When the ACS Committee on Trauma released the Grey Book in 2022, it included a brand-new requirement covering the mental health needs of injured patients.
According to Standard 5.29, Level I and II trauma centers must have screening and referral processes in place for patients who are at high risk for mental health problems. In comparison, Level III centers are only required to have a referral process for mental health issues that arise.
As we often see with ACS standards, this requirement may be simple on the page but implementation can be a challenge. The starting point is to take a careful look at what Standard 5.29 actually requires.
Do not read more into the standard than is actually there
If you read Standard 5.29 carefully, you will see that it requires trauma centers to have screening protocols in place for patients at high risk of mental health issues.
It does not say that trauma centers need to screen for any particular mental health issue. It also does not say that trauma centers must use a specific screening tool.
In my experience, many trauma programs have focused on post-traumatic stress disorder (PTSD). And many of these programs have chosen to use the Injured Trauma Survivor Screen (ITSS), which screens for both PTSD and depression.
As we all know, PTSD can be a real problem for patients who survive injury, and the ITSS is a validated tool developed specifically for the trauma population. However, nowhere in Standard 5.29 does it say that trauma centers must screen for PTSD (or depression or anxiety or any other particular issue) or that they must use the ITSS.
In fact, the ACS Best Practice Guideline: Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient includes an extensive list of validated mental health screening tools (see page 65, Table 10).
The bottom line is that your trauma program can focus on any mental health issue in the trauma patient population and you can use any validated screening tool to do so.
No need to reinvent the wheel
With that in mind, the first step to implementing a mental health screening protocol that is compliant with Standard 5.29 is to see which screening processes are already in place at your hospital.
Most likely, your hospital is already screening patients on admission for various psychosocial needs. These screens are designed to identify potential mental health concerns, including depression, anxiety, stress disorders and other issues.
For example, the Joint Commission requires suicidal ideation screening for all patients being evaluated or treated for a behavioral health condition as their primary reason for care (National Patient Safety Goal 15.01.01). This means your hospital must already be using a validated tool to screen patient for suicide risk. In that event, one option is simply to document this process within your trauma program’s clinical practice guidelines and create a protocol to make sure the screen is delivered to injured patients.
Another possibility: Hospital-based violence intervention programs typically use various tools to screen trauma patients for mental health and social support issues. Again, depending on what screening tool is being used, your trauma program could simply incorporate the existing practice into trauma program operations.
Similarly, your hospital likely already has staff members who are trained in psychosocial assessment. Work with these staff (nurses, social workers or other healthcare providers) to make sure mental health screenings are administered to trauma patients.
Develop a protocol and process guidelines
Under Standard 5.29, Level I and II trauma centers must have a structured approach to identifying patients at high risk for mental health problems.
To comply with this requirements, create a guideline that defines patients at high risk for psychological sequelae. For example, your guideline might define your high-risk criteria as:
- History of drug or alcohol abuse
- Death-involved incident
- Suicide attempt
- New spinal cord injury or amputee
- Provider discretion
In addition, a trauma program might also incorporate reason for admission (e.g., victim of assault, motor vehicle collision) and/or level of trauma activation into its screening criteria.
Your screening guideline will state that trauma patients who meet these high-risk criteria and are admitted for injury care will receive a psychosocial assessment.
As noted above, your hospital may have an existing protocol to screen all patients for psychosocial issues. Even so, it still makes sense to establish trauma-specific screening criteria that are tailored to the unique needs of injured patients.
Standard 5.29 also requires all centers (Levels I, II and III) to have a process for referring patients to a mental health provider.
- For Level I and II centers, these are patients who screened positive for a mental health issue.
- For Level III centers, these are patients for whom a problem or risk is “identified during inpatient admission”.
Your referral guideline will state that for trauma patients who screen positive for a mental health issue (or for whom an issue is identified), the responsible professional (e.g., social worker, nurse) will provide a referral to specific local resources.
As always, monitor compliance
As with every performance issue, trauma programs need to monitor compliance with their mental health screening and referral guidelines.
To measure compliance with your screening guideline, calculate:
# of patients screened / # of patients who met high-risk criteria
To measure compliance with your referral guideline, calculate:
# of patients receiving referral / # of patients who screened positive
These two percentages are your measures of compliance. Once these measures are in place, trauma program staff should monitor them on a regular basis — daily, weekly or (at a minimum) monthly.
You can track these measures “manually” by adding all patients who meet high-risk criteria to a spreadsheet.
The better alternative is to use the trauma registry to identify patients who meet high-risk criteria. Depending on your guideline criteria, ICD-10 codes can be used to flag patients for inclusion. Make sure the trauma registry captures not just injury diagnoses but pre-existing conditions, including psychiatric diagnoses. This enhances the accuracy and completeness of data abstraction, facilitating easier auditing.
I recommend adding your mental health screening and referral measures to your trauma program’s quality dashboard. This will facilitate ongoing monitoring and performance improvement.
Note that the ACS has not established a “compliance threshold” for Standard 5.29. It is up to trauma program leadership to (a) decide what is “acceptable” performance and, even more important, (b) look for opportunities to better meet the mental health needs of injured patients.
Learn more about mental health screening and referral
As I mentioned above, the wording of Standard 5.29 is fairly clear. It’s implementing this standard in your trauma center that can be challenging.
With that in mind, we recently hosted a webinar that explores all the “nuts and bolts” issues of mental health screening and referral in the trauma population:
How to Collaborate with Hospital Social Workers to Meet the Mental Health Needs of Trauma Patients
In this webinar, the trauma social worker at a Level I trauma center on the East Coast shared her experience running a successful mental health screening and referral program for injured patients.
This webinar examined common mental health issues in the trauma population, barriers to mental health treatment, and processes for ensuring that injured patients receive the mental health support they need. To access the webinar replay on demand, click here.
Angie Chisolm, MBA, BSN, RN, CFRN, TCRN is a nationally recognized expert in trauma program operational efficiency, coding and billing, site survey readiness and performance improvement. Angie is also president and managing partner of Optimal Healthcare Advisors.
Elizabeth Noonan MSW, LSW is the trauma social worker at Robert Wood Johnson University Hospital, a Level I trauma center in New Brunswick, New Jersey.