Adopting Trauma Informed Care Principles to the Emergency Department Environment
Key Highlights
- Comprehensive trauma-informed care training in emergency departments may reduce the duration and frequency of physical and chemical restraint use and help address racial disparities in their application.
- Emerging evidence suggests potential benefits for reducing staff burnout and patient pain perception.
- Practical strategies for trauma-informed care include empowering patients by offering choices, building trust through validation, fostering collaboration, using grounding exercises for distressed patients, as well as maintaining transparent, safety-focused communication during behavioral health crises.
In this podcast, emergency medicine physician Taylor Brown, MD, of Harvard Medical School breaks down how trauma-informed care can transform interactions in high-pressure emergency settings. She discusses practical strategies to empower patients, reduce re-traumatization, and enhance outcomes, even in the most acute clinical encounters.
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TRANSCRIPTION:
Kate Young: Hello everyone, and welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Kate Young, with Consultant360, a multidisciplinary medical information network.
Dr. Taylor Brown is here with us today to speak to us about trauma informed care in emergency medicine. Dr. Brown is an emergency medicine physician at Harvard Medical School and is board certified in emergency medicine. Thank you for joining us today, Dr. Brown. Can you please define what trauma is in the context of clinical care?
Taylor Brown, MD: When I talk about trauma, I use the substance abuse and mental health services definition, and they use the three E's. I think about it as any kind of event series or set of circumstances that an individual experiences as life threatening or harmful in some way, and then it has some lasting effect on them. When you use a definition that broad, it can be at an individual level, like a car accident, it can be interpersonal, such as interpersonal violence, but it can also be as big as something societal, like we all lived through the COVID pandemic, and it can be structural as well. I mention things like racism, sexism, homophobia.
Young: How does that definition change, if at all, in the context of an emergency situation?
Dr Brown: I don't think that definition changes too much. I think in emergency medicine, we see maybe a larger proportion of folks who are experiencing some kind of acute traumatic event, but we have to keep in mind in our patient population as well, plenty of individuals have experienced trauma and adversity in their life before that may not be directly related to what they're coming into the emergency room with.
Young: Emergency departments are often high pressure and time constrained environments. What strategies do you recommend for integrating trauma informed care practices into that fast-paced emergency department workflow without compromising efficiency?
Dr Brown: Efficiency is something I get asked about a lot when I teach trauma informed care, so especially when I'm teaching to colleagues who have already been practicing, already have an approach to patient care, I really emphasize that it's just a shift in your approach. Some good patient care is trauma informed, but it's really having providers shift from thinking and asking a patient what's wrong with you to instead asking them what has happened to you in your life and how has that impacted you.
I'm also sure to emphasize to providers that we're not providing trauma-focused therapy, especially in the emergency department, but it's really this universal precaution that we use with patients that aims to prevent their re-traumatization. That can be as simple as small adjustments to your physical body and space when you're doing a physical exam or minor adjustments to your language that can make a huge difference for patients.
Young: What does current evidence tell us about the impact of trauma-informed care on patient outcomes?
Dr Brown: I wish we had more patient outcomes data. Trauma informed care is really an evolving field, especially in emergency medicine, although it's been around since the '90s. There is limited patient outcomes evidence so far. In emergency medicine, our best studied area of patient outcomes is in behavioral health and behavioral health crises. So we have data to say that comprehensive training and trauma informed care for emergency room staff results in both a decrease in the total number of patients that we have to place in any kind of physical or chemical restraint and it decreases the amount of time that all patients spend in any kind of physical or chemical restraint, and what was really cool about that study in particular is it also showed that through trauma informed care training, that institution was able to reduce the racial disparities that they had in restraint use as well.
There's other areas that have been studied that the data is not statistically significant, although there is some limited data out there to suggest that, again, kind of comprehensive trauma informed care at an institutional level can reduce staff burnout. And then in patient care, there was another QA study that looked at patient pain perception that showed maybe a signal that if we are practicing trauma informed care, patients perceive less pain, but again those last two unfortunately were not statistically significant yet, but I think as more research comes out we'll find more ways that this is truly impacting patient outcomes.
Young: Would you be able to provide a couple of examples of trauma-informed communication and clinical practice?
Dr Brown: Sure, so usually when I'm trying to think about how I'm framing trauma informed care and what practices are actually trauma informed care, I use the SAMHSA's six principles. One of the most important of those is empowerment. So when I'm able, I try to offer patient choices in the clinical interaction. We teach our medical students about trauma informed procedures, and so a lot of that is offering patients, you know, a position of comfort. Is it more comfortable for you to sit like this or like that for the procedure? If the procedure is going to be painful, would you prefer oral pain medication or would you prefer that we do the shot of lidocaine in the wound itself? So much of when people experience trauma and adversity is about a loss of control, that as much as we're able to in the clinical interaction, in our communication with patients, reintroduce some power and some choice, that's a great way to actually demonstrate trauma informed care in your communication.
Young: What are some specific trauma informed communication practices that emergency physicians in particular can adopt quickly, particularly when interacting with patients in acute distress?
Dr Brown: A couple pointers that I teach the residents, if it's a patient who's maybe you're performing a physical exam and they're becoming distressed, we talk about grounding exercises, and there's actually some great data behind grounding exercises, both in the social work literature, all the way up to performance psychology and the military teaches grounding exercises as well. Those can be simple breathing exercises, like square breathing where you have patients inhale for four, hold their breath for four, exhale for four, and then hold again, and then exhale for four. But even a simple breathing exercise in that moment can help a patient come back into their window of tolerance and be better able to engage.
There's a couple of things emergency physicians can do if it's a patient who is maybe very upset with their care. A couple of things that I do very rapidly is to establish trust. Trust is one of the principles. I usually do that by validating their experience and concern. I'll say something like, "I'm sorry you felt ignored the last time you were in the emergency department." And then I flip to collaboration, another one of the principles, and try to rapidly identify the patient's main concern and then collaborate, coordinate with the patient to address that. So I'll say, you know, if pain is their main concern, I'll say something like, “I also want to treat your pain. Help me do that. What has worked well for you in the past?” So in that way, we're collaborating, and then we're even empowering the patient to become involved in their care. Share with us share with us the answer, help us get to the right answer as quickly as possible for you.
Young: Could you also provide some examples for how to adopt trauma informed communication practices in a behavioral crisis?
Dr Brown: This comes up not infrequently in emergency medicine, where we interact with patients with behavioral health crisis. I think two really important, I guess three important principles. The first being safety. We need to make sure that in those interactions that our staff are safe and feel safe, as well as we're also trying to protect the patient and maintain their own safety.
Transparency is really important that's one of the principles and usually for patients I demonstrate this in terms of setting very clear limits. I identify this behavior, whether that is yelling, swearing, you know, maybe it's being physically aggressive with staff. I say this behavior and identify it will result in this consequence. And I clearly state what the consequence will be. If that's either has to be physical restraint or restraint with medication. And then I try to offer some control back into that situation as well. I always offer patients the opportunity to take oral medication or I offer them, you know, a chance to stop their behavior, return to their room, and if they're not able to do that, they know what the consequence is. It's not a perfect system, but as much as we're able to reintroduce those principles of trauma informed care into that interaction, hopefully that keeps our staff and our patients safe.
Young: Thank you so much for joining us on the podcast today. We appreciate your time.