possibility exists, therefore, that this longer recovery time might, in part, be reflective of our observed differences in immediate care, in particular removal from play,” the authors wrote. Immediate removal from play was also more common in cases where an athletic trainer played a part in evaluating players for SRC.
 

Eliminating the one-size-fits-all approach

Current concussion management is based on a “one-size-fits-all” model, said Dr. Stewart. Male and female athletes are treated following a common concussion management protocol, covering concussion detection through to rehabilitation. “This model of management is based on research that is almost exclusively in male athletes.”

What the study showed is this one-size-fits-all approach may be flawed, letting down female athletes. “We should be pursuing more research in sex differences in concussion and, importantly, putting these into practice in sex-specific concussion management protocols,” he suggested.

Future studies should also look at the effects of athletic trainer employment on SRC metrics. “Although this was a large, statewide epidemiological study of reported SRC in adolescent soccer athletes, inclusive of high schools with and without access to athletic trainers, the Head Injury Reporting System did not include information on the whether there were athletic trainer services available at each school, including specific athletic training services for soccer,” wrote the investigators, in citing the study’s limitations.
 

Girls report symptoms more often

“The researchers are to be commended for taking a prospective approach to address this common observation in high school sports,” said Keith J. Loud, MD, MSc, FAAP, a sports pediatrician at Children’s Hospital at Dartmouth-Hitchcock in Manchester, N.H. The results are “entirely believable,” said Dr. Loud, who was not affiliated with the study. “We have long postulated differences in neurophysiology, neck strength, style of play, and tendency to report as explanations for the observation that girls in high school soccer are diagnosed with more concussions than boys.”

The findings suggest that boys play more aggressively, but sustain fewer concussions, he added. Girls in the meantime, are more likely to speak up about their injury.

“Concussion diagnosis still relies to a large degree on the athlete to report symptoms, which is one of our hypotheses as to why girls seem to sustain more concussions – they report symptoms more often. That could also be why they have a prolonged recovery,” offered Dr. Loud. A main limitation of this study is it can’t overcome this reporting bias.

Dr. Loud was also concerned that girls were less likely to be removed from game play, even though they apparently sustained more concussions. “Perhaps that is because their injuries are less obvious on the field, and they are diagnosed when reported after the games.”

Dr. Stewart reported receiving grants from The Football Association and National Health Service Research Scotland during the study. He also served as a nonremunerated member of the Fédération Internationale de Football Association Independent Football Concussion Advisory Group and the Football Association Expert Panel on Concussion and Head Injury in Football. None of the other authors had disclosures.

A large study of adolescent soccer players in Michigan revealed key differences in concussion injury metrics among males and females, underscoring a need to develop sex-specific approaches to managing injury in the sport.

Sport-related concussion (SRC) is a specific concern in young female athletes, study authors Abigail C. Bretzin, PhD, and colleagues noted in their paper, which appears in JAMA Network Open. Previous surveillance studies on SRC at the high school and college level have reported higher rates of injury risk and longer recovery outcomes in female soccer athletes. Taking a deeper dive into these trends, the investigators explored whether sex-associated differences existed in SRC, addressing the mechanics, management, and recovery from SRC.

“This is an area that is remarkably underresearched,” William Stewart, MBChB, PhD, the study’s corresponding author, said in an interview. Prior studies of males and females have shown that female axons are thinner, with fewer microtubules or internal scaffolding than male axons. This potentially increases risk of shear injury in females. Limited research has also cited differences in concussion risk across the menstrual cycle in female athletes.
 

Reporting system targets four injury areas

The investigators conducted a high school injury surveillance project in 43,741 male and 39,637 female soccer athletes participating in the Michigan High School Athletic Association (MHSAA) Head Injury Reporting System. The study included students from 9th to 12th grade, spanning from the beginning of academic year 2016-2017 to the end of academic year 2018-2019. Since 2015, the state has mandated high schools to submit data to MHSAA.

MHSAA captures data on four categories: person-to-person contact, person-to-object contact, person-to-playing surface contact, or uncertain about cause of the event. Study outcomes included details regarding injury mechanism, immediate management, and return-to-play time for each documented SRC.

Investigators reported notable differences among male and female players. Documented SRC risk was 1.88 times higher among adolescent girls than boys across all academic years (RR, 1.88; 95% CI, 1.69-2.09; P < .001). They also cited inconsistencies in distribution of injury mechanisms among the sexes. Females were most likely to suffer injury from equipment contact such as heading a ball (41.9%), whereas male players commonly sustained SRC from contact with another player (48.4%). The authors suggested that “female soccer athletes have lower neck strength and girth, compared with male athletes, with these variables inversely associated with linear and rotational head acceleration after soccer ball heading.”

Boys had greater odds of immediate removal from play and but also returned to the sport 2 days sooner than girls. “The possibility exists, therefore, that this longer recovery time might, in part, be reflective of our observed differences in immediate care, in particular removal from play,” the authors wrote. Immediate removal from play was also more common in cases where an athletic trainer played a part in evaluating players for SRC.
 

Eliminating the one-size-fits-all approach

Current concussion management is based on a “one-size-fits-all” model, said Dr. Stewart. Male and female athletes are treated following a common concussion management protocol, covering concussion detection through to rehabilitation. “This model of management is based on research that is almost exclusively in male athletes.”

What the study showed is this one-size-fits-all approach may be flawed, letting down female athletes. “We should be pursuing more research in sex differences in concussion and, importantly, putting these into practice in sex-specific concussion management protocols,” he suggested.

Future studies should also look at the effects of athletic trainer employment on SRC metrics. “Although this was a large, statewide epidemiological study of reported SRC in adolescent soccer athletes, inclusive of high schools with and without access to athletic trainers, the Head Injury Reporting System did not include information on the whether there were athletic trainer services available at each school, including specific athletic training services for soccer,” wrote the investigators, in citing the study’s limitations.
 

Girls report symptoms more often

“The researchers are to be commended for taking a prospective approach to address this common observation in high school sports,” said Keith J. Loud, MD, MSc, FAAP, a sports pediatrician at Children’s Hospital at Dartmouth-Hitchcock in Manchester, N.H. The results are “entirely believable,” said Dr. Loud, who was not affiliated with the study. “We have long postulated differences in neurophysiology, neck strength, style of play, and tendency to report as explanations for the observation that girls in high school soccer are diagnosed with more concussions than boys.”

The findings suggest that boys play more aggressively, but sustain fewer concussions, he added. Girls in the meantime, are more likely to speak up about their injury.

“Concussion diagnosis still relies to a large degree on the athlete to report symptoms, which is one of our hypotheses as to why girls seem to sustain more concussions – they report symptoms more often. That could also be why they have a prolonged recovery,” offered Dr. Loud. A main limitation of this study is it can’t overcome this reporting bias.

Dr. Loud was also concerned that girls were less likely to be removed from game play, even though they apparently sustained more concussions. “Perhaps that is because their injuries are less obvious on the field, and they are diagnosed when reported after the games.”

Dr. Stewart reported receiving grants from The Football Association and National Health Service Research Scotland during the study. He also served as a nonremunerated member of the Fédération Internationale de Football Association Independent Football Concussion Advisory Group and the Football Association Expert Panel on Concussion and Head Injury in Football. None of the other authors had disclosures.

A large study of adolescent soccer players in Michigan revealed key differences in concussion injury metrics among males and females, underscoring a need to develop sex-specific approaches to managing injury in the sport.

Sport-related concussion (SRC) is a specific concern in young female athletes, study authors Abigail C. Bretzin, PhD, and colleagues noted in their paper, which appears in JAMA Network Open. Previous surveillance studies on SRC at the high school and college level have reported higher rates of injury risk and longer recovery outcomes in female soccer athletes. Taking a deeper dive into these trends, the investigators explored whether sex-associated differences existed in SRC, addressing the mechanics, management, and recovery from SRC.

“This is an area that is remarkably underresearched,” William Stewart, MBChB, PhD, the study’s corresponding author, said in an interview. Prior studies of males and females have shown that female axons are thinner, with fewer microtubules or internal scaffolding than male axons. This potentially increases risk of shear injury in females. Limited research has also cited differences in concussion risk across the menstrual cycle in female athletes.
 

Reporting system targets four injury areas

The investigators conducted a high school injury surveillance project in 43,741 male and 39,637 female soccer athletes participating in the Michigan High School Athletic Association (MHSAA) Head Injury Reporting System. The study included students from 9th to 12th grade, spanning from the beginning of academic year 2016-2017 to the end of academic year 2018-2019. Since 2015, the state has mandated high schools to submit data to MHSAA.

MHSAA captures data on four categories: person-to-person contact, person-to-object contact, person-to-playing surface contact, or uncertain about cause of the event. Study outcomes included details regarding injury mechanism, immediate management, and return-to-play time for each documented SRC.

Investigators reported notable differences among male and female players. Documented SRC risk was 1.88 times higher among adolescent girls than boys across all academic years (RR, 1.88; 95% CI, 1.69-2.09; P < .001). They also cited inconsistencies in distribution of injury mechanisms among the sexes. Females were most likely to suffer injury from equipment contact such as heading a ball (41.9%), whereas male players commonly sustained SRC from contact with another player (48.4%). The authors suggested that “female soccer athletes have lower neck strength and girth, compared with male athletes, with these variables inversely associated with linear and rotational head acceleration after soccer ball heading.”

Boys had greater odds of immediate removal from play and but also returned to the sport 2 days sooner than girls. “The possibility exists, therefore, that this longer recovery time might, in part, be reflective of our observed differences in immediate care, in particular removal from play,” the authors wrote. Immediate removal from play was also more common in cases where an athletic trainer played a part in evaluating players for SRC.
 

Eliminating the one-size-fits-all approach

Current concussion management is based on a “one-size-fits-all” model, said Dr. Stewart. Male and female athletes are treated following a common concussion management protocol, covering concussion detection through to rehabilitation. “This model of management is based on research that is almost exclusively in male athletes.”

What the study showed is this one-size-fits-all approach may be flawed, letting down female athletes. “We should be pursuing more research in sex differences in concussion and, importantly, putting these into practice in sex-specific concussion management protocols,” he suggested.

Future studies should also look at the effects of athletic trainer employment on SRC metrics. “Although this was a large, statewide epidemiological study of reported SRC in adolescent soccer athletes, inclusive of high schools with and without access to athletic trainers, the Head Injury Reporting System did not include information on the whether there were athletic trainer services available at each school, including specific athletic training services for soccer,” wrote the investigators, in citing the study’s limitations.
 

Girls report symptoms more often

“The researchers are to be commended for taking a prospective approach to address this common observation in high school sports,” said Keith J. Loud, MD, MSc, FAAP, a sports pediatrician at Children’s Hospital at Dartmouth-Hitchcock in Manchester, N.H. The results are “entirely believable,” said Dr. Loud, who was not affiliated with the study. “We have long postulated differences in neurophysiology, neck strength, style of play, and tendency to report as explanations for the observation that girls in high school soccer are diagnosed with more concussions than boys.”

The findings suggest that boys play more aggressively, but sustain fewer concussions, he added. Girls in the meantime, are more likely to speak up about their injury.

“Concussion diagnosis still relies to a large degree on the athlete to report symptoms, which is one of our hypotheses as to why girls seem to sustain more concussions – they report symptoms more often. That could also be why they have a prolonged recovery,” offered Dr. Loud. A main limitation of this study is it can’t overcome this reporting bias.

Dr. Loud was also concerned that girls were less likely to be removed from game play, even though they apparently sustained more concussions. “Perhaps that is because their injuries are less obvious on the field, and they are diagnosed when reported after the games.”

Dr. Stewart reported receiving grants from The Football Association and National Health Service Research Scotland during the study. He also served as a nonremunerated member of the Fédération Internationale de Football Association Independent Football Concussion Advisory Group and the Football Association Expert Panel on Concussion and Head Injury in Football. None of the other authors had disclosures.

In 2019, the U.S. suicide rate dropped for the first time in 14 years, driven largely by a significant decline in firearm-related deaths, according to a new analysis of National Vital Statistics System data.

Since firearms are the “most common and most lethal” mechanism of suicide, the drop in deaths is “particularly encouraging,” Deborah M. Stone, ScD, MSW, MPH, and associates wrote in the Morbidity and Mortality Weekly Report.

The national suicide rate decreased from 14.2 per 100,000 population in 2018 to 13.9 per 100,000 in 2019, a statistically significant drop of 2.1% that reversed a 20-year trend that saw the rate increase by 33% since 1999, they said.

The rate for firearm use, which is involved in half of all suicides, declined from 7.0 per 100,000 to 6.8, for a significant change of 2.9%, said Dr. Stone and associates at the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.

The only other method with a drop in suicide rate from 2018 to 2019 was suffocation – the second most common mechanism of injury – but the relative change of 2.3% was not significant, they noted.

Significant declines also occurred in several subgroups: Whites; those aged 15-24, 55-64, and 65-74 years; and those living in counties classified as large fringe metropolitan or micropolitan (urban cluster of ≥ 10,000 but less than 50,000 population), they said, based on data from the National Vital Statistics System.

“These declines, although encouraging, were not uniform, and several states experienced significant rate increases,” the investigators wrote.

The states with significant increases were Hawaii (30.3%) and Nebraska (20.1%), while declines in the suicide rate were significant in five states – Idaho, Indiana, Massachusetts, North Carolina, and Virginia, Dr. Stone and associates reported. Altogether, the rate fell in 31 states, increased in 18, and did not change in 2.

The significance of those changes varied between males and females. Declines were significant for females in Indiana, Massachusetts, and Washington, and for males in Florida, Kentucky, Massachusetts, North Carolina, and West Virginia. Minnesota was the only state with a significant increase among females, with Hawaii and Wyoming posting increases for males, they said.

As the response to the COVID-19 pandemic continues, the investigators pointed out, “prevention is more important than ever. Past research indicates that suicide rates remain stable or decline during infrastructure disruption (e.g., natural disasters), only to rise afterwards as the longer-term sequelae unfold in persons, families, and communities.”

[email protected]

In 2019, the U.S. suicide rate dropped for the first time in 14 years, driven largely by a significant decline in firearm-related deaths, according to a new analysis of National Vital Statistics System data.

Since firearms are the “most common and most lethal” mechanism of suicide, the drop in deaths is “particularly encouraging,” Deborah M. Stone, ScD, MSW, MPH, and associates wrote in the Morbidity and Mortality Weekly Report.

The national suicide rate decreased from 14.2 per 100,000 population in 2018 to 13.9 per 100,000 in 2019, a statistically significant drop of 2.1% that reversed a 20-year trend that saw the rate increase by 33% since 1999, they said.

The rate for firearm use, which is involved in half of all suicides, declined from 7.0 per 100,000 to 6.8, for a significant change of 2.9%, said Dr. Stone and associates at the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.

The only other method with a drop in suicide rate from 2018 to 2019 was suffocation – the second most common mechanism of injury – but the relative change of 2.3% was not significant, they noted.

Significant declines also occurred in several subgroups: Whites; those aged 15-24, 55-64, and 65-74 years; and those living in counties classified as large fringe metropolitan or micropolitan (urban cluster of ≥ 10,000 but less than 50,000 population), they said, based on data from the National Vital Statistics System.

“These declines, although encouraging, were not uniform, and several states experienced significant rate increases,” the investigators wrote.

The states with significant increases were Hawaii (30.3%) and Nebraska (20.1%), while declines in the suicide rate were significant in five states – Idaho, Indiana, Massachusetts, North Carolina, and Virginia, Dr. Stone and associates reported. Altogether, the rate fell in 31 states, increased in 18, and did not change in 2.

The significance of those changes varied between males and females. Declines were significant for females in Indiana, Massachusetts, and Washington, and for males in Florida, Kentucky, Massachusetts, North Carolina, and West Virginia. Minnesota was the only state with a significant increase among females, with Hawaii and Wyoming posting increases for males, they said.

As the response to the COVID-19 pandemic continues, the investigators pointed out, “prevention is more important than ever. Past research indicates that suicide rates remain stable or decline during infrastructure disruption (e.g., natural disasters), only to rise afterwards as the longer-term sequelae unfold in persons, families, and communities.”

[email protected]

In 2019, the U.S. suicide rate dropped for the first time in 14 years, driven largely by a significant decline in firearm-related deaths, according to a new analysis of National Vital Statistics System data.

Since firearms are the “most common and most lethal” mechanism of suicide, the drop in deaths is “particularly encouraging,” Deborah M. Stone, ScD, MSW, MPH, and associates wrote in the Morbidity and Mortality Weekly Report.

The national suicide rate decreased from 14.2 per 100,000 population in 2018 to 13.9 per 100,000 in 2019, a statistically significant drop of 2.1% that reversed a 20-year trend that saw the rate increase by 33% since 1999, they said.

The rate for firearm use, which is involved in half of all suicides, declined from 7.0 per 100,000 to 6.8, for a significant change of 2.9%, said Dr. Stone and associates at the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.

The only other method with a drop in suicide rate from 2018 to 2019 was suffocation – the second most common mechanism of injury – but the relative change of 2.3% was not significant, they noted.

Significant declines also occurred in several subgroups: Whites; those aged 15-24, 55-64, and 65-74 years; and those living in counties classified as large fringe metropolitan or micropolitan (urban cluster of ≥ 10,000 but less than 50,000 population), they said, based on data from the National Vital Statistics System.

“These declines, although encouraging, were not uniform, and several states experienced significant rate increases,” the investigators wrote.

The states with significant increases were Hawaii (30.3%) and Nebraska (20.1%), while declines in the suicide rate were significant in five states – Idaho, Indiana, Massachusetts, North Carolina, and Virginia, Dr. Stone and associates reported. Altogether, the rate fell in 31 states, increased in 18, and did not change in 2.

The significance of those changes varied between males and females. Declines were significant for females in Indiana, Massachusetts, and Washington, and for males in Florida, Kentucky, Massachusetts, North Carolina, and West Virginia. Minnesota was the only state with a significant increase among females, with Hawaii and Wyoming posting increases for males, they said.

As the response to the COVID-19 pandemic continues, the investigators pointed out, “prevention is more important than ever. Past research indicates that suicide rates remain stable or decline during infrastructure disruption (e.g., natural disasters), only to rise afterwards as the longer-term sequelae unfold in persons, families, and communities.”

[email protected]

Emergency department visits related to child abuse and neglect dropped by half early in the pandemic, compared with 2019, but the visits in 2020 were significantly more likely to result in hospitalization, based on analysis of a national ED database.

The number of ED visits involving child abuse and neglect was down by 53% during the 4-week period from March 29 to April 25, 2020, compared with the 4 weeks from March 31 to April 27, 2019. The proportion of those ED visits that ended in hospitalizations, however, increased from 2.1% in 2019 to 3.2% in 2020, Elizabeth Swedo, MD, and associates at the Centers for Disease Control and Prevention said in the Morbidity and Mortality Weekly Report.

“ED visits related to suspected or confirmed child abuse and neglect decreased beginning the week of March 15, 2020, coinciding with the declaration of a national emergency related to COVID-19 and implementation of community mitigation measures,” they wrote.

An earlier study involving the same database (the National Syndromic Surveillance Program) showed that, over the two same 4-week periods, the volume of all ED visits in 2020 was down 72% for children aged 10 years and younger and 71% for those aged 11-14 years.

In the current study, however, all age subgroups had significant increases in hospital admissions. The proportion of ED visits related to child abuse and neglect that resulted in hospitalization rose from 3.5% in 2019 to 5.3% in 2020 among ages 0-4 years, 0.7% to 1.3% for ages 5-11 years, and 1.6% to 2.2% for adolescents aged 12-17, Dr. Swedo and associates reported.

The absence of a corresponding drop in hospitalizations may be tied to risk factors related to the pandemic, “such as loss of income, increased stress related to parental child care and schooling responsibilities, and increased substance use and mental health conditions among adults,” the investigators added.

The National Syndromic Surveillance Program receives daily data from 3,310 EDs in 47 states, but the number of facilities meeting the investigators’ criteria averaged 2,970 a week for the 8 weeks of the study period.

[email protected]

SOURCE: Swedo E et al. MMWR. 2020 Dec. 11;69(49):1841-7.

Emergency department visits related to child abuse and neglect dropped by half early in the pandemic, compared with 2019, but the visits in 2020 were significantly more likely to result in hospitalization, based on analysis of a national ED database.

The number of ED visits involving child abuse and neglect was down by 53% during the 4-week period from March 29 to April 25, 2020, compared with the 4 weeks from March 31 to April 27, 2019. The proportion of those ED visits that ended in hospitalizations, however, increased from 2.1% in 2019 to 3.2% in 2020, Elizabeth Swedo, MD, and associates at the Centers for Disease Control and Prevention said in the Morbidity and Mortality Weekly Report.

“ED visits related to suspected or confirmed child abuse and neglect decreased beginning the week of March 15, 2020, coinciding with the declaration of a national emergency related to COVID-19 and implementation of community mitigation measures,” they wrote.

An earlier study involving the same database (the National Syndromic Surveillance Program) showed that, over the two same 4-week periods, the volume of all ED visits in 2020 was down 72% for children aged 10 years and younger and 71% for those aged 11-14 years.

In the current study, however, all age subgroups had significant increases in hospital admissions. The proportion of ED visits related to child abuse and neglect that resulted in hospitalization rose from 3.5% in 2019 to 5.3% in 2020 among ages 0-4 years, 0.7% to 1.3% for ages 5-11 years, and 1.6% to 2.2% for adolescents aged 12-17, Dr. Swedo and associates reported.

The absence of a corresponding drop in hospitalizations may be tied to risk factors related to the pandemic, “such as loss of income, increased stress related to parental child care and schooling responsibilities, and increased substance use and mental health conditions among adults,” the investigators added.

The National Syndromic Surveillance Program receives daily data from 3,310 EDs in 47 states, but the number of facilities meeting the investigators’ criteria averaged 2,970 a week for the 8 weeks of the study period.

[email protected]

SOURCE: Swedo E et al. MMWR. 2020 Dec. 11;69(49):1841-7.

Emergency department visits related to child abuse and neglect dropped by half early in the pandemic, compared with 2019, but the visits in 2020 were significantly more likely to result in hospitalization, based on analysis of a national ED database.

The number of ED visits involving child abuse and neglect was down by 53% during the 4-week period from March 29 to April 25, 2020, compared with the 4 weeks from March 31 to April 27, 2019. The proportion of those ED visits that ended in hospitalizations, however, increased from 2.1% in 2019 to 3.2% in 2020, Elizabeth Swedo, MD, and associates at the Centers for Disease Control and Prevention said in the Morbidity and Mortality Weekly Report.

“ED visits related to suspected or confirmed child abuse and neglect decreased beginning the week of March 15, 2020, coinciding with the declaration of a national emergency related to COVID-19 and implementation of community mitigation measures,” they wrote.

An earlier study involving the same database (the National Syndromic Surveillance Program) showed that, over the two same 4-week periods, the volume of all ED visits in 2020 was down 72% for children aged 10 years and younger and 71% for those aged 11-14 years.

In the current study, however, all age subgroups had significant increases in hospital admissions. The proportion of ED visits related to child abuse and neglect that resulted in hospitalization rose from 3.5% in 2019 to 5.3% in 2020 among ages 0-4 years, 0.7% to 1.3% for ages 5-11 years, and 1.6% to 2.2% for adolescents aged 12-17, Dr. Swedo and associates reported.

The absence of a corresponding drop in hospitalizations may be tied to risk factors related to the pandemic, “such as loss of income, increased stress related to parental child care and schooling responsibilities, and increased substance use and mental health conditions among adults,” the investigators added.

The National Syndromic Surveillance Program receives daily data from 3,310 EDs in 47 states, but the number of facilities meeting the investigators’ criteria averaged 2,970 a week for the 8 weeks of the study period.

[email protected]

SOURCE: Swedo E et al. MMWR. 2020 Dec. 11;69(49):1841-7.

Background: Venous thromboembolism and pulmonary embolism are common after major trauma. Anticoagulant prophylaxis usually is not considered because of the increased risk of bleeding. Despite the limited data, many trauma centers use inferior vena cava (IVC) filters as a primary means to prevent pulmonary embolism.

Study design: Randomized, controlled, and multicenter trial.

Setting: Four tertiary hospitals in Australia.

Synopsis: 240 major trauma patients were randomly assigned to receive either IVC filter or no IVC filter within 72 hours after admission. The primary endpoint was a composite of 90-day mortality or symptomatic pulmonary embolism confirmed on imaging. There was no difference in the rate of composite outcome in those with IVC filter, compared with those with no IVC filter.

Bottom line: After major trauma, early prophylactic placement of IVC filter did not reduce the 90-day mortality or incidence of symptomatic pulmonary embolism.

Citation: Ho KM et al. A multicenter trial of vena cava filters in severely injured patients. N Engl J Med. 2019 Jul 25;381:328-37.

Dr. Hoque Sharmy is a hospitalist and assistant professor of medicine in the division of hospital medicine at St. Louis University School of Medicine.

Background: Venous thromboembolism and pulmonary embolism are common after major trauma. Anticoagulant prophylaxis usually is not considered because of the increased risk of bleeding. Despite the limited data, many trauma centers use inferior vena cava (IVC) filters as a primary means to prevent pulmonary embolism.

Study design: Randomized, controlled, and multicenter trial.

Setting: Four tertiary hospitals in Australia.

Synopsis: 240 major trauma patients were randomly assigned to receive either IVC filter or no IVC filter within 72 hours after admission. The primary endpoint was a composite of 90-day mortality or symptomatic pulmonary embolism confirmed on imaging. There was no difference in the rate of composite outcome in those with IVC filter, compared with those with no IVC filter.

Bottom line: After major trauma, early prophylactic placement of IVC filter did not reduce the 90-day mortality or incidence of symptomatic pulmonary embolism.

Citation: Ho KM et al. A multicenter trial of vena cava filters in severely injured patients. N Engl J Med. 2019 Jul 25;381:328-37.

Dr. Hoque Sharmy is a hospitalist and assistant professor of medicine in the division of hospital medicine at St. Louis University School of Medicine.

Background: Venous thromboembolism and pulmonary embolism are common after major trauma. Anticoagulant prophylaxis usually is not considered because of the increased risk of bleeding. Despite the limited data, many trauma centers use inferior vena cava (IVC) filters as a primary means to prevent pulmonary embolism.

Study design: Randomized, controlled, and multicenter trial.

Setting: Four tertiary hospitals in Australia.

Synopsis: 240 major trauma patients were randomly assigned to receive either IVC filter or no IVC filter within 72 hours after admission. The primary endpoint was a composite of 90-day mortality or symptomatic pulmonary embolism confirmed on imaging. There was no difference in the rate of composite outcome in those with IVC filter, compared with those with no IVC filter.

Bottom line: After major trauma, early prophylactic placement of IVC filter did not reduce the 90-day mortality or incidence of symptomatic pulmonary embolism.

Citation: Ho KM et al. A multicenter trial of vena cava filters in severely injured patients. N Engl J Med. 2019 Jul 25;381:328-37.

Dr. Hoque Sharmy is a hospitalist and assistant professor of medicine in the division of hospital medicine at St. Louis University School of Medicine.

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

A version of this article originally appeared on Medscape.com.

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

A version of this article originally appeared on Medscape.com.

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

A version of this article originally appeared on Medscape.com.

Concentrations of neurofilament light (NfL) chain in blood can detect concussion, its severity and help predict recovery in patients with mild traumatic brain injury (TBI), new research indicates.

“Blood NfL may be used to aid in the diagnosis of patients with concussion or mild TBI [and] to identify individuals at increased risk of developing persistent postconcussive symptoms following TBI,” said lead author Pashtun Shahim, MD, PhD, National Institutes of Health Clinical Center, Bethesda, Md.

“This study is the first to do a detailed assessment of serum NfL chain and advanced brain imaging in multiple cohorts, brain injury severities, and time points after injury. The cohorts included professional athletes and nonathletes, and over time up to 5 years after TBI,” Dr. Shahim added.

The study was published online July 8 in Neurology.
 

Rapid indicator of neuronal damage

The researchers studied two cohorts of patients with head injuries. In the first, they determined serum and CSF NfL chain levels in professional Swedish ice hockey players (median age, 27 years), including 45 with acute concussion, 31 with repetitive concussions and persistent post-concussive symptoms (PCS), 28 who contributed samples during preseason with no recent concussion, and 14 healthy nonathletes.

CSF and serum NfL concentrations were closely correlated (r = 0.71; P < .0001). Serum NfL distinguished players with persistent PCS due to repetitive concussions from preseason concussion-free players, with an area under the receiver operating characteristic curve of 0.97. Higher CSF and serum NfL levels were associated with a higher number of concussions and severity of PCS after 1 year.

The second cohort involved 230 clinic-based adults (mean age, 43 years), including 162 with TBI and 68 healthy controls. In this cohort, patients with TBI had increased serum NfL concentrations compared with controls for up to 5 years, and these concentrations were able to distinguish between mild, moderate, and severe TBI. Serum NfL also correlated with measures of functional outcome, MRI brain atrophy, and diffusion tensor imaging estimates of traumatic axonal injury.

“Our findings suggest that NfL concentrations in serum offer rapid and accessible means of assessing and predicting neuronal damage in patients with TBI,” the investigators wrote.

What’s needed going forward, said Dr. Shahim, is “validation in larger cohorts for determining what levels of NfL in blood may be associated with a specific type of TBI, and what the levels are in healthy individuals of different ages.”

Not ready for prime time

In an accompanying editorial, Christopher Filley, MD, University of Colorado at Denver, Aurora, noted that NfL “may prove useful in identifying TBI patients at risk for prolonged symptoms and in enabling more focused treatment for these individuals.”

“These reports are richly laden with acute and longitudinal data that not only support the use of NfL as a convenient diagnostic test for TBI, but plausibly correlate with the neuropathology of TBI that is thought to play a major role in immediate and lasting cognitive disability,” he wrote.

Although the origin of TBI-induced cognitive decline is not entirely explained by traumatic axonal injury, “NfL appears to have much promise as a blood test that relates directly to the ubiquitous white matter damage of TBI, revealing a great deal about not only whether a TBI occurred, but also the extent of injury sustained, and how this injury may affect patient outcome for years thereafter,” Dr. Filley wrote.

However, he cautioned more research is needed before the blood test can be routinely applied to TBI diagnosis in clinical practice. “Among the hurdles still ahead are the standardization of measurement techniques across analytical platforms, and the determination of precise cutoffs between normal and abnormal values in different ages groups and at varying levels of TBI severity,” Dr. Filley noted.

The research was supported by the National Institutes of Health, the Department of Defense, the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University, and the Swedish Research Council. Dr. Shahim and Dr. Filley have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Concentrations of neurofilament light (NfL) chain in blood can detect concussion, its severity and help predict recovery in patients with mild traumatic brain injury (TBI), new research indicates.

“Blood NfL may be used to aid in the diagnosis of patients with concussion or mild TBI [and] to identify individuals at increased risk of developing persistent postconcussive symptoms following TBI,” said lead author Pashtun Shahim, MD, PhD, National Institutes of Health Clinical Center, Bethesda, Md.

“This study is the first to do a detailed assessment of serum NfL chain and advanced brain imaging in multiple cohorts, brain injury severities, and time points after injury. The cohorts included professional athletes and nonathletes, and over time up to 5 years after TBI,” Dr. Shahim added.

The study was published online July 8 in Neurology.
 

Rapid indicator of neuronal damage

The researchers studied two cohorts of patients with head injuries. In the first, they determined serum and CSF NfL chain levels in professional Swedish ice hockey players (median age, 27 years), including 45 with acute concussion, 31 with repetitive concussions and persistent post-concussive symptoms (PCS), 28 who contributed samples during preseason with no recent concussion, and 14 healthy nonathletes.

CSF and serum NfL concentrations were closely correlated (r = 0.71; P < .0001). Serum NfL distinguished players with persistent PCS due to repetitive concussions from preseason concussion-free players, with an area under the receiver operating characteristic curve of 0.97. Higher CSF and serum NfL levels were associated with a higher number of concussions and severity of PCS after 1 year.

The second cohort involved 230 clinic-based adults (mean age, 43 years), including 162 with TBI and 68 healthy controls. In this cohort, patients with TBI had increased serum NfL concentrations compared with controls for up to 5 years, and these concentrations were able to distinguish between mild, moderate, and severe TBI. Serum NfL also correlated with measures of functional outcome, MRI brain atrophy, and diffusion tensor imaging estimates of traumatic axonal injury.

“Our findings suggest that NfL concentrations in serum offer rapid and accessible means of assessing and predicting neuronal damage in patients with TBI,” the investigators wrote.

What’s needed going forward, said Dr. Shahim, is “validation in larger cohorts for determining what levels of NfL in blood may be associated with a specific type of TBI, and what the levels are in healthy individuals of different ages.”

Not ready for prime time

In an accompanying editorial, Christopher Filley, MD, University of Colorado at Denver, Aurora, noted that NfL “may prove useful in identifying TBI patients at risk for prolonged symptoms and in enabling more focused treatment for these individuals.”

“These reports are richly laden with acute and longitudinal data that not only support the use of NfL as a convenient diagnostic test for TBI, but plausibly correlate with the neuropathology of TBI that is thought to play a major role in immediate and lasting cognitive disability,” he wrote.

Although the origin of TBI-induced cognitive decline is not entirely explained by traumatic axonal injury, “NfL appears to have much promise as a blood test that relates directly to the ubiquitous white matter damage of TBI, revealing a great deal about not only whether a TBI occurred, but also the extent of injury sustained, and how this injury may affect patient outcome for years thereafter,” Dr. Filley wrote.

However, he cautioned more research is needed before the blood test can be routinely applied to TBI diagnosis in clinical practice. “Among the hurdles still ahead are the standardization of measurement techniques across analytical platforms, and the determination of precise cutoffs between normal and abnormal values in different ages groups and at varying levels of TBI severity,” Dr. Filley noted.

The research was supported by the National Institutes of Health, the Department of Defense, the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University, and the Swedish Research Council. Dr. Shahim and Dr. Filley have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Concentrations of neurofilament light (NfL) chain in blood can detect concussion, its severity and help predict recovery in patients with mild traumatic brain injury (TBI), new research indicates.

“Blood NfL may be used to aid in the diagnosis of patients with concussion or mild TBI [and] to identify individuals at increased risk of developing persistent postconcussive symptoms following TBI,” said lead author Pashtun Shahim, MD, PhD, National Institutes of Health Clinical Center, Bethesda, Md.

“This study is the first to do a detailed assessment of serum NfL chain and advanced brain imaging in multiple cohorts, brain injury severities, and time points after injury. The cohorts included professional athletes and nonathletes, and over time up to 5 years after TBI,” Dr. Shahim added.

The study was published online July 8 in Neurology.
 

Rapid indicator of neuronal damage

The researchers studied two cohorts of patients with head injuries. In the first, they determined serum and CSF NfL chain levels in professional Swedish ice hockey players (median age, 27 years), including 45 with acute concussion, 31 with repetitive concussions and persistent post-concussive symptoms (PCS), 28 who contributed samples during preseason with no recent concussion, and 14 healthy nonathletes.

CSF and serum NfL concentrations were closely correlated (r = 0.71; P < .0001). Serum NfL distinguished players with persistent PCS due to repetitive concussions from preseason concussion-free players, with an area under the receiver operating characteristic curve of 0.97. Higher CSF and serum NfL levels were associated with a higher number of concussions and severity of PCS after 1 year.

The second cohort involved 230 clinic-based adults (mean age, 43 years), including 162 with TBI and 68 healthy controls. In this cohort, patients with TBI had increased serum NfL concentrations compared with controls for up to 5 years, and these concentrations were able to distinguish between mild, moderate, and severe TBI. Serum NfL also correlated with measures of functional outcome, MRI brain atrophy, and diffusion tensor imaging estimates of traumatic axonal injury.

“Our findings suggest that NfL concentrations in serum offer rapid and accessible means of assessing and predicting neuronal damage in patients with TBI,” the investigators wrote.

What’s needed going forward, said Dr. Shahim, is “validation in larger cohorts for determining what levels of NfL in blood may be associated with a specific type of TBI, and what the levels are in healthy individuals of different ages.”

Not ready for prime time

In an accompanying editorial, Christopher Filley, MD, University of Colorado at Denver, Aurora, noted that NfL “may prove useful in identifying TBI patients at risk for prolonged symptoms and in enabling more focused treatment for these individuals.”

“These reports are richly laden with acute and longitudinal data that not only support the use of NfL as a convenient diagnostic test for TBI, but plausibly correlate with the neuropathology of TBI that is thought to play a major role in immediate and lasting cognitive disability,” he wrote.

Although the origin of TBI-induced cognitive decline is not entirely explained by traumatic axonal injury, “NfL appears to have much promise as a blood test that relates directly to the ubiquitous white matter damage of TBI, revealing a great deal about not only whether a TBI occurred, but also the extent of injury sustained, and how this injury may affect patient outcome for years thereafter,” Dr. Filley wrote.

However, he cautioned more research is needed before the blood test can be routinely applied to TBI diagnosis in clinical practice. “Among the hurdles still ahead are the standardization of measurement techniques across analytical platforms, and the determination of precise cutoffs between normal and abnormal values in different ages groups and at varying levels of TBI severity,” Dr. Filley noted.

The research was supported by the National Institutes of Health, the Department of Defense, the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University, and the Swedish Research Council. Dr. Shahim and Dr. Filley have reported no relevant financial relationships.

This article first appeared on Medscape.com.

COVID-19 has created stressors that are unprecedented in our modern era, prompting health care systems to adapt rapidly. Demand for telehealth has skyrocketed, and clinicians, many of whom had planned to adopt virtual practices in the future, have been pressured to do so immediately.¹ In March 2020, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services, removing many barriers to virtual care.² Similar remedy was not necessary for the Veterans Health Administration (VHA) which reported more than 2.6 million episodes of telehealth care in 2019.³ By the time the pandemic was underway in the US, use of telehealth was widespread across the agency. In late March 2020, VHA released a COVID-19 Response Plan, in which telehealth played a critical role in safe, uninterrupted delivery of services.⁴ While telehealth has been widely used in VHA, the call for replacement of most in-person outpatient visits with telehealth visits was a fundamental paradigm shift for many patients and clinicians.⁴

The Coronavirus Aid, Relief, and Economic Security (CARES) Act (HR 748) gave the US Department of Veterans Affairs (VA) funding to expand coronavirus-related telehealth services, including the purchase of mobile devices and broadband expansion. CARES authorized the agency to expand telemental health services, enter into short-term agreements with telecommunications companies to provide temporary broadband services to veterans, temporarily waived an in-person home visit requirement (accepting video and phone calls as an alternative), and provided means to make telehealth available for homeless veterans and case managers through the HUD-VASH (US Department of Housing and Urban Development-VA Supportive Housing) program.

VHA is a national telehealth exemplar, initiating telehealth by use of closed-circuit televisions as early as 1968, and continuing to expand through 2017 with the implementation of the Veterans Video Connect (VVC) platform.⁵ VVC has enabled veterans to participate in virtual visits from distant locations, including their homes. VVC was used successfully during hurricanes Sandy, Harvey, Irma, and Maria and is being widely deployed in the current crisis.^6-8

While telehealth can take many forms, the current discussion will focus on live (synchronous) videoconferencing: a 2-way audiovisual link between a patient and clinician, such as VVC, which enables patients to maintain a safe and social distance from others while connecting with the health care team and receiving urgent as well as ongoing medical care for both new and established conditions.⁹ VHA has developed multiple training resources for use of VVC across many settings, including primary care, mental health, and specialties. In this review, we will make the novel case for applying a trauma-informed lens to telehealth care across VHA and beyond to other health care systems.

Trauma-Informed Care

Although our current focus is rightly on mitigating the health effects of a pandemic, we must recognize that stressful phenomena like COVID-19 occur against a backdrop of widespread physical, sexual, psychological, and racial trauma in our communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁰ Trauma exposure is both ubiquitous worldwide and inequitably distributed, with vulnerable populations disproportionately impacted.^11,12

Veterans as a population are often highly trauma exposed, and while VHA routinely screens for experiences of trauma, such as military sexual trauma (MST) and intimate partner violence (IPV), and potential mental health sequelae of trauma, including posttraumatic stress disorder (PTSD) and suicidality, veterans may experience other forms of trauma or be unwilling or unable to talk about past exposures.¹³ One common example is that of adverse childhood experiences (ACEs), which include household dysfunction, neglect, and physical and sexual abuse before the age of 18 years.¹⁴ ACEs have been associated with a wide range of risk behaviors and poor health outcomes in adulthood.¹⁴ In population-based data, both male and female veterans have reported higher ACE scores.¹⁵ In addition, ACE scores are higher overall for those serving in the all-volunteer era (after July 1, 1973).¹⁶ Because trauma may be unseen, unmeasured, and unnamed, it is important to deliver all medical care with sensitivity to its potential presence.

It is important to distinguish the concept of trauma-informed care (TIC) from trauma-focused services. Trauma-focused or trauma-specific treatment refers to evidence-based and best practice treatment models that have been proven to facilitate recovery from problems resulting from the experience of trauma, such as PTSD.¹⁷ These treatments directly address the emotional, behavioral, and physiologic impact of trauma on an individual’s life and facilitate improvement in related symptoms and functioning: They are designed to treat the consequences of trauma. VHA offers a wide range of trauma-specific treatments, and considerable experience in delivering evidence-based trauma-focused treatment through telehealth exists.^18,19 Given the range of possible responses to the experience of trauma, not all veterans with trauma histories need to, chose to, or feel ready to access trauma-specific treatments.²⁰

In contrast, TIC is a global, universal precautions approach to providing quality care that can be applied to all aspects of health care and to all patients.²¹ TIC is a strengths-based service delivery framework that is grounded in an understanding of, and responsiveness to, the disempowering impact of experiencing trauma. It seeks to maximize physical, psychological, and emotional safety in all health care encounters, not just those that are specifically trauma-focused, and creates opportunities to rebuild a sense of control and empowerment while fostering healing through safe and collaborative patient-clinician relationships.²² TIC is not accomplished through any single technique or checklist but through continuous appraisal of approaches to care delivery. SAMHSA has elucidated 6 fundamental principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment; voice and choice; and sensitivity to cultural, historical, and gender issues.¹⁰

TIC is based on the understanding that often traditional service delivery models of care may trigger, silence, or disempower survivors of trauma, exacerbating physical and mental health symptoms and potentially increasing disengagement from care and poorer outcomes.²³ Currier and colleagues aptly noted, “TIC assumes that trustworthiness is not something that an organization creates in a veteran client, but something that he or she will freely grant to an organization.”²⁴ Given the global prevalence of trauma, its well-established and deleterious impact on lifelong health, and the potential for health care itself to be traumatizing, TIC is a fundamental construct to apply universally with any patient at any time, especially in the context of a large-scale community trauma, such as a pandemic.¹²

Trauma-Informed COVID-19 Care

Catastrophic events, such as natural disasters and pandemics, may serve as both newly traumatic and as potential triggers for survivors who have endured prior trauma.^25,26 Increases in depression, PTSD, and substance use disorder (SUD) are common sequalae, occurring during the event, the immediate aftermath, and beyond.^25,27 In 2003, quarantine contained the spread of Severe acute respiratory syndrome (SARS) but resulted in a high prevalence of psychological distress, including PTSD and depression.²⁷ Many veterans may have deployed in support of humanitarian assistance/disaster relief missions, which typically do not involve armed combat but may expose service members to warlike situations, including social insecurity and suffering populations.²⁸ COVID-19 may be reminiscent of some of these deployments as well.

The impact of the current COVID-19 pandemic on patients is pervasive. Those with preexisting financial insecurity now face additional economic hardship and health challenges, which are amplified by loneliness and loss of social support networks.²⁶ Widespread unemployment and closures of many businesses add to stress and may exacerbate preexisting mental and physical health concerns for many; some veterans also may be at increased risk.²⁹ While previous postdisaster research suggests that psychopathology in the general population will significantly remit over time, high-risk groups remain vulnerable to PTSD and bear the brunt of social and economic consequences associated with the crisis.²⁵ Veterans with preexisting trauma histories and mental health conditions are at increased risk for being retraumatized by the current pandemic and impacted by isolation and unplanned job or wage loss from it.²⁹ Compounding this, social distancing serves to protect communities but may amplify isolation and danger in abusive relationships or exacerbate underlying mental illness.^26,30

Thus, as we expand our use of telehealth, replacing our face-to-face visits with virtual encounters, it is critical for clinicians to be mindful that the pandemic and public health responses to it may result in trauma and retraumatization for veterans and other vulnerable patients, which in turn can impact both access and response to care. The application of trauma-informed principles to our virtual encounters has the potential to mitigate some of these health impacts, increase engagement in care, and provide opportunities for protective, healing connections.

In the setting of the continued fear and uncertainty of the COVID-19 pandemic, we believe that application of a trauma-informed lens to telehealth efforts is timely. While virtual visits may seem to lack the warmth and immediacy of traditional medical encounters, accumulated experience suggests otherwise.¹⁹ Telehealth is fundamentally more patient-focused than traditional encounters, overcomes service delivery barriers, offers a greater range of options for treatment engagement, and can enhance clinician-patient partnerships.^6,31,32 Although the rapid transition to telehealth may be challenging for those new to it, experienced clinicians and patients express high degrees of satisfaction with virtual care because direct communication is unhampered by in-office challenges and travel logistics.³³

While it may feel daunting to integrate principles of TIC into telehealth during a crisis-driven scale-up, a growing practice and body of research can inform these efforts. To help better understand how trauma-exposed patients respond to telehealth, we reviewed findings from trauma-focused telemental health (TMH) treatment. This research demonstrates that telehealth promotes safety and collaboration—fundamental principles of TIC—that can, in turn, be applied to telehealth visits in primary care and other medical and surgical specialties. When compared with traditional in-person treatment, studies of both individual and group formats of TMH found no significant differences in satisfaction, acceptability, or outcomes (such as reduction in PTSD symptom severity scores³⁴), and TMH did not impede development of rapport.^19,35

Although counterintuitive, the virtual space created by the combined physical and psychological distance of videoconferencing has been shown to promote safety and transparency. In TMH, patients have reported greater honesty due to the protection afforded by this virtual space.³¹ Engaging in telehealth visits from the comfort of one’s home can feel emotionally safer than having to travel to a medical office, resulting in feeling more at ease during encounters.³¹ In one TMH study, veterans with PTSD described high comfort levels and ability to let their guard down during virtual treatment.¹⁹ Similarly, in palliative telehealth care, patients reported that clinicians successfully nurtured an experience of intimacy, expressed empathy verbally and nonverbally, and responded to the patient’s unique situation and emotions.³³

Trauma-Informed Telehealth

We have discussed how telehealth’s greater flexibility may create an ideal environment in which to implement principles of TIC. It may allow increased collaboration and closeness between patients and clinicians, empowering patients to codesign their care.^31,33 The Table reviews 6 core SAMHSA principles of TIC and offers examples of their application to telehealth visits. The following case illustrates the application of trauma-informed telehealth care.

Case Presentation

S is a 45-year-old male veteran of Operation Enduring Freedom (OEF) who served as a combat medic. He has a history of osteoarthritis and PTSD related to combat experiences like caring for traumatic amputees. Before the pandemic began, he was employed as a server at a local restaurant but was laid off as the business transitioned to takeout orders only. The patient worked near a VA primary care clinic and frequently dropped by to see the staff and to pick up prescriptions. He had never agreed to video visits despite receiving encouragement from his medical team. He was reluctant to try telehealth, but he had developed a painful, itchy rash on his lower leg and was concerned about getting care.

For patients like S who may be reluctant to try telehealth, it is important to understand the cause. Potential barriers to telehealth may include lack of Internet access or familiarity with technology, discomfort with being on video, shame about the appearance of one’s home, or a strong cultural preference for face-to-face medical visits. Some may miss the social support benefit of coming into a clinic, particularly in VHA, which is designed specifically for veteran patients. For these reasons it is important to offer the patient a choice and to begin with a supportive phone call that explores and strives to address the patient’s concerns about videoconferencing.

The clinic nurse called S who agreed to try a VVC visit with gentle encouragement. He shared that he was embarrassed about the appearance of his apartment and fearful about pictures being recorded of his body due to “a bad experience in my past.” The patient was reassured that visits are private and will not be recorded. The nurse also reminded him that he can choose the location in which the visit will take place and can turn his camera off at any time. Importantly, the nurse did not ask him to recount additional details of what happened in his past. Next, the nurse verified his location and contact information and explained why obtaining this information was necessary. Next, she asked his consent to proceed with the visit, reminding him that the visit can end at any point if he feels uncomfortable. After finishing this initial discussion, the nurse told him that his primary care physician (PCP) would join the visit and address his concerns with his leg.

S was happy to see his PCP despite his hesitations about video care. The PCP noticed that he seemed anxious and was avoiding talking about the rash. Knowing that he was anxious about this VVC visit, the PCP was careful to look directly at the camera to make eye contact and to be sure her face was well lit and not in shadows. She gave him some time to acclimate to the virtual environment and thanked him for joining the visit. Knowing that he was a combat veteran, she warned him that there have been sudden, loud construction noises outside her window. Although the PCP was pressed for time, she was aware that S may have had a previous difficult experience around images of his body or even combat-related trauma. She gently brought up the rash and asked for permission to examine it, avoiding commands or personalizing language such as “show me your leg” or “take off your pants for me.”³⁶After some hesitation, the patient revealed his leg that appeared to have multiple excoriations and old scars from picking. After the examination, the PCP waited until the patient’s leg was fully covered before beginning a discussion of the care plan. Together they collaboratively reviewed treatments that would soothe the skin. They decided to virtually consult a social worker to obtain emergency economic assistance and to speak with the patient’s care team psychologist to reduce some of the anxiety that may be leading to his leg scratching.

Case Discussion

This case illustrates the ways in which TIC can be applied to telehealth for a veteran with combat-related PTSD who may have experienced additional interpersonal trauma. It was not necessary to know more detail about the veteran’s trauma history to conduct the visit in a trauma-informed manner. Connecting to patients at home while considering these principles may thus foster mutuality, mitigate retraumatization, and cultivate enhanced collaboration with health care teams in this era of social distancing.

While a virtual physical examination creates both limitations and opportunity in telehealth, patients may find the greater degree of choice over their clothing and surroundings to be empowering. Telehealth also can allow for a greater portion of time to be dedicated to quality discussion and collaborative planning, with the clinician hearing and responding to the patient’s needs with reduced distraction. This may include opportunities to discuss mental health concerns openly, normalize emotional reactions, and offer connection to mental health and support services available through telehealth, including for patients who have not previously engaged in such care.

Conclusions

Telehealth expansion is occurring out of necessity in a time of crisis. While VHA is expanding its already robust telehealth program to replace some in-person visits, many other health care systems are just beginning to use telehealth. Trauma-informed virtual care during the COVID-19 pandemic has the potential to ensure and even expand continuity of medical care, offer connection and support to trauma survivors, and enhance patient and clinician resilience in this time of need. Clinicians have a unique opportunity in this pandemic to apply TIC principles early on and to envision how telehealth may contribute to a more meaningful care experience for all and a more equitable future for those we care for.

COVID-19 has created stressors that are unprecedented in our modern era, prompting health care systems to adapt rapidly. Demand for telehealth has skyrocketed, and clinicians, many of whom had planned to adopt virtual practices in the future, have been pressured to do so immediately.¹ In March 2020, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services, removing many barriers to virtual care.² Similar remedy was not necessary for the Veterans Health Administration (VHA) which reported more than 2.6 million episodes of telehealth care in 2019.³ By the time the pandemic was underway in the US, use of telehealth was widespread across the agency. In late March 2020, VHA released a COVID-19 Response Plan, in which telehealth played a critical role in safe, uninterrupted delivery of services.⁴ While telehealth has been widely used in VHA, the call for replacement of most in-person outpatient visits with telehealth visits was a fundamental paradigm shift for many patients and clinicians.⁴

The Coronavirus Aid, Relief, and Economic Security (CARES) Act (HR 748) gave the US Department of Veterans Affairs (VA) funding to expand coronavirus-related telehealth services, including the purchase of mobile devices and broadband expansion. CARES authorized the agency to expand telemental health services, enter into short-term agreements with telecommunications companies to provide temporary broadband services to veterans, temporarily waived an in-person home visit requirement (accepting video and phone calls as an alternative), and provided means to make telehealth available for homeless veterans and case managers through the HUD-VASH (US Department of Housing and Urban Development-VA Supportive Housing) program.

VHA is a national telehealth exemplar, initiating telehealth by use of closed-circuit televisions as early as 1968, and continuing to expand through 2017 with the implementation of the Veterans Video Connect (VVC) platform.⁵ VVC has enabled veterans to participate in virtual visits from distant locations, including their homes. VVC was used successfully during hurricanes Sandy, Harvey, Irma, and Maria and is being widely deployed in the current crisis.^6-8

While telehealth can take many forms, the current discussion will focus on live (synchronous) videoconferencing: a 2-way audiovisual link between a patient and clinician, such as VVC, which enables patients to maintain a safe and social distance from others while connecting with the health care team and receiving urgent as well as ongoing medical care for both new and established conditions.⁹ VHA has developed multiple training resources for use of VVC across many settings, including primary care, mental health, and specialties. In this review, we will make the novel case for applying a trauma-informed lens to telehealth care across VHA and beyond to other health care systems.

Trauma-Informed Care

Although our current focus is rightly on mitigating the health effects of a pandemic, we must recognize that stressful phenomena like COVID-19 occur against a backdrop of widespread physical, sexual, psychological, and racial trauma in our communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁰ Trauma exposure is both ubiquitous worldwide and inequitably distributed, with vulnerable populations disproportionately impacted.^11,12

Veterans as a population are often highly trauma exposed, and while VHA routinely screens for experiences of trauma, such as military sexual trauma (MST) and intimate partner violence (IPV), and potential mental health sequelae of trauma, including posttraumatic stress disorder (PTSD) and suicidality, veterans may experience other forms of trauma or be unwilling or unable to talk about past exposures.¹³ One common example is that of adverse childhood experiences (ACEs), which include household dysfunction, neglect, and physical and sexual abuse before the age of 18 years.¹⁴ ACEs have been associated with a wide range of risk behaviors and poor health outcomes in adulthood.¹⁴ In population-based data, both male and female veterans have reported higher ACE scores.¹⁵ In addition, ACE scores are higher overall for those serving in the all-volunteer era (after July 1, 1973).¹⁶ Because trauma may be unseen, unmeasured, and unnamed, it is important to deliver all medical care with sensitivity to its potential presence.

It is important to distinguish the concept of trauma-informed care (TIC) from trauma-focused services. Trauma-focused or trauma-specific treatment refers to evidence-based and best practice treatment models that have been proven to facilitate recovery from problems resulting from the experience of trauma, such as PTSD.¹⁷ These treatments directly address the emotional, behavioral, and physiologic impact of trauma on an individual’s life and facilitate improvement in related symptoms and functioning: They are designed to treat the consequences of trauma. VHA offers a wide range of trauma-specific treatments, and considerable experience in delivering evidence-based trauma-focused treatment through telehealth exists.^18,19 Given the range of possible responses to the experience of trauma, not all veterans with trauma histories need to, chose to, or feel ready to access trauma-specific treatments.²⁰

In contrast, TIC is a global, universal precautions approach to providing quality care that can be applied to all aspects of health care and to all patients.²¹ TIC is a strengths-based service delivery framework that is grounded in an understanding of, and responsiveness to, the disempowering impact of experiencing trauma. It seeks to maximize physical, psychological, and emotional safety in all health care encounters, not just those that are specifically trauma-focused, and creates opportunities to rebuild a sense of control and empowerment while fostering healing through safe and collaborative patient-clinician relationships.²² TIC is not accomplished through any single technique or checklist but through continuous appraisal of approaches to care delivery. SAMHSA has elucidated 6 fundamental principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment; voice and choice; and sensitivity to cultural, historical, and gender issues.¹⁰

TIC is based on the understanding that often traditional service delivery models of care may trigger, silence, or disempower survivors of trauma, exacerbating physical and mental health symptoms and potentially increasing disengagement from care and poorer outcomes.²³ Currier and colleagues aptly noted, “TIC assumes that trustworthiness is not something that an organization creates in a veteran client, but something that he or she will freely grant to an organization.”²⁴ Given the global prevalence of trauma, its well-established and deleterious impact on lifelong health, and the potential for health care itself to be traumatizing, TIC is a fundamental construct to apply universally with any patient at any time, especially in the context of a large-scale community trauma, such as a pandemic.¹²

Trauma-Informed COVID-19 Care

Catastrophic events, such as natural disasters and pandemics, may serve as both newly traumatic and as potential triggers for survivors who have endured prior trauma.^25,26 Increases in depression, PTSD, and substance use disorder (SUD) are common sequalae, occurring during the event, the immediate aftermath, and beyond.^25,27 In 2003, quarantine contained the spread of Severe acute respiratory syndrome (SARS) but resulted in a high prevalence of psychological distress, including PTSD and depression.²⁷ Many veterans may have deployed in support of humanitarian assistance/disaster relief missions, which typically do not involve armed combat but may expose service members to warlike situations, including social insecurity and suffering populations.²⁸ COVID-19 may be reminiscent of some of these deployments as well.

The impact of the current COVID-19 pandemic on patients is pervasive. Those with preexisting financial insecurity now face additional economic hardship and health challenges, which are amplified by loneliness and loss of social support networks.²⁶ Widespread unemployment and closures of many businesses add to stress and may exacerbate preexisting mental and physical health concerns for many; some veterans also may be at increased risk.²⁹ While previous postdisaster research suggests that psychopathology in the general population will significantly remit over time, high-risk groups remain vulnerable to PTSD and bear the brunt of social and economic consequences associated with the crisis.²⁵ Veterans with preexisting trauma histories and mental health conditions are at increased risk for being retraumatized by the current pandemic and impacted by isolation and unplanned job or wage loss from it.²⁹ Compounding this, social distancing serves to protect communities but may amplify isolation and danger in abusive relationships or exacerbate underlying mental illness.^26,30

Thus, as we expand our use of telehealth, replacing our face-to-face visits with virtual encounters, it is critical for clinicians to be mindful that the pandemic and public health responses to it may result in trauma and retraumatization for veterans and other vulnerable patients, which in turn can impact both access and response to care. The application of trauma-informed principles to our virtual encounters has the potential to mitigate some of these health impacts, increase engagement in care, and provide opportunities for protective, healing connections.

In the setting of the continued fear and uncertainty of the COVID-19 pandemic, we believe that application of a trauma-informed lens to telehealth efforts is timely. While virtual visits may seem to lack the warmth and immediacy of traditional medical encounters, accumulated experience suggests otherwise.¹⁹ Telehealth is fundamentally more patient-focused than traditional encounters, overcomes service delivery barriers, offers a greater range of options for treatment engagement, and can enhance clinician-patient partnerships.^6,31,32 Although the rapid transition to telehealth may be challenging for those new to it, experienced clinicians and patients express high degrees of satisfaction with virtual care because direct communication is unhampered by in-office challenges and travel logistics.³³

While it may feel daunting to integrate principles of TIC into telehealth during a crisis-driven scale-up, a growing practice and body of research can inform these efforts. To help better understand how trauma-exposed patients respond to telehealth, we reviewed findings from trauma-focused telemental health (TMH) treatment. This research demonstrates that telehealth promotes safety and collaboration—fundamental principles of TIC—that can, in turn, be applied to telehealth visits in primary care and other medical and surgical specialties. When compared with traditional in-person treatment, studies of both individual and group formats of TMH found no significant differences in satisfaction, acceptability, or outcomes (such as reduction in PTSD symptom severity scores³⁴), and TMH did not impede development of rapport.^19,35

Although counterintuitive, the virtual space created by the combined physical and psychological distance of videoconferencing has been shown to promote safety and transparency. In TMH, patients have reported greater honesty due to the protection afforded by this virtual space.³¹ Engaging in telehealth visits from the comfort of one’s home can feel emotionally safer than having to travel to a medical office, resulting in feeling more at ease during encounters.³¹ In one TMH study, veterans with PTSD described high comfort levels and ability to let their guard down during virtual treatment.¹⁹ Similarly, in palliative telehealth care, patients reported that clinicians successfully nurtured an experience of intimacy, expressed empathy verbally and nonverbally, and responded to the patient’s unique situation and emotions.³³

Trauma-Informed Telehealth

We have discussed how telehealth’s greater flexibility may create an ideal environment in which to implement principles of TIC. It may allow increased collaboration and closeness between patients and clinicians, empowering patients to codesign their care.^31,33 The Table reviews 6 core SAMHSA principles of TIC and offers examples of their application to telehealth visits. The following case illustrates the application of trauma-informed telehealth care.

Case Presentation

S is a 45-year-old male veteran of Operation Enduring Freedom (OEF) who served as a combat medic. He has a history of osteoarthritis and PTSD related to combat experiences like caring for traumatic amputees. Before the pandemic began, he was employed as a server at a local restaurant but was laid off as the business transitioned to takeout orders only. The patient worked near a VA primary care clinic and frequently dropped by to see the staff and to pick up prescriptions. He had never agreed to video visits despite receiving encouragement from his medical team. He was reluctant to try telehealth, but he had developed a painful, itchy rash on his lower leg and was concerned about getting care.

For patients like S who may be reluctant to try telehealth, it is important to understand the cause. Potential barriers to telehealth may include lack of Internet access or familiarity with technology, discomfort with being on video, shame about the appearance of one’s home, or a strong cultural preference for face-to-face medical visits. Some may miss the social support benefit of coming into a clinic, particularly in VHA, which is designed specifically for veteran patients. For these reasons it is important to offer the patient a choice and to begin with a supportive phone call that explores and strives to address the patient’s concerns about videoconferencing.

The clinic nurse called S who agreed to try a VVC visit with gentle encouragement. He shared that he was embarrassed about the appearance of his apartment and fearful about pictures being recorded of his body due to “a bad experience in my past.” The patient was reassured that visits are private and will not be recorded. The nurse also reminded him that he can choose the location in which the visit will take place and can turn his camera off at any time. Importantly, the nurse did not ask him to recount additional details of what happened in his past. Next, the nurse verified his location and contact information and explained why obtaining this information was necessary. Next, she asked his consent to proceed with the visit, reminding him that the visit can end at any point if he feels uncomfortable. After finishing this initial discussion, the nurse told him that his primary care physician (PCP) would join the visit and address his concerns with his leg.

S was happy to see his PCP despite his hesitations about video care. The PCP noticed that he seemed anxious and was avoiding talking about the rash. Knowing that he was anxious about this VVC visit, the PCP was careful to look directly at the camera to make eye contact and to be sure her face was well lit and not in shadows. She gave him some time to acclimate to the virtual environment and thanked him for joining the visit. Knowing that he was a combat veteran, she warned him that there have been sudden, loud construction noises outside her window. Although the PCP was pressed for time, she was aware that S may have had a previous difficult experience around images of his body or even combat-related trauma. She gently brought up the rash and asked for permission to examine it, avoiding commands or personalizing language such as “show me your leg” or “take off your pants for me.”³⁶After some hesitation, the patient revealed his leg that appeared to have multiple excoriations and old scars from picking. After the examination, the PCP waited until the patient’s leg was fully covered before beginning a discussion of the care plan. Together they collaboratively reviewed treatments that would soothe the skin. They decided to virtually consult a social worker to obtain emergency economic assistance and to speak with the patient’s care team psychologist to reduce some of the anxiety that may be leading to his leg scratching.

Case Discussion

This case illustrates the ways in which TIC can be applied to telehealth for a veteran with combat-related PTSD who may have experienced additional interpersonal trauma. It was not necessary to know more detail about the veteran’s trauma history to conduct the visit in a trauma-informed manner. Connecting to patients at home while considering these principles may thus foster mutuality, mitigate retraumatization, and cultivate enhanced collaboration with health care teams in this era of social distancing.

While a virtual physical examination creates both limitations and opportunity in telehealth, patients may find the greater degree of choice over their clothing and surroundings to be empowering. Telehealth also can allow for a greater portion of time to be dedicated to quality discussion and collaborative planning, with the clinician hearing and responding to the patient’s needs with reduced distraction. This may include opportunities to discuss mental health concerns openly, normalize emotional reactions, and offer connection to mental health and support services available through telehealth, including for patients who have not previously engaged in such care.

Conclusions

Telehealth expansion is occurring out of necessity in a time of crisis. While VHA is expanding its already robust telehealth program to replace some in-person visits, many other health care systems are just beginning to use telehealth. Trauma-informed virtual care during the COVID-19 pandemic has the potential to ensure and even expand continuity of medical care, offer connection and support to trauma survivors, and enhance patient and clinician resilience in this time of need. Clinicians have a unique opportunity in this pandemic to apply TIC principles early on and to envision how telehealth may contribute to a more meaningful care experience for all and a more equitable future for those we care for.

COVID-19 has created stressors that are unprecedented in our modern era, prompting health care systems to adapt rapidly. Demand for telehealth has skyrocketed, and clinicians, many of whom had planned to adopt virtual practices in the future, have been pressured to do so immediately.¹ In March 2020, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services, removing many barriers to virtual care.² Similar remedy was not necessary for the Veterans Health Administration (VHA) which reported more than 2.6 million episodes of telehealth care in 2019.³ By the time the pandemic was underway in the US, use of telehealth was widespread across the agency. In late March 2020, VHA released a COVID-19 Response Plan, in which telehealth played a critical role in safe, uninterrupted delivery of services.⁴ While telehealth has been widely used in VHA, the call for replacement of most in-person outpatient visits with telehealth visits was a fundamental paradigm shift for many patients and clinicians.⁴

The Coronavirus Aid, Relief, and Economic Security (CARES) Act (HR 748) gave the US Department of Veterans Affairs (VA) funding to expand coronavirus-related telehealth services, including the purchase of mobile devices and broadband expansion. CARES authorized the agency to expand telemental health services, enter into short-term agreements with telecommunications companies to provide temporary broadband services to veterans, temporarily waived an in-person home visit requirement (accepting video and phone calls as an alternative), and provided means to make telehealth available for homeless veterans and case managers through the HUD-VASH (US Department of Housing and Urban Development-VA Supportive Housing) program.

VHA is a national telehealth exemplar, initiating telehealth by use of closed-circuit televisions as early as 1968, and continuing to expand through 2017 with the implementation of the Veterans Video Connect (VVC) platform.⁵ VVC has enabled veterans to participate in virtual visits from distant locations, including their homes. VVC was used successfully during hurricanes Sandy, Harvey, Irma, and Maria and is being widely deployed in the current crisis.^6-8

While telehealth can take many forms, the current discussion will focus on live (synchronous) videoconferencing: a 2-way audiovisual link between a patient and clinician, such as VVC, which enables patients to maintain a safe and social distance from others while connecting with the health care team and receiving urgent as well as ongoing medical care for both new and established conditions.⁹ VHA has developed multiple training resources for use of VVC across many settings, including primary care, mental health, and specialties. In this review, we will make the novel case for applying a trauma-informed lens to telehealth care across VHA and beyond to other health care systems.

Trauma-Informed Care

Although our current focus is rightly on mitigating the health effects of a pandemic, we must recognize that stressful phenomena like COVID-19 occur against a backdrop of widespread physical, sexual, psychological, and racial trauma in our communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁰ Trauma exposure is both ubiquitous worldwide and inequitably distributed, with vulnerable populations disproportionately impacted.^11,12

Veterans as a population are often highly trauma exposed, and while VHA routinely screens for experiences of trauma, such as military sexual trauma (MST) and intimate partner violence (IPV), and potential mental health sequelae of trauma, including posttraumatic stress disorder (PTSD) and suicidality, veterans may experience other forms of trauma or be unwilling or unable to talk about past exposures.¹³ One common example is that of adverse childhood experiences (ACEs), which include household dysfunction, neglect, and physical and sexual abuse before the age of 18 years.¹⁴ ACEs have been associated with a wide range of risk behaviors and poor health outcomes in adulthood.¹⁴ In population-based data, both male and female veterans have reported higher ACE scores.¹⁵ In addition, ACE scores are higher overall for those serving in the all-volunteer era (after July 1, 1973).¹⁶ Because trauma may be unseen, unmeasured, and unnamed, it is important to deliver all medical care with sensitivity to its potential presence.

It is important to distinguish the concept of trauma-informed care (TIC) from trauma-focused services. Trauma-focused or trauma-specific treatment refers to evidence-based and best practice treatment models that have been proven to facilitate recovery from problems resulting from the experience of trauma, such as PTSD.¹⁷ These treatments directly address the emotional, behavioral, and physiologic impact of trauma on an individual’s life and facilitate improvement in related symptoms and functioning: They are designed to treat the consequences of trauma. VHA offers a wide range of trauma-specific treatments, and considerable experience in delivering evidence-based trauma-focused treatment through telehealth exists.^18,19 Given the range of possible responses to the experience of trauma, not all veterans with trauma histories need to, chose to, or feel ready to access trauma-specific treatments.²⁰

In contrast, TIC is a global, universal precautions approach to providing quality care that can be applied to all aspects of health care and to all patients.²¹ TIC is a strengths-based service delivery framework that is grounded in an understanding of, and responsiveness to, the disempowering impact of experiencing trauma. It seeks to maximize physical, psychological, and emotional safety in all health care encounters, not just those that are specifically trauma-focused, and creates opportunities to rebuild a sense of control and empowerment while fostering healing through safe and collaborative patient-clinician relationships.²² TIC is not accomplished through any single technique or checklist but through continuous appraisal of approaches to care delivery. SAMHSA has elucidated 6 fundamental principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment; voice and choice; and sensitivity to cultural, historical, and gender issues.¹⁰

TIC is based on the understanding that often traditional service delivery models of care may trigger, silence, or disempower survivors of trauma, exacerbating physical and mental health symptoms and potentially increasing disengagement from care and poorer outcomes.²³ Currier and colleagues aptly noted, “TIC assumes that trustworthiness is not something that an organization creates in a veteran client, but something that he or she will freely grant to an organization.”²⁴ Given the global prevalence of trauma, its well-established and deleterious impact on lifelong health, and the potential for health care itself to be traumatizing, TIC is a fundamental construct to apply universally with any patient at any time, especially in the context of a large-scale community trauma, such as a pandemic.¹²

Trauma-Informed COVID-19 Care

Catastrophic events, such as natural disasters and pandemics, may serve as both newly traumatic and as potential triggers for survivors who have endured prior trauma.^25,26 Increases in depression, PTSD, and substance use disorder (SUD) are common sequalae, occurring during the event, the immediate aftermath, and beyond.^25,27 In 2003, quarantine contained the spread of Severe acute respiratory syndrome (SARS) but resulted in a high prevalence of psychological distress, including PTSD and depression.²⁷ Many veterans may have deployed in support of humanitarian assistance/disaster relief missions, which typically do not involve armed combat but may expose service members to warlike situations, including social insecurity and suffering populations.²⁸ COVID-19 may be reminiscent of some of these deployments as well.

The impact of the current COVID-19 pandemic on patients is pervasive. Those with preexisting financial insecurity now face additional economic hardship and health challenges, which are amplified by loneliness and loss of social support networks.²⁶ Widespread unemployment and closures of many businesses add to stress and may exacerbate preexisting mental and physical health concerns for many; some veterans also may be at increased risk.²⁹ While previous postdisaster research suggests that psychopathology in the general population will significantly remit over time, high-risk groups remain vulnerable to PTSD and bear the brunt of social and economic consequences associated with the crisis.²⁵ Veterans with preexisting trauma histories and mental health conditions are at increased risk for being retraumatized by the current pandemic and impacted by isolation and unplanned job or wage loss from it.²⁹ Compounding this, social distancing serves to protect communities but may amplify isolation and danger in abusive relationships or exacerbate underlying mental illness.^26,30

Thus, as we expand our use of telehealth, replacing our face-to-face visits with virtual encounters, it is critical for clinicians to be mindful that the pandemic and public health responses to it may result in trauma and retraumatization for veterans and other vulnerable patients, which in turn can impact both access and response to care. The application of trauma-informed principles to our virtual encounters has the potential to mitigate some of these health impacts, increase engagement in care, and provide opportunities for protective, healing connections.

In the setting of the continued fear and uncertainty of the COVID-19 pandemic, we believe that application of a trauma-informed lens to telehealth efforts is timely. While virtual visits may seem to lack the warmth and immediacy of traditional medical encounters, accumulated experience suggests otherwise.¹⁹ Telehealth is fundamentally more patient-focused than traditional encounters, overcomes service delivery barriers, offers a greater range of options for treatment engagement, and can enhance clinician-patient partnerships.^6,31,32 Although the rapid transition to telehealth may be challenging for those new to it, experienced clinicians and patients express high degrees of satisfaction with virtual care because direct communication is unhampered by in-office challenges and travel logistics.³³

While it may feel daunting to integrate principles of TIC into telehealth during a crisis-driven scale-up, a growing practice and body of research can inform these efforts. To help better understand how trauma-exposed patients respond to telehealth, we reviewed findings from trauma-focused telemental health (TMH) treatment. This research demonstrates that telehealth promotes safety and collaboration—fundamental principles of TIC—that can, in turn, be applied to telehealth visits in primary care and other medical and surgical specialties. When compared with traditional in-person treatment, studies of both individual and group formats of TMH found no significant differences in satisfaction, acceptability, or outcomes (such as reduction in PTSD symptom severity scores³⁴), and TMH did not impede development of rapport.^19,35

Although counterintuitive, the virtual space created by the combined physical and psychological distance of videoconferencing has been shown to promote safety and transparency. In TMH, patients have reported greater honesty due to the protection afforded by this virtual space.³¹ Engaging in telehealth visits from the comfort of one’s home can feel emotionally safer than having to travel to a medical office, resulting in feeling more at ease during encounters.³¹ In one TMH study, veterans with PTSD described high comfort levels and ability to let their guard down during virtual treatment.¹⁹ Similarly, in palliative telehealth care, patients reported that clinicians successfully nurtured an experience of intimacy, expressed empathy verbally and nonverbally, and responded to the patient’s unique situation and emotions.³³

Trauma-Informed Telehealth

We have discussed how telehealth’s greater flexibility may create an ideal environment in which to implement principles of TIC. It may allow increased collaboration and closeness between patients and clinicians, empowering patients to codesign their care.^31,33 The Table reviews 6 core SAMHSA principles of TIC and offers examples of their application to telehealth visits. The following case illustrates the application of trauma-informed telehealth care.

Case Presentation

S is a 45-year-old male veteran of Operation Enduring Freedom (OEF) who served as a combat medic. He has a history of osteoarthritis and PTSD related to combat experiences like caring for traumatic amputees. Before the pandemic began, he was employed as a server at a local restaurant but was laid off as the business transitioned to takeout orders only. The patient worked near a VA primary care clinic and frequently dropped by to see the staff and to pick up prescriptions. He had never agreed to video visits despite receiving encouragement from his medical team. He was reluctant to try telehealth, but he had developed a painful, itchy rash on his lower leg and was concerned about getting care.

For patients like S who may be reluctant to try telehealth, it is important to understand the cause. Potential barriers to telehealth may include lack of Internet access or familiarity with technology, discomfort with being on video, shame about the appearance of one’s home, or a strong cultural preference for face-to-face medical visits. Some may miss the social support benefit of coming into a clinic, particularly in VHA, which is designed specifically for veteran patients. For these reasons it is important to offer the patient a choice and to begin with a supportive phone call that explores and strives to address the patient’s concerns about videoconferencing.

The clinic nurse called S who agreed to try a VVC visit with gentle encouragement. He shared that he was embarrassed about the appearance of his apartment and fearful about pictures being recorded of his body due to “a bad experience in my past.” The patient was reassured that visits are private and will not be recorded. The nurse also reminded him that he can choose the location in which the visit will take place and can turn his camera off at any time. Importantly, the nurse did not ask him to recount additional details of what happened in his past. Next, the nurse verified his location and contact information and explained why obtaining this information was necessary. Next, she asked his consent to proceed with the visit, reminding him that the visit can end at any point if he feels uncomfortable. After finishing this initial discussion, the nurse told him that his primary care physician (PCP) would join the visit and address his concerns with his leg.

S was happy to see his PCP despite his hesitations about video care. The PCP noticed that he seemed anxious and was avoiding talking about the rash. Knowing that he was anxious about this VVC visit, the PCP was careful to look directly at the camera to make eye contact and to be sure her face was well lit and not in shadows. She gave him some time to acclimate to the virtual environment and thanked him for joining the visit. Knowing that he was a combat veteran, she warned him that there have been sudden, loud construction noises outside her window. Although the PCP was pressed for time, she was aware that S may have had a previous difficult experience around images of his body or even combat-related trauma. She gently brought up the rash and asked for permission to examine it, avoiding commands or personalizing language such as “show me your leg” or “take off your pants for me.”³⁶After some hesitation, the patient revealed his leg that appeared to have multiple excoriations and old scars from picking. After the examination, the PCP waited until the patient’s leg was fully covered before beginning a discussion of the care plan. Together they collaboratively reviewed treatments that would soothe the skin. They decided to virtually consult a social worker to obtain emergency economic assistance and to speak with the patient’s care team psychologist to reduce some of the anxiety that may be leading to his leg scratching.

Case Discussion

This case illustrates the ways in which TIC can be applied to telehealth for a veteran with combat-related PTSD who may have experienced additional interpersonal trauma. It was not necessary to know more detail about the veteran’s trauma history to conduct the visit in a trauma-informed manner. Connecting to patients at home while considering these principles may thus foster mutuality, mitigate retraumatization, and cultivate enhanced collaboration with health care teams in this era of social distancing.

While a virtual physical examination creates both limitations and opportunity in telehealth, patients may find the greater degree of choice over their clothing and surroundings to be empowering. Telehealth also can allow for a greater portion of time to be dedicated to quality discussion and collaborative planning, with the clinician hearing and responding to the patient’s needs with reduced distraction. This may include opportunities to discuss mental health concerns openly, normalize emotional reactions, and offer connection to mental health and support services available through telehealth, including for patients who have not previously engaged in such care.

Conclusions

Telehealth expansion is occurring out of necessity in a time of crisis. While VHA is expanding its already robust telehealth program to replace some in-person visits, many other health care systems are just beginning to use telehealth. Trauma-informed virtual care during the COVID-19 pandemic has the potential to ensure and even expand continuity of medical care, offer connection and support to trauma survivors, and enhance patient and clinician resilience in this time of need. Clinicians have a unique opportunity in this pandemic to apply TIC principles early on and to envision how telehealth may contribute to a more meaningful care experience for all and a more equitable future for those we care for.

A quality initiative to restrict the use of Foley catheters in middle-aged and geriatric trauma patients with hip fracture reduced the risk of urinary tract infections (UTI) and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.

The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.

After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.

When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.

Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).

When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).

“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.

Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.

The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.

Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.

Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).

“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.

Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”

Dr. Konda reported a financial relationship with Stryker.
 

A quality initiative to restrict the use of Foley catheters in middle-aged and geriatric trauma patients with hip fracture reduced the risk of urinary tract infections (UTI) and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.

The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.

After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.

When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.

Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).

When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).

“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.

Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.

The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.

Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.

Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).

“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.

Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”

Dr. Konda reported a financial relationship with Stryker.
 

A quality initiative to restrict the use of Foley catheters in middle-aged and geriatric trauma patients with hip fracture reduced the risk of urinary tract infections (UTI) and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.

The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.

After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.

When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.

Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).

When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).

“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.

Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.

The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.

Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.

Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).

“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.

Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”

Dr. Konda reported a financial relationship with Stryker.