Selection and Implementation of a Screening and Referral Process for Acute Stress Disorder and Post-Traumatic Stress Disorder in Orthopedic Trauma Patients
DOI:
https://doi.org/10.55576/job.v6i3.89Keywords:
Post-traumatic stress disorder, PTSD, Acute Stress Disorder (ASD), Orthopedic TraumaAbstract
Objectives: In 2022 the American College of Surgeons (ACS) Best Practice Guidelines (BPG) placed a greater emphasis on the implementation of a screening and referral process for patients at high risk for the development of psychological sequalae after trauma. Our center selected and implemented a verified predictive tool to screen for Acute Stress Disorder (ASD) and Post-traumatic Stress Disorder (PTSD). The aim of this study is to evaluate the implementation of this protocol among orthopedic trauma patients to better understand the psychological burden carried by this patient population and to highlight the importance of incorporating mental health screening into orthopedic trauma care.
Design: Retrospective case series
Setting: Level II Trauma Center
Patients: 710 orthopedic trauma patients aged 8 and above who presented to our facility between March 25, 2024 and May 31, 2025
Outcome Measures: Psychological Distress Score, Screening Compliance
Results:
3052 trauma patients aged 8 and older were admitted to our facility between March 25, 2024 and May 31, 2025. 710 patients had Orthopedic injuries. Point value correlation with risk potential was the same for all ages. 407 (57%) of patients were screened, with 326 (80%) scoring 0-13 (low risk), 45 (11%) scoring 7-13 (moderate risk), and 34 (8%) scoring >23 (high risk). Spearman analyses showed significant associations between age and hospital LOS (ρ=0.16, p<0.001), ISS and LOS (ρ=0.40, p<0.001), age and risk score (ρ=−0.20, p<0.001), and LOS and risk score (ρ=0.17, p<0.001). No significant correlations were observed between ISS and age (ρ≈0, p=0.98) or between ISS and risk score (ρ=0.04, p=0.07).
Conclusions: Implementation of a risk-stratifying screening and referral process illuminates the prevalence of ASD/PTSD predictors in orthopedic trauma patients. Identifying patients in need of intervention can help optimize post-injury psychological, physiological success, and reduce financial burden on hospitals.
Key Words: Post-traumatic stress disorder, PTSD, Acute Stress Disorder (ASD), Orthopedic Trauma
LEVEL OF EVIDENCE: Level III
References
deRoon-Cassini TA, Hunt JC, Geier TJ, et al. Screening and treating hospitalized trauma survivors for posttraumatic stress disorder and depression. J Trauma Acute Care Surg. 2019;87(2):440–450. doi:10.1097/TA.0000000000002370
Lowe SR, Ratanatharathorn A, Lai BS, et al. Posttraumatic stress disorder symptom trajectories within the first year following emergency department admissions: pooled results from the International Consortium to Predict PTSD. Psychol Med. 2021;51(7):1129–1139. doi:10.1017/S0033291719004008
Moss J, Roberts MB, Shea L, et al. Association between perceived threat and the development of posttraumatic stress disorder symptoms in patients with life-threatening medical emergencies. Acad Emerg Med. 2020;27(2):109–116. doi:10.1111/acem.13877
Joseph NM, Benedick A, Flanagan CD, Breslin MA, Vallier HA. Risk factors for posttraumatic stress disorder in acute trauma patients. J Orthop Trauma. 2021;35(6):e209–e215. doi:10.1097/BOT.0000000000001990
Jaramillo S, Suffoletto B, Callaway C, Pacella-LaBarbara M. Early screening for posttraumatic stress disorder and depression among injured emergency department patients: a feasibility study. Acad Emerg Med. 2019;26(11):1232–1244. doi:10.1111/acem.13816
Agarwal TM, Muneer M, Asim M, et al. Psychological trauma in different mechanisms of traumatic injury: a hospital-based cross-sectional study. PLOS ONE. 2020;15(11):e0242849. doi:10.1371/journal.pone.0242849
Spoont MR, Williams JW, Kehle-Forbes S, et al. Does this patient have posttraumatic stress disorder? Rational clinical examination systematic review. JAMA. 2015;314(5):501–510. doi:10.1001/jama.2015.7877
Kartiko S, Atahar J, Rattan R, et al. Posttraumatic stress disorder mitigation in trauma patients: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2025. Advance online publication. doi:10.1097/TA.0000000000004639
Schultebraucks K, Shalev AY, Michopoulos V, et al. A validated predictive algorithm of post-traumatic stress course following emergency department admission after a traumatic stressor. Nat Med. 2020;26(7):1084–1088. doi:10.1038/s41591-020-0951-z
Wafa MH, Viprey M, Magaud L, et al. Identification of biopsychosocial factors predictive of post-traumatic stress disorder in patients admitted to the emergency department after a trauma (ISSUE): protocol for a multicenter prospective study. BMC Psychiatry. 2019;19(1):163. doi:10.1186/s12888-019-2154-z
LaRose M, Cunningham D, Paniagua A, Gage MJ. Long-term post-traumatic stress disorder after orthopaedic injury: prevalence and risk factors. J Orthop Trauma. 2022;36(4):e122–e128. doi:10.1097/BOT.0000000000002250
Muscatelli S, Spurr H, O’Hara NN, O’Hara LM, Sprague SA, Slobogean GP. Prevalence of depression and posttraumatic stress disorder after acute orthopaedic trauma: a systematic review and meta-analysis. J Orthop Trauma. 2017;31(1):47–55. doi:10.1097/BOT.0000000000000664
Wang X, Li X, Qi M, Hu X, Zhu H, Shi X. Incidence of post-traumatic stress disorder in survivors of traumatic fracture: a systematic review and meta-analysis. Psychol Health Med. 2022;27(4):902–916. doi:10.1080/13548506.2021.1957953
Starr AJ, Smith WR, Frawley WH, Borer DS, Morgan SJ, Reinert CM, Mendoza-Welch M. Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am. 2004;86(6):1115–1121. doi:10.2106/00004623-200406000-00001
Lee CH, Choi CH, Yoon SY, Lee JK. Posttraumatic stress disorder associated with orthopaedic trauma: a study in patients with extremity fractures. J Orthop Trauma. 2015;29(6):e198–e202. doi:10.1097/BOT.0000000000000255
Kang KK, Ciminero ML, Parry JA, Mauffrey C. The psychological effects of musculoskeletal trauma. J Am Acad Orthop Surg. 2021;29(7):e322–e329. doi:10.5435/JAAOS-D-20-00637
Vincent HK, Horodyski M, Vincent KR, Brisbane ST, Sadasivan KK. Psychological distress after orthopedic trauma: prevalence in patients and implications for rehabilitation. PM R. 2015;7(9):978–989. doi:10.1016/j.pmrj.2015.03.007
Chavez MA, Caplan JP, McKnight CA, et al. Early psychiatric consultation is associated with decreased cost and length of stay in the patient population at a Level I trauma center. Cureus. 2021;13(8):e17572. doi:10.7759/cureus.17572
Prater L, Bulger E, Maier RV, et al. Emergency department and inpatient utilization reductions and cost savings associated with trauma center mental health intervention: results from a 5-year longitudinal randomized clinical trial analysis. Ann Surg. 2024;279(1):17–23. doi:10.1097/SLA.0000000000006102
Brunet A, Weiss DS, Metzler TJ, Best SR, Neylan TC, Rogers C, Fagan J, Marmar CR. The Peritraumatic Distress Inventory: a proposed measure of PTSD criterion A2. Am J Psychiatry. 2001;158(9):1480–1485. doi:10.1176/appi.ajp.158.9.1480
Nishi D, Matsuoka Y, Yonemoto N, Noguchi H, Kim Y, Kanba S. Peritraumatic Distress Inventory as a predictor of post-traumatic stress disorder after a severe motor vehicle accident. Psychiatry Clin Neurosci. 2010;64(2):149–156. doi:10.1111/j.1440-1819.2010.02065.x
Guardia D, Brunet A, Duhamel A, Ducrocq F, Demarty AL, Vaiva G. Prediction of trauma-related disorders: a proposed cutoff score for the peritraumatic distress inventory. Prim Care Companion CNS Disord. 2013;15(1):PCC.12l01406. doi:10.4088/PCC.12l01406
Bunnell BE, Davidson TM, Ruggiero KJ. The Peritraumatic Distress Inventory: factor structure and predictive validity in traumatically injured patients admitted through a Level I trauma center. J Anxiety Disord. 2018;55:8–13. doi:10.1016/j.janxdis.2018.03.002
American College of Surgeons. Best Practices Guidelines: Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient. Chicago, IL: American College of Surgeons; 2022.
Nedder VJ, Breslin MA, Ho VP, Vallier HA. Prevalence of posttraumatic stress disorder in orthopedic trauma patients and a call to implement the Injured Trauma Survivor Screen as a prospective screening protocol in the United States. J Trauma Inj. 2024;37(1):67–73. doi:10.20408/jti.2023.0068
Simske NM, Audet MA, Kim CY, Benedick A, Vallier HA. Mental illness is associated with more pain and worse functional outcomes after ankle fracture. OTA Int. 2019;2(3):e037. doi:10.1097/OI9.0000000000000037
Weinberg DS, Narayanan AS, Boden KA, Breslin MA, Vallier HA. Psychiatric illness is common among patients with orthopaedic polytrauma and is linked with poor outcomes. J Bone Joint Surg Am. 2016;98(5):341–348. doi:10.2106/JBJS.15.00751
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Pouyan Nasab, Alexa Rubenau, Nicholas Mannering, Frieda Hulka, Peter Althausen
This work is licensed under a Creative Commons Attribution 4.0 International License.
