THE VOICE OF EXPERIENCE
Assessing and Optimizing Imaging of Patients with Posttraumatic Stress Disorder Jessica C. Germino, MD, Elliot J. Rapp, MD, Daniel S. Hippe, MS, Anura C. Shah, LICSW, MHA, Miles E. McFall, PhD, Puneet Bhargava, MD THE PROBLEM: RADIOLOGY PREPAREDNESS TO SERVE PATIENTS WITH POSTTRAUMATIC STRESS DISORDER
Posttraumatic stress disorder (PTSD) is more common among military veterans than the general public. According to recent estimates the prevalence of PTSD among deployed veterans is 14% to 16% [1]. Patients with PTSD are known to reexperience psychological distress when exposed to triggers (internal or external) that “resemble or symbolize an aspect of a traumatic event [2]”. Furthermore, they may experience flashbacks (reliving a previous traumatic experience), make deliberate efforts to avoid stimuli associated with a traumatic event, or have persistent anxiety or increased arousal [2]. As with the general population, patients with PTSD may require diagnostic imaging for workup of medical problems. Most radiologic examinations require patients to comply with instructions and may invoke anxiety, fear, or discomfort [3-9]. Moreover, placement in a confined space for an extended period of time may be problematic for the patient with PTSD, especially if external triggers resemble a previous traumatic event. A notable example is the bore of an MRI scanner, a tightly enclosed space in which patients must remain for up to an hour or more [4]. We conducted a quality assessment and quality improvement (QA/QI) project to evaluate our preparedness to serve patients with PTSD and identified steps we can take to improve the imaging experience of this population in the future.
WHAT WE DID
After approval by the departmental QA/QI committee, we elected to survey our staff (attending radiologists, radiology residents/fellows, technologists, front desk personnel, and other staff) regarding their personal experiences with patients with PTSD, their knowledge of the disorder, and their comfort level at adequately and safely meeting the needs of this population. Next, we evaluated whether or not our department adequately utilizes existing resources within the Veterans Affairs (VA) system. Our colleagues in the Department of Psychiatry and Behavioral Sciences taught us how to recognize symptoms of PTSD and helped us understand how we can better support the needs of this patient population. We met with the Program Coordinator for Prevention and Management of Disruptive Behavior to discuss resources for staff training. Additionally, we learned about the protocols and procedures of a code green, which denotes either (1) a behavioral emergency that is dangerous to the patient, staff, or other patients; or (2) an acutely disruptive patient who cannot be successfully and safely de-escalated by normal procedures. Other VA departments that similarly have procedure-based encounters with patients with PTSD, such as the Department of Dentistry, have developed dedicated staff training modules. We viewed the dentistry intranet module on PTSD to learn from their experiences with this patient population. We met with representatives from the VA Police Department to discuss the role of
ª 2014 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.10.020
law enforcement action in the context of caring for patients exhibiting hostile or aggressive behavior and employing de-escalation techniques. Finally, based on the above discussions and staff survey results (described later), we determined that our department is in need of additional training on (1) recognizing PTSD; (2) successfully completing radiologic studies involving patients with PTSD; (3) de-escalating disruptive behavior when necessary; and (4) identifying emergency behavioral situations and properly utilizing emergency resources, such as code greens and the panic button available at our front desk. We organized a departmental staff training session, in collaboration with a psychologist with PTSD expertise and a VA Police sergeant, to impart these findings and provide additional staff training on working with patients with PTSD. OUTCOMES: STAFF SURVEY RESULTS AND RECOGNIZING THE NEED FOR RADIOLOGYSPECIFIC STAFF TRAINING ON PTSD
We distributed 50 surveys to department staff with 40 returned (80%). The voluntary survey evaluated respondents’ comfort in identifying symptoms of PTSD and determined if staff members felt prepared to handle encounters with this patient population. On average, respondents were “unsure” of their ability to recognize PTSD symptoms and had similar uncertainty regarding preparedness to work with patients with PTSD. Residents and fellows reported lower levels of comfort and preparation than 1
2 The Voice of Experience
Table 1. Responses to radiology staff survey on preparedness to serve patients with PTSD All Residents/ Variable Respondents Attendings Fellows Technologists Respondents, n (%) Level of comfort, mean (SD, range)† Level of preparedness, mean (SD, range)† Hours of PTSD training in last year, mean (SD, range) Hours of PTSD training in career, mean (SD, range) Adequate preparation, percent responding “yes” Adequate environment, percent responding “yes” Prior experience with patient with PTSD, percent responding “yes”
Other*
40 (100) 3.1 (1.0, 1-5) 3.0 (1.1, 1-5)
8 (20) 3.4 (1.3, 1-5) 2.9 (1.4, 1-5)
10 (25) 2.1 (1, 1-4) 2.2 (0.9, 1-4)
18 (45) 3.3 (0.6, 2-4) 3.4 (0.8, 2-4)
4 (10) 3.8 (1, 3-5) 3 (1.7, 1-4)
0.6 (1.7, 0-10)
0.6 (0.7, 0-2)
0.25 (0.6, 0-2)
0.6 (2.5, 0-10)
1.8 (0.3, 1.5-2)
2.8 (4.2, 0-20)
4 (2.9, 0-10)
1.4 (0.7, 0-2)
1 (2.5, 0-10)
10.5 (7.4, 2-20)
13%
25%
20%
11%
0%
55%
38%
70%
56%
75%
40%
50%
10%
50%
50%
*“Other” staff include front desk and file room personnel. †Likert scale wherein 1¼ very uncomfortable or very unprepared and 5 ¼ very comfortable or very prepared.
other participant groups (Table 1). Finally, in an open response section of the survey, staff offered suggestions for improving departmental personnel interactions with patients with PTSD, as summarized in Figure 1. SOLUTIONS AND FEEDBACK
Our survey and informal discussion with staff, colleagues, and ancillary departments indicated that staff education regarding PTSD was the area of highest need. This is illustrated by the fact that although 55% of respondents reported that their work environment was appropriately configured to safely complete radiologic studies in patients with PTSD, only 13% felt personally prepared to safely and effectively
serve these patients (Table 1). Furthermore, most staff members did not know about resources provided by the Prevention and Management of Disruptive Behavior Program or the availability of code greens and a panic button within our department. For these reasons, we organized a multidisciplinary learning session upon completing the QA/QI project to present survey results and educate staff. The conference incorporated the following: (1) discussion of PTSD symptoms facilitated by a psychologist with PTSD expertise; (2) information regarding management of disruptive behavior (code greens and the role of police action) provided by a sergeant from the VA Police Department; and (3)
Fig 1. Radiology do’s and don’ts: staff suggestions for improving the imaging experience of patients with PTSD.
presentation of teaching materials developed by the Prevention and Management of Disruptive Behavior Program. Finally, we directed staff to an informative VA Talent Management System web module on recognizing signs of stress and escalation in behaviors. Our second area of focus was to proactively recognize potentially negative patient experiences or adverse situations in our department before they occur. Based on survey results and our discussions with staff, it was clear that technologists desire methods to identify and better serve patients with PTSD. Such methods might involve taking extra care when describing an examination or allowing more time to complete a study or procedure. Given concern regarding potential invasion of privacy and sensitive mental health information, staff experts recommended that technologists do not personally screen patients by asking whether or not they have PTSD. Although the diagnosis is usually indicated in the problem list in the electronic medical record, most technologists indicated they do not routinely have time to check the electronic medical record. Furthermore, given the notable prevalence of PTSD among the VA Medical Center population
The Voice of Experience 3
(and acknowledging that most patients complete radiologic studies without incident), we determined that screening patients for PTSD before studies is not an efficient use of resources. For these reasons, we focused instead on imaging modalities considered higher risk for inducing anxiety or stress reactions in patients with PTSD, notably MRI [10-13]. We hope to identify patients at risk for such a reaction by adding the following question to our MRI safety sheet: “Have you ever been unable to tolerate an MRI exam for reasons such as claustrophobia, fear or anxiety?” If the response is “yes”, the provider would be asked to call the radiologist to discuss alternatives (eg, sedation, open MRI, or employing a different imaging modality). An abbreviated protocol may also increase the likelihood that the patient will successfully complete the radiologic examination. We believe optimizing the imaging experience of the patient
with PTSD is a valuable area for improved awareness and future research. ACKNOWLEDGMENTS
The authors thank Sergeant Nicholas Wigginton of VA Police for his contributions to radiology staff training on PTSD. REFERENCES 1. Gates MA, Holowka DW, Vasterling JJ, et al. Posttraumatic stress disorder in veterans and military personnel: epidemiology, screening, and case recognition. Psychol Serv 2012;9:361-82. 2. American Psychiatric Association. Diagnostic criteria from DSM-IV-TR. Washington, D.C.: American Psychiatric Association; 2000. 3. Nightingale JM, Murphy FJ, Blakeley C. ‘I thought it was just an x-ray’: a qualitative investigation of patient experiences in cardiac SPECT-CT imaging. Nucl Med Commun 2012;33:246-54. 4. Quirk ME, Letendre AJ, Ciottone RA, et al. Evaluation of three psychologic interventions to reduce anxiety during MR imaging. Radiology 1989;173:759-62. 5. Melendez JC, McCrank E. Anxiety-related reactions associated with magnetic
resonance imaging examinations. JAMA 1993;270:745-7. 6. Depies M, Balint S, Guell M, et al. MRI anxiety reduction. Adm Radiol 1991;10:43-4, 8. 7. Murphy F. Understanding the humanistic interaction with medical imaging technology. Radiography 2001;7:193-201. 8. Thorpe S, Salkovskis PM, Dittner A. Claustrophobia in MRI: the role of cognitions. Magn Reson Imaging 2008;26: 1081-8. 9. Dewey M, Schink T, Dewey CF. Claustrophobia during magnetic resonance imaging: cohort study in over 55,000 patients. J Magn Reson Imaging 2007;26:1322-7. 10. Kilborn LC, Labbe EE. Magnetic resonance imaging scanning procedures: development of phobic response during scan and at onemonth follow-up. J Behav Med 1990;13: 391-401. 11. Lukins R, Davan IG, Drummond PD. A cognitive behavioural approach to preventing anxiety during magnetic resonance imaging. J Behav Ther Exp Psychiatry 1997;28:97-104. 12. Eshed I, Althoff CE, Hamm B, et al. Claustrophobia and premature termination of magnetic resonance imaging examinations. J Magn Reson Imaging 2007;26:401-4. 13. Thorp D, Owens RG, Whitehouse G, et al. Subjective experiences of magnetic resonance imaging. Clin Radiol 1990;41:276-8.
Jessica C. Germino, MD, Elliot J. Rapp, MD, Daniel S. Hippe, MS are from Department of Radiology, University of Washington, Seattle, Washington. Anura C. Shah, LICSW, MHA, is from Department of Prevention and Management of Disruptive Behavior, Veterans Affairs Puget Sound Health Care System, Seattle Division, Seattle, Washington. Miles E. McFall, PhD, is from Veterans Affairs Puget Sound Health Care System, Seattle Division, Seattle, Washington, and University of Washington, Department of Psychiatry and Behavioral Sciences Seattle, Washington. Puneet Bhargava, MD, is from Department of Radiology, University of Washington, Seattle, Washington and from VA Puget Health Care System, Seattle, Washington. Puneet Bhargava, MD, Unviersity of Washington and VA Puget Sound Health Care System, Seattle Division, Diagnostic Imaging Services, S-114-RAD, 1660 S Columbian Way, Mail Box 358280, Seattle, WA 98108; e-mail: [email protected].
Assessing and Optimizing Imaging of Patients with Posttraumatic Stress Disorder Jessica C. Germino, MD, Elliot J. Rapp, MD, Daniel S. Hippe, MS, Anura C. Shah, LICSW, MHA, Miles E. McFall, PhD, Puneet Bhargava, MD THE PROBLEM: RADIOLOGY PREPAREDNESS TO SERVE PATIENTS WITH POSTTRAUMATIC STRESS DISORDER
Posttraumatic stress disorder (PTSD) is more common among military veterans than the general public. According to recent estimates the prevalence of PTSD among deployed veterans is 14% to 16% [1]. Patients with PTSD are known to reexperience psychological distress when exposed to triggers (internal or external) that “resemble or symbolize an aspect of a traumatic event [2]”. Furthermore, they may experience flashbacks (reliving a previous traumatic experience), make deliberate efforts to avoid stimuli associated with a traumatic event, or have persistent anxiety or increased arousal [2]. As with the general population, patients with PTSD may require diagnostic imaging for workup of medical problems. Most radiologic examinations require patients to comply with instructions and may invoke anxiety, fear, or discomfort [3-9]. Moreover, placement in a confined space for an extended period of time may be problematic for the patient with PTSD, especially if external triggers resemble a previous traumatic event. A notable example is the bore of an MRI scanner, a tightly enclosed space in which patients must remain for up to an hour or more [4]. We conducted a quality assessment and quality improvement (QA/QI) project to evaluate our preparedness to serve patients with PTSD and identified steps we can take to improve the imaging experience of this population in the future.
WHAT WE DID
After approval by the departmental QA/QI committee, we elected to survey our staff (attending radiologists, radiology residents/fellows, technologists, front desk personnel, and other staff) regarding their personal experiences with patients with PTSD, their knowledge of the disorder, and their comfort level at adequately and safely meeting the needs of this population. Next, we evaluated whether or not our department adequately utilizes existing resources within the Veterans Affairs (VA) system. Our colleagues in the Department of Psychiatry and Behavioral Sciences taught us how to recognize symptoms of PTSD and helped us understand how we can better support the needs of this patient population. We met with the Program Coordinator for Prevention and Management of Disruptive Behavior to discuss resources for staff training. Additionally, we learned about the protocols and procedures of a code green, which denotes either (1) a behavioral emergency that is dangerous to the patient, staff, or other patients; or (2) an acutely disruptive patient who cannot be successfully and safely de-escalated by normal procedures. Other VA departments that similarly have procedure-based encounters with patients with PTSD, such as the Department of Dentistry, have developed dedicated staff training modules. We viewed the dentistry intranet module on PTSD to learn from their experiences with this patient population. We met with representatives from the VA Police Department to discuss the role of
ª 2014 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.10.020
law enforcement action in the context of caring for patients exhibiting hostile or aggressive behavior and employing de-escalation techniques. Finally, based on the above discussions and staff survey results (described later), we determined that our department is in need of additional training on (1) recognizing PTSD; (2) successfully completing radiologic studies involving patients with PTSD; (3) de-escalating disruptive behavior when necessary; and (4) identifying emergency behavioral situations and properly utilizing emergency resources, such as code greens and the panic button available at our front desk. We organized a departmental staff training session, in collaboration with a psychologist with PTSD expertise and a VA Police sergeant, to impart these findings and provide additional staff training on working with patients with PTSD. OUTCOMES: STAFF SURVEY RESULTS AND RECOGNIZING THE NEED FOR RADIOLOGYSPECIFIC STAFF TRAINING ON PTSD
We distributed 50 surveys to department staff with 40 returned (80%). The voluntary survey evaluated respondents’ comfort in identifying symptoms of PTSD and determined if staff members felt prepared to handle encounters with this patient population. On average, respondents were “unsure” of their ability to recognize PTSD symptoms and had similar uncertainty regarding preparedness to work with patients with PTSD. Residents and fellows reported lower levels of comfort and preparation than 1
2 The Voice of Experience
Table 1. Responses to radiology staff survey on preparedness to serve patients with PTSD All Residents/ Variable Respondents Attendings Fellows Technologists Respondents, n (%) Level of comfort, mean (SD, range)† Level of preparedness, mean (SD, range)† Hours of PTSD training in last year, mean (SD, range) Hours of PTSD training in career, mean (SD, range) Adequate preparation, percent responding “yes” Adequate environment, percent responding “yes” Prior experience with patient with PTSD, percent responding “yes”
Other*
40 (100) 3.1 (1.0, 1-5) 3.0 (1.1, 1-5)
8 (20) 3.4 (1.3, 1-5) 2.9 (1.4, 1-5)
10 (25) 2.1 (1, 1-4) 2.2 (0.9, 1-4)
18 (45) 3.3 (0.6, 2-4) 3.4 (0.8, 2-4)
4 (10) 3.8 (1, 3-5) 3 (1.7, 1-4)
0.6 (1.7, 0-10)
0.6 (0.7, 0-2)
0.25 (0.6, 0-2)
0.6 (2.5, 0-10)
1.8 (0.3, 1.5-2)
2.8 (4.2, 0-20)
4 (2.9, 0-10)
1.4 (0.7, 0-2)
1 (2.5, 0-10)
10.5 (7.4, 2-20)
13%
25%
20%
11%
0%
55%
38%
70%
56%
75%
40%
50%
10%
50%
50%
*“Other” staff include front desk and file room personnel. †Likert scale wherein 1¼ very uncomfortable or very unprepared and 5 ¼ very comfortable or very prepared.
other participant groups (Table 1). Finally, in an open response section of the survey, staff offered suggestions for improving departmental personnel interactions with patients with PTSD, as summarized in Figure 1. SOLUTIONS AND FEEDBACK
Our survey and informal discussion with staff, colleagues, and ancillary departments indicated that staff education regarding PTSD was the area of highest need. This is illustrated by the fact that although 55% of respondents reported that their work environment was appropriately configured to safely complete radiologic studies in patients with PTSD, only 13% felt personally prepared to safely and effectively
serve these patients (Table 1). Furthermore, most staff members did not know about resources provided by the Prevention and Management of Disruptive Behavior Program or the availability of code greens and a panic button within our department. For these reasons, we organized a multidisciplinary learning session upon completing the QA/QI project to present survey results and educate staff. The conference incorporated the following: (1) discussion of PTSD symptoms facilitated by a psychologist with PTSD expertise; (2) information regarding management of disruptive behavior (code greens and the role of police action) provided by a sergeant from the VA Police Department; and (3)
Fig 1. Radiology do’s and don’ts: staff suggestions for improving the imaging experience of patients with PTSD.
presentation of teaching materials developed by the Prevention and Management of Disruptive Behavior Program. Finally, we directed staff to an informative VA Talent Management System web module on recognizing signs of stress and escalation in behaviors. Our second area of focus was to proactively recognize potentially negative patient experiences or adverse situations in our department before they occur. Based on survey results and our discussions with staff, it was clear that technologists desire methods to identify and better serve patients with PTSD. Such methods might involve taking extra care when describing an examination or allowing more time to complete a study or procedure. Given concern regarding potential invasion of privacy and sensitive mental health information, staff experts recommended that technologists do not personally screen patients by asking whether or not they have PTSD. Although the diagnosis is usually indicated in the problem list in the electronic medical record, most technologists indicated they do not routinely have time to check the electronic medical record. Furthermore, given the notable prevalence of PTSD among the VA Medical Center population
The Voice of Experience 3
(and acknowledging that most patients complete radiologic studies without incident), we determined that screening patients for PTSD before studies is not an efficient use of resources. For these reasons, we focused instead on imaging modalities considered higher risk for inducing anxiety or stress reactions in patients with PTSD, notably MRI [10-13]. We hope to identify patients at risk for such a reaction by adding the following question to our MRI safety sheet: “Have you ever been unable to tolerate an MRI exam for reasons such as claustrophobia, fear or anxiety?” If the response is “yes”, the provider would be asked to call the radiologist to discuss alternatives (eg, sedation, open MRI, or employing a different imaging modality). An abbreviated protocol may also increase the likelihood that the patient will successfully complete the radiologic examination. We believe optimizing the imaging experience of the patient
with PTSD is a valuable area for improved awareness and future research. ACKNOWLEDGMENTS
The authors thank Sergeant Nicholas Wigginton of VA Police for his contributions to radiology staff training on PTSD. REFERENCES 1. Gates MA, Holowka DW, Vasterling JJ, et al. Posttraumatic stress disorder in veterans and military personnel: epidemiology, screening, and case recognition. Psychol Serv 2012;9:361-82. 2. American Psychiatric Association. Diagnostic criteria from DSM-IV-TR. Washington, D.C.: American Psychiatric Association; 2000. 3. Nightingale JM, Murphy FJ, Blakeley C. ‘I thought it was just an x-ray’: a qualitative investigation of patient experiences in cardiac SPECT-CT imaging. Nucl Med Commun 2012;33:246-54. 4. Quirk ME, Letendre AJ, Ciottone RA, et al. Evaluation of three psychologic interventions to reduce anxiety during MR imaging. Radiology 1989;173:759-62. 5. Melendez JC, McCrank E. Anxiety-related reactions associated with magnetic
resonance imaging examinations. JAMA 1993;270:745-7. 6. Depies M, Balint S, Guell M, et al. MRI anxiety reduction. Adm Radiol 1991;10:43-4, 8. 7. Murphy F. Understanding the humanistic interaction with medical imaging technology. Radiography 2001;7:193-201. 8. Thorpe S, Salkovskis PM, Dittner A. Claustrophobia in MRI: the role of cognitions. Magn Reson Imaging 2008;26: 1081-8. 9. Dewey M, Schink T, Dewey CF. Claustrophobia during magnetic resonance imaging: cohort study in over 55,000 patients. J Magn Reson Imaging 2007;26:1322-7. 10. Kilborn LC, Labbe EE. Magnetic resonance imaging scanning procedures: development of phobic response during scan and at onemonth follow-up. J Behav Med 1990;13: 391-401. 11. Lukins R, Davan IG, Drummond PD. A cognitive behavioural approach to preventing anxiety during magnetic resonance imaging. J Behav Ther Exp Psychiatry 1997;28:97-104. 12. Eshed I, Althoff CE, Hamm B, et al. Claustrophobia and premature termination of magnetic resonance imaging examinations. J Magn Reson Imaging 2007;26:401-4. 13. Thorp D, Owens RG, Whitehouse G, et al. Subjective experiences of magnetic resonance imaging. Clin Radiol 1990;41:276-8.
Jessica C. Germino, MD, Elliot J. Rapp, MD, Daniel S. Hippe, MS are from Department of Radiology, University of Washington, Seattle, Washington. Anura C. Shah, LICSW, MHA, is from Department of Prevention and Management of Disruptive Behavior, Veterans Affairs Puget Sound Health Care System, Seattle Division, Seattle, Washington. Miles E. McFall, PhD, is from Veterans Affairs Puget Sound Health Care System, Seattle Division, Seattle, Washington, and University of Washington, Department of Psychiatry and Behavioral Sciences Seattle, Washington. Puneet Bhargava, MD, is from Department of Radiology, University of Washington, Seattle, Washington and from VA Puget Health Care System, Seattle, Washington. Puneet Bhargava, MD, Unviersity of Washington and VA Puget Sound Health Care System, Seattle Division, Diagnostic Imaging Services, S-114-RAD, 1660 S Columbian Way, Mail Box 358280, Seattle, WA 98108; e-mail: [email protected].
