http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2014; 28(4): 448–455 ! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.890746

ORIGINAL ARTICLE

The emergency department social work intervention for mild traumatic brain injury (SWIFT-Acute): A pilot study Megan Moore1, Amy Winkelman2,3, Sharon Kwong4, Steven P. Segal5, Geoffrey T. Manley2,3, & Martha Shumway6 1

School of Social Work, University of Washington, Seattle, WA, USA, 2Brain and Spinal Cord Injury Center, University of California, San Francisco, CA, USA, 3Neurosurgery Department, San Francisco General Hospital and Trauma Center, 44Department of Social Services, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA, 5School of Social Welfare, University of California, Berkeley, CA, USA, and 6Department of Psychiatry, University of California, San Francisco, CA, USA Abstract

Keywords

Objective: To determine acceptability and preliminary effectiveness of Emergency Department (ED) Social Work Intervention for Mild Traumatic Brain Injury (SWIFT-Acute) on alcohol use, community functioning, depression, anxiety, post-concussive symptoms, post-traumatic stress disorder and service use. Methods: This study enrolled 64 patients who received head CT after mild traumatic brain injury (mTBI) and were discharged 524 hours from a Level 1 trauma centre ED. The cohort study compared outcomes for SWIFT-Acute (n ¼ 32) and Usual Care (n ¼ 32) 3 months post-injury. SWIFT-Acute includes education about symptoms and decreasing alcohol use, coping strategies, reassurance and education about recovery process and follow-up guidelines and resources. Measures: Alcohol Use Disorders Identification Test (AUDIT), Community Integration Questionnaire (CIQ), Patient Health Questionnaire-4, Rivermead Post-concussion Symptoms Questionnaire, PTSD Checklist-Civilian, acceptability and service use surveys. Results: Paired t-test revealed SWIFT-Acute group maintained pre-injury community functioning; Usual Care significantly declined in functioning on the CIQ. Both groups reported ‘hazardous’ pre-injury drinking on AUDIT. Wilcoxon Signed Rank test showed the SWIFT-Acute group significantly reduced alcohol use; the Usual Care group did not. Both groups significantly increased medical service use. No statistically significant differences were found on other measures. Acceptability ratings were extremely high. Conclusions: SWIFT-Acute was acceptable to patients. There is preliminary evidence of effectiveness for reducing alcohol use and preventing functional decline. Future randomized studies are needed.

Brain injury, implementation, intervention study, treatment outcome.

Mild traumatic brain injury (mTBI) is a prevalent and costly public health problem with potentially disabling consequences. Common sequelae after mTBI include physical, cognitive and psychiatric symptoms [1]. In addition, substance abuse, including alcohol abuse, often co-occurs with TBI [2–5]. For the majority of patients, the physical, cognitive and psychiatric symptoms of mTBI resolve quickly. However, some 10–15% of individuals continue to report significant and often disabling symptoms 3 months or more after injury [6,7]. The exact prevalence and aetiology of prolonged symptomatology are not known. Researchers have hypothesized cumulative, multi-dimensional models that suggest pre-existing personality traits, life stressors, medical and psychiatric history, secondary gain, negative coping after Correspondance: Megan Moore, PhD, School of Social Work, University of Washington, 4101 15th Ave NE, Box 354900, Seattle, WA 981954900, USA. Tel: +1 206 616 2862. Fax: +1 206 543 1228. Email: [email protected]

Received 15 August 2013 Revised 13 January 2014 Accepted 28 January 2014 Published online 3 April 2014

injury or the combination of any of these factors contribute to the development of persistent post-concussive symptoms [6,8–10]. Substance abuse, including alcohol abuse, has also been associated with poor outcome after injury [2]. Other research suggests that severity and type of injury, such as traumatic axonal injury and brain lesion or skull fracture also contribute to poor outcome [11,12]. However, the relatively small percentage of mTBI patients with detectable and objectively measured structural injury on CT scan does not account for all patients reporting prolonged and significant symptoms, a commonly cited reason for dismissal of these patients’ problems as non-TBI related. Recent findings from the TRACK-TBI study indicated that understanding differential outcomes after mTBI has been hampered in part by limitations in the current diagnostic models [13]. In their recent study, 27% of patients with normal admission head CTs had an abnormal MRI [13]. Evidence of brain contusion or threshold haemorrhagic axonal injury on MRI were associated with poorer 3-month outcome after controlling for known socioeconomic confounders [13].

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Introduction

History

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This cumulative evidence suggests a sub-set of patients with mTBI suffer with disabling and prolonged postconcussive symptoms [6,7], substance abuse [2], contusion or haemorrhagic axonal injury [13] or some combination of these. These patients may require ongoing neuropsychological-social care. Meeting their needs requires augmenting medical care with acute psychosocial services and targeted linkage to appropriate follow-up services. Because there are no reliable models to acutely identify patients in the ED at risk for poor outcome, many of these patients are discharged from the ED and may be lost to follow-up afterwards. Therefore, providing brief psychosocial care in the ED that is guided by a multidimensional cumulative stressor model may be necessary to effectively prevent or alleviate physical, cognitive and psychiatric sequelae after mTBI. The multidimensional cumulative stressor model highlights the complexity of the development of poor outcomes after mTBI. Pre-existing psychological, social and environmental stressors interact with the physical, cognitive and emotional symptoms triggered by an mTBI and lead to prolonged recovery and poor outcome [8,14,15]. One such cumulative stressor model for development of post-concussion syndrome after mTBI includes (1) the mTBI injury, (2) predisposing factors such as anxiety, depression, life experiences and expectations, (3) social environmental factors such as social support and (4) perpetuating factors in three categories; cognition, emotion and behaviour [16]. As early as 2 weeks post-injury, the interaction of the perpetuating factors, including negative perceptions or cognitions about recovery after mTBI, stress, anxiety and depression and all-or-nothing behaviour, with a person’s injury severity, pre-existing problems and social environment were theoretically linked to risk of post-concussive syndrome development [16]. In addition to alcohol abuse intervention, interventions targeting these areas linked to the development of persistent post-concussive symptoms may be particularly promising [16]. Using accessible and efficient providers, such as social workers, who are already integrated into the current healthcare system may be a critical strategy to ensure uptake and endurance of such interventions. Several systematic reviews have assessed the effectiveness of psychosocial interventions for mTBI [17–21]. While results are not definitive, there is some evidence to support the use of early education and reassurance interventions. Typically, these interventions provide patients with information about mTBI, symptoms to expect, practical coping strategies and reassurance about expected recovery. Studies testing such interventions have reported a shorter timeline for recovery and improved outcomes and lower distress [22–26]. Early education and reassurance has been shown to be as effective as more extensive treatment in reducing symptoms after mTBI at 3 months and even 1 year post-injury [27,28]. Indeed, some form of an early educational intervention has been recommended by the Defense and Veterans Brain Injury Center [29] and in mTBI treatment guidelines from a Canadian expert panel [30]. However, the usefulness of such interventions may be over-stated in the literature [17] and interventions that enhance this basic model with a more targeted approach to improving post-concussive symptoms and other risk factors, such as alcohol use, are an important next step.

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Implementaion of an enhanced education and reassurance intervention may prove difficult given that implementation and consistent provision of the basic education and reassurance intervention in the trauma centre ED remains a difficult task that is not consistently performed [31]. Spending time outlining mTBI-specific symptoms, recovery recommendations and coping strategies and providing reassurance and follow-up resources is more time-consuming than giving patients brief, standard discharge instructions. ED medical providers, whose attention is often diverted by other high priority or life-threatening emergencies, may not be able to devote the extra time needed to provide this intervention to patients with mTBI. In addition, despite evidence of alcohol abuse as a risk factor for poor outcome, education and reassurance interventions have not typically included an alcohol use intervention. Social workers are trained, effective and available providers of biopsychosocial assessments, mental health and substance abuse services, case management and resource linkage in the ED [32]. They can contribute to the specialized care of individuals and their families suffering from the acute and chronic consequences of mTBI, particularly in the trauma centre ED where medical provider time must be appropriately diverted to address other patient needs. However, they have not been widely used in mTBI intervention studies, and it remains unclear whether their skills, with some minimal additional training on mTBI specific information, can be applied to working effectively with patients with mTBI. The pilot study presented here aimed to (1) assess acceptability of The Emergency Department Social Work Intervention for Mild Traumatic Brain Injury (SWIFT-Acute), as measured by participants ratings on the acceptability survey and (2) determine preliminary effectiveness of SWIFTAcute on alcohol use, community functioning, depression, anxiety and PTSD 3 months after mTBI. This study hypothesized that the SWIFT-Acute intervention would be acceptable to patients and positively impact patient outcomes when compared to Usual Care. Outcomes from the SWIFTAcute group were compared to a Usual Care group who received standard ED care only. In addition to alcohol use, SWIFT-Acute targets the cognitive, emotional and behavioural risk factors for development of persistent post-concussive symptoms identified in the mulitdimensional cumulative stressor model. SWIFT-Acute aims to prevent negative cognitions about the impact of the mTBI on the persons’ life by providing re-assurance and education about recovery process and follow-up guidelines; it targets post-concussive symptoms like headache and difficulty concentrating as well as anxiety and depression symptoms by providing education about the potential development of these symptoms and coping strategies; and SWIFT-Acute targets all-or-nothing behaviour by providing tips for healthy recovery and timelines to return to activities. In addition, SWIFT-Acute includes a brief alcohol intervention and resources for follow-up.

Methods Participants Institutional Review Board (IRB) approval was obtained from the University of California, San Francisco (UCSF). The

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University of California, Berkeley, operating under its Federal Wide Assurance, agreed to rely upon the decision made by the UCSF IRB and authorized the study. Participants were recruited from an urban, Level 1 trauma centre emergency department (ED) and enrolled from October 2011–June 2012. All participants had a confirmed mTBI diagnosis based on the World Health Organization recommended mTBI operational definition [33]. Participants met the following criteria: admitted to the ED within 48 hours of an acute traumatic brain injury; Glasgow Coma Scale score of 13–15 after 30 minutes post-injury or later upon presentation to the ED; presented with or reported any one of the following symptoms: confusion or disorientation, loss of consciousness for 30 minutes or less, post-traumatic amnesia for less than 24 hours, other transient neurological abnormalities (focal signs, seizure, intracranial lesion not requiring surgery); English speaking; had a working phone number; and received a head CT scan while being treated in the ED. The following served as exclusion criteria: patients 518 years of age; intracranial lesion requiring surgery; admission to an inpatient hospital unit from the ED; and patients in police custody. The study site utilizes both clinical judgement and ACEP/CDC criteria for head CT. Patients who meet these criteria generally have more severe injuries than mTBI patients not triaged to head CT. Therefore, this study included only patients who received a head CT in order to target patients with potentially more severe injuries, a risk factor for persistent postconcussive symptoms. A total of 64 persons with confirmed mTBI diagnoses were assessed 3 months post-injury. Participants in the Usual Care group (n ¼ 32) were identified via radiological scan records and mTBI diagnosis was confirmed via chart review. The Usual Care group was then contacted by telephone by study staff, provided with details of the study and consent was obtained. Participants in the SWIFT-Acute group (n ¼ 32) were identified and mTBI diagnosis confirmed by ED medical staff during the ED visit. Because SWIFT-Acute had been adopted as a standard of care at the study site prior to the initiation of the study, after identification by ED medical staff patients were provided with SWIFT-Acute in the ED. Study staff then contacted potential participants, provided details about the study and obtained informed consent. An IRB waiver of written consent was granted; verbal consent was obtained solely by telephone contact for both groups. Study staff attempted to contact all eligible potential participants. A total of 170 eligible patients who received Usual Care were identified. Contact was attempted but not successful for 116, 22 declined to participate and 32 (19%) were enrolled. The relatively low enrolment rate in this group was largely due to the short time window between identification of eligibility based on CT scan and time to research interview. A total of 58 eligible patients who received SWIFT-Acute were identified. Contact was attempted but not successful for 12, 14 declined to participate and 32 (55%) were enrolled in the SWIFT-Acute group. Outcome measures Baseline demographic and injury characteristics were collected via medical record review and during research

Brain Inj, 2014; 28(4): 448–455

interviews conducted by phone 3 months after injury. Both groups completed the Short Orientation Memory and Concentration Test (SOMCT) before the 3-month interview to determine cognitive ability to participate in the research interview [34]. Participants who did not receive a score of 23 or higher on the SOMCT (n ¼ 3) did not continue the research interview. This procedure was put into place as a protection for participants to ensure they were able to give informed consent. The outcome measures were the Alcohol Use Disorders Identification Test (AUDIT), the Community Integration Questionnaire (CIQ), qualitative patient acceptability survey, Patient Health Questionnaire-4 (PHQ-4), Rivermead Post-concussion Symptoms Questionnaire (RPQ), Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and service use survey. Changes in AUDIT, CIQ and service use were assessed during the 3-month interview using retrospective patient report of pre-injury status. Those reports were then compared to self-reported status 3 months post-injury. One research interviewer conducted all research interviews. The AUDIT is a 10-item scale used to assess the presence of an alcohol use disorder and to distinguish hazardous drinking and harmful use patterns. It has good internal consistency; mean across 18 studies (Cronbach’s alpha ¼ 0.83) [35]. The AUDIT has good test–re-test reliability and it satisfactorily identifies hazardous drinking [35]. The score range is 0–40, with a score of 8 or more indicating hazardous drinking [36]. The CIQ is a 15-item scale used to assess overall community integration, home integration, social integration and productive activity after TBI [37]. Patients were asked about their level of independence and participation in activities of daily living, social activities, finances and work activities. The CIQ has acceptable internal consistency (Cronbach’s alpha40.80 across three studies) and can distinguish between persons with TBI and controls [38]. Scores can range from 0–29, with higher scores indicating greater integration [38]. The PHQ-4 is a 4-item scale that combines the first two items on the Patient Health Questionnaire-9, which have been shown to reliably assess depressive disorders and the first two items on the Generalized Anxiety Disorder-7 scale, which have been shown to reliably assess anxiety disorders [39]. Patients are asked how often over the last 2 weeks they have experienced (1) feeling nervous, anxious or on edge, (2) not being able to stop or control worrying, (3) felt down, depressed or hopeless and (4) had little interest or pleasure in doing things on a 4-point scale (0 ¼ Not at all to 3 ¼ Nearly every day) [39]. The PHQ-4 has good internal consistency (Cronbach’s alpha ¼ 0.78) [40]. A score of 0–2 is considered normal, a score of 3–5 is considered mild depression/anxiety, a score of 6–8 is considered moderate depression/anxiety and a score of 9–12 is considered severe depression/anxiety [39]. The RPQ is a 16-item scale used to assess presence and severity of post-concussive symptoms commonly reported after TBI [41]. It asks patients to rate the degree to which the 16 most common post-concussive symptoms have been bothering them compared with before their injury on a 5-point scale (0 ¼ Not experienced at all to 4 ¼ A severe problem) [41]. The developers did not report reliability coefficients.

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Scatter plots indicating good test–re-test reliability over 24 hour re-test interval at 8 days post-injury and 10-day re-test interval at 6 months post-injury were reported [35]. The RPQ can distinguish presence of Post-Concussive Syndrome in patients with mTBI and can distinguish between patients ‘on sick leave’ from work and those who were not [35]. Scores range from 0–64, with higher scores indicating an increasing number and severity of symptoms. The PCL-C is a 17-item, self-reported scale that maps directly onto the Diagnostic and Statistical Manual of Mental Disorders IV for PTSD [35]. Patients are asked to identify to what degree they have experienced PTSD symptoms over the last 30 days on a 5-point scale (1 ¼ Not at all to 5 ¼ Extremely) [42]. The scale has good internal consistency (Cronbach’s alpha ¼ 0.94) and test–re-test reliability (r ¼ 0.88 at 2–3 days; r ¼ 0.88 at 1-week) [43,44]. The PCL-C has a score range from 17–85, with the cut-off for PTSD set at 50 points [42]. Participants in both groups were asked about number and type of medical appointments attended and psychiatric services used. Participants in the SWIFT-Acute group were asked to complete an acceptability survey that asked participants to identify parts of the intervention materials in order to determine accuracy of recall; they were asked to recall the concussion recovery tips and asked which, if any, they had used; they were asked about the helpfulness of the take home packet on a scale from 0 ¼ not at all helpful to 3 ¼ extremely helpful; they were asked two open-ended questions about (1) what was most helpful and (2) ideas for improving the intervention/materials. Intervention Development of SWIFT-Acute was a collaborative effort between ED social work and the Neurosurgery Department (NSU). NSU contributed the medical education and written material provided to participants in SWIFT-Acute. ED social work contributed suggestions for coping strategies and community resources. SWIFT-Acute targets the cognitive, emotional and behavioural risk factors for development of persistent post-concussive symptoms identified in the multidimensional cumulative stressor model. In particular, the intervention attempts to impact cognitions about the injury, emotions, including depression and anxiety and behaviour or return-to-activity. SWIFT-Acute was adapted from previously used mTBI interventions. The education component of the intervention includes a verbal explanation of a brochure or booklet that explains to the patients what an mTBI diagnosis means and common symptoms after mTBI; the patients are allowed to keep the brochure [22,24–26,28,45–48]. The purpose of education about mTBI is to legitimize and normalize symptoms and the goal is to reduce distress about symptoms. In addition, this study provided suggested coping strategies and community resources. The reassurance component of the intervention includes verbal explanation by a healthcare professional of expected symptoms, encouragement of a good recovery and explanation of common coping strategies used for common symptoms after mTBI [22,24,25,28,46,48]. The goals of reassurance are to normalize the symptoms and recovery, reduce distress about

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symptoms and provide ideas for coping within a construct of good recovery. Patients were instructed to call the NSU patient medical line if symptoms persisted beyond 1 month post injury. Discussion and education about reducing alcohol consumption was added. ED social workers participated in one-time group training on delivery of SWIFT-Acute and then booster trainings as needed. The group training was delivered during the staff retreat prior to the implementation of the intervention. Staff participated in an educational session on mTBI, the symptoms and recommended coping strategies, an overview of the intervention development process, an overview of the intervention, details of the intervention delivery process and specific guidelines on provision of the intervention. The booster session trainings were done on an as-needed basis if requested by social workers and periodic, individual checkins were conducted to answer any questions and informally assess reactions and adherence to the intervention model. In addition to a training packet, a checklist of the intervention components was used during training and during delivery of intervention. After medical provider referral, SWIFT-Acute was delivered by the ED social worker (n ¼ 7) on duty. The intervention can be completed in  10 minutes, but can take up to 20 minutes if patients have multiple questions. Patients who received SWIFT-Acute received usual medical care and a brief intervention meeting with a social worker in the ED the day of injury. During the meeting, social workers provided the written educational material and verbally discussed the material with the patients. Educational materials specifically included information about post-concussive symptoms, anxiety and depression and presented coping strategies for these symptoms. In order to target negative behaviours or all or nothing behaviours, recommendations for return-to-work/ school/activities, timelines for recovery and a brief alcohol intervention that included advice for no alcohol/drug use were discussed with patients. The next portion of the brief intervention targeted negative cognitions about the impact of mTBI and included reassurance and education about the recovery process and follow-up guidelines. Finally, patients were informed of community and medical resources to contact if they have further questions or if symptoms persisted beyond 1 month. The dedicated in-hospital NSU patient medical phone line was highlighted as a primary resource. Patients were instructed to call this line at any time with nonurgent medical questions related to the mTBI. After the verbal explanation of the material the social work staff answered any questions. See Table I for comparison of interventions provided in Usual Care and SWIFT-Acute. Analysis Baseline comparability of the Usual Care and SWIFT-Acute groups was examined. Characteristics compared included age, sex, race, marital status, insurance status and injury characteristics. In addition, these characteristics were compared amongst those eligible and not enrolled and those enrolled in order to assess enrollment bias. Group differences on categorical variables were examined with chi-square tests and differences on continuous variables were examined with

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Table I. Interventions provided in each group. Usual care Standard ED care

Table II. Baseline demographic and injury characteristics.

SWIFT-Acute Standard ED care Social work referral Social work intervention (SWIFT-Acute)  Education on common symptoms  Suggestions for coping strategies  Return-to-work/timelines for recovery  Brief educational alcohol intervention  Reassurance and education about recovery process; follow-up guidelines  Community resource provision  Discussion of patient questions Take home packet of information and resources discussed in social work meeting

the non-parametric Mann-Whitney U-test or t-test for the CIQ. All comparisons were done using two-tailed tests of significance with alpha ¼ 0.05. The paired sample t-test was used to assess community functioning outcomes. The non-parametric Mann Whitney test was used to compare groups on the PHQ-4, RPQ, PCL-C and the Wilcoxon Signed Rank test was used to compare groups on the AUDIT and service use survey. The impact of outliers was assessed by converting outcome scores to zscores and accounted for by using non-parametric tests when appropriate, which are robust to the presence of outliers. Quantitative analyses were done using SPSS version 18. Qualitative themes from the patient acceptability survey were identified through systematic review of all survey responses.

Results Outcomes The groups were comparable at baseline with regard to all demographic and injury characteristics assessed (see Table II). There was no enrolment bias in either group. Usual Care group enrollees were comparable to those not enrolled on all assessed characteristics, including sex, 2 (1, n ¼ 167) ¼ 0.678, p ¼ 0.410; race, 2 (3, n ¼ 165) ¼ 4.325, p ¼ 0.504; mechanism of injury, 2 (4, n ¼ 169) ¼ 1.859, p ¼ 0.762; loss of consciousness, 2 (1, n ¼ 152) ¼ 1.678, p ¼ 0.196; ETOH present, 2 (1, n ¼ 144) ¼ 3.367, p ¼ 0.067; GCS scores, Mean (enrolled) ¼ 14.63, Mean (not enrolled) ¼ 14.69, U ¼ 1874.500, z ¼ 0.800, p ¼ 0.424; and age, Mean (enrolled) ¼ 41.76, Mean (not enrolled) ¼ 38.99, U ¼ 1677.500, z ¼ 1.367, p ¼ 0.172. SWIFT-Acute Group enrollees were comparable to those not enrolled on all assessed characteristics, including sex, 2 (1, n ¼ 57) ¼ 0.143, p ¼ 0.706; race, 2 (3, n ¼ 56) ¼ 2.963, p ¼ 0.397; mechanism of injury, 2 (4, n ¼ 57) ¼ 6.246, p ¼ 0.182; loss of consciousness, 2 (1, n ¼ 48) ¼ 1.517, p ¼ 0.218; ETOH present, 2 (1, n ¼ 52) ¼ 0.026, p ¼ 0.873; GCS scores, Mean (enrolled) ¼ 14.58, Mean (not enrolled) ¼ 14.76, U ¼ 327.500, z ¼ 1.217, p ¼ 0.223; and age, Mean (enrolled) ¼ 36.44, Mean (not enrolled) ¼ 34.96, U ¼ 360.000, z ¼ 0.644, p ¼ 0.520. When interviewed 3 months post-injury, both groups reported pre-injury drinking in the ‘hazardous’ range. There was no significant pre-injury difference between the groups

Age (years, mean ± SD) Male Race White African American Latino Asian/PI/Native Am Married Insured Mechanism Assault Bike accident Motor vehicle accident Fall Other Loss of consciousness GCS ¼ 15 ETOH present

Usual care (n ¼ 32)* n (%)

SWIFT-Acute (n ¼ 32)** n (%)

43 ± 16 25 (78)

36 ± 16 22 (69)

19 4 6 3 9 23

(59) (13) (19) (9) (31) (79)

16 6 6 4 6 23

(50) (19) (19) (13) (19) (72)

12 7 2 8 3 27 19 13

(38) (22) (6) (25) (9) (84) (63) (41)

4 12 3 5 8 23 19 11

(13) (38) (9) (16) (25) (79) (61) (35)

p Value 0.091 0.396 0.849

0.266 0.501 0.075

0.817 0.798 0.674

Note: Numbers rounded to nearest whole number (except p values). *n ¼ 29 for Married and Insured; n ¼ 30 for Age due to missing data in chart; n ¼ 30 for GCS due to missing data in chart. **SWIFT-Acute Group: n ¼ 31 for ETOH present; n ¼ 29 for GCS due to missing data.

on the AUDIT (p ¼ 0.89). As shown in Table III, the SWIFTAcute group reported significantly reduced alcohol use from pre-injury to post-intervention (p50.05). The Usual Care group maintained their pre-injury level of drinking. There was no significant difference between the groups at baseline on the CIQ (p ¼ 0.83). Analysis of the community functioning measure revealed the SWIFT-Acute group maintained preinjury levels of community functioning, while the Usual Care group reported significant decline in functioning (p50.05). Both groups significantly increased medical service use following injury, but psychiatric service use did not significantly change in either group. All other analyses of outcome measures trended in favour of the intervention group, but were not statistically significant. The SWIFT-Acute group reported lower scores on the PHQ-4, the RPQ and the PCL-C. Acceptability All social workers in the ED at the time of the study (n ¼ 7) successfully completed the intervention with minimal training in the trauma centre setting. Results from the SWIFT-Acute patient acceptability survey indicated that 96% of participants who completed the survey (n ¼ 25) found it somewhat or extremely helpful. Patients who did not complete the survey reported not recalling the details of the intervention in the ED. In response to the open-ended question about the most helpful aspects of the intervention, 60% reported it was most helpful to learn about symptoms to expect because this decreased anxiety about symptoms, 28% reported that the recovery tips were most helpful and 24% reported that education about ceasing alcohol use was most helpful.

Discussion The interdisciplinary team designed and implemented a social work delivered ED intervention (SWIFT-Acute) to impact

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Table III. Outcomes.

Interquartile range

3 months post-injury Mean ± SD

9.75 9.0 1.0 0.0 0.0 0.0

20.9 ± 4.9 22.0 ± 4.1 7.5 ± 7.3 5.2 ± 4.4 2.7 ± 1.7 2.1 ± 3.9 0.1 ± 0.6 0.5 ± 2.2

6.0 4.0 3.0 1.0 0.0 0.0

9.5 5.5 2.0 3.0 0.0 0.0

Usual care, n ¼ 29 SWIFT-Acute, n ¼ 30

3.1 ± 4.4 2.2 ± 3.0

1.0 1.0

5.5 3.3

Usual care, n ¼ 29 SWIFT-Acute, n ¼ 30

13.8 ± 16.8 11.0 ± 11.9

4.0 6.0

25.0 18.8

Usual care, n ¼ 29 SWIFT-Acute, n ¼ 30

28.2 ± 16.7 25.2 ± 10.6

21.0 21.0

11.8 11.8

Before injury Mean ± SD

Measure CIQ AUDIT Medical service use Psychiatric service use

Usual care, n ¼ 25 SWIFT-Acute, n ¼ 30 Usual care, n ¼ 28 SWIFT-Acute, n ¼ 30 Usual care, n ¼ 27 SWIFT-Acute, n ¼ 30 Usual care, n ¼ 27 SWIFT-Acute, n ¼ 30

22.6 ± 3.4 22.4 ± 3.8 7.8 ± 6.7 9.6 ± 10.4 0.7 ± 1.2 0.2 ± 0.7 0.2 ± 0.8 0.2 ± 0.6

Median

7.0 6.0 0.0 0.0 0.0 0.0

Median

Interquartile range

PHQ-4

p Value 0.01+* 0.26+ 0.43++ 0.01++* 50.01++** 50.01++** 0.32++ 0.71 0.78+++ 0.92+++

RPQ PCL-C

0.98+++

*Significant at p ¼ 0.01. **Significant at p50.01. + Two-sided statistical significance value by dependent t-test. ++ Two-sided statistical significance value by Wilcoxon Signed Ranks test. +++ Two-sided statistical significance value by Mann-Whitney U-test.

patient recovery after mTBI. The pilot study determined (1) patient acceptability and perceived helpfulness of the intervention and (2) preliminary effectiveness. Findings from this study suggest that alcohol use can be significantly decreased in patients with mTBI, even with a brief alcohol use education intervention and pre-injury community and social functioning can be maintained with an intervention focused on education, reassurance and resource provision. The noted decrease in alcohol use and maintenance of community functioning are clinically significant outcomes. Alcohol use is a risk factor for re-injury and poor outcome and the measure of community functioning includes probes about work, school and social activity attendance as well as ability to plan and complete household activities. These are important aspects of daily life and likely contribute to overall recovery. The increase in medical service use in both groups indicates the potential for residual complications due to the direct effects of the mTBI or possibly due to the effects of other physical injuries incurred concurrently. Participants reported an extremely high level of satisfaction with the intervention and reported that education about symptoms to expect and decreasing alcohol use were particularly salient aspects of the intervention. Social workers were successful in providing the intervention. Social workers have not been widely engaged in mTBI intervention studies to date. In order to sustain interventions for patients with mTBI in this economic climate, it is extremely important to produce the maximum treatment effect using efficient providers. Social workers are well placed in hospitals and EDs to contribute to the care of individuals suffering from the acute and chronic consequences of mTBI. They are economically efficient and clinically trained to provide psychosocial interventions and case management to patients. Social workers are key members of interprofessional medical treatment teams and enhancing their skills to provide

specialized services to patients with mTBI may save valuable medical provider time. This study contributes initial evidence that, with some additional training on mTBI-specific patient needs and intervention strategies, social workers can provide the brief psychosocial mTBI intervention. In addition, the use of existing social work providers in the ED for this study underscores the potential for translatability of the intervention. Providers from other disciplines, including nursing, psychiatry or psychology, may also be successful in delivering SWIFT-Acute, especially if they are already embedded in ED treatment teams. Conducting this research in the ED using existing infrastructure and providers demonstrates the feasibility of the intervention in the intended practice setting. The development of the intervention was a collaborative effort between Neurosurgery and ED social work. In addition, ED medical staff were involved in implementation of SWIFTAcute. This interdisciplinary work to implement and test a new intervention aimed at improving patient outcomes required consistent and deliberate efforts. It required acknowledgement and incorporation on all sides of each specialty’s expertise. Implementing new interventions in the busy, trauma centre ED setting can prove extremely challenging due to the fast pace and urgency of medical care. The success of the collaboration presented here highlights the potential impact of effective interdisciplinary team work. mTBI is a major public health concern with disabling consequences. Patients reporting prolonged and severe symptoms represent a significant number of people with high medical costs, high levels of lost productivity and distress. Many patients with significant symptoms are lost to follow-up and do not receive needed services. Economically and socially disadvantaged populations, whom consistently experience significant barriers to accessing appropriate medical and psychiatric care, are disproportionately affected. It is imperative to work interdisciplinarily to meet the multifacted needs of at-risk patients with mTBI. Theoretically grounded

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and targeted at addressing the cognitive, emotional and behavioural components of recovery, SWIFT-Acute provides education, coping strategies, a brief alcohol intervention, reassurance and resources to shape patients’ perception of the impact of the mTBI on their life, patients’ emotions and patients’ behaviour patterns in relation to their experience of symptoms. This study provides preliminary support for the use of SWIFT-Acute in the ED. It was acceptable to patients treated in the trauma centre setting. The results can be viewed as relevant primarily to patients with mTBI who meet ACEP/ CDC ED criteria for head CT, who generally have more severe injuries than patients not triaged to head CT in the ED. Future studies can enhance understanding of service use by collecting more detailed information on type of services used and for what purpose. Future studies should consider survey themes about the importance of symptom education and alcohol use education to inform strategies to enhance the intervention and potentially increase the impact on additional outcomes of interest, including post-concussive symptoms, anxiety, depression and PTSD. Randomized designs with adequate sample size are needed. In addition, the use of longitudinal follow-ups should be used to examine the sustainability of gains from the intervention. Limitations The quasi-experimental design does not allow for causal inferences to be made regarding the direct effect of the SWIFT-Acute on outcomes of interest. The relatively small sample size limited power to detect differences on some measures that trended in favour of the SWIFT-Acute Group but were not statistically significantly different between groups. Due to non-normal distribution of data, non-parametric tests were required for some comparisons, potentially increasing the type I error rate. In addition, utilization of retrospective evaluation of pre-injury health status has been shown to create a small but significant upward bias in patients’ recall of pre-injury health status [49].

Acknowledgements We thank the San Francisco General Hospital Emergency Department social workers, especially Eve Ekman, Sylvia Huang, Anna Keaney, Ed Kinchley, Nicole McKeown, Myra Murrillo and Shaw Talley, the medical staff and nursing staff for their assistance in the implementation of this intervention.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. The production of the patient educational materials was supported by a grant from the San Francisco Hearts and Heroes Foundation.

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