A call for trauma-informed intensive care

Abstract

Psychological trauma impacts two-thirds of Americans, suggesting that many intensive care unit (ICU) patients have a history of trauma. Our manuscript calls for translating the well-established system of trauma-informed care to the ICU setting – an approach we term “trauma-informed intensive care.” While trauma-informed approaches are being increasingly applied in medical settings such as emergency departments and burn units, the ICU is often overlooked, despite the fact that the ICU environment may be perceived as particularly threatening to those who have experienced trauma. Now is an ideal time to advance efforts for trauma-informed intensive care, given heightened public attention to the ICU experience as a result of the COVID-19 pandemic. Trauma-informed intensive care may promote more positive patient experiences and support patient recovery from critical illness.

Introduction

Trauma is experienced by 62%−90% of American adults (Kilpatrick et al., 2013; Merrick, Ford, Ports, & Guinn, 2018). Thus, it is likely that most intensive care unit (ICU) patients have experienced trauma at some time during their life. Trauma is “the result of an event or circumstances that are experienced by an individual as physically or emotionally harmful or life threatening and have lasting adverse effects on functioning, health, and/or well-being” (Substance Abuse and Mental Health Services Administration, 2014). Trauma, in this context, is a psychoemotional experience and differs from physical, bodily trauma. Whether an experience is traumatic varies based upon individual and contextual factors, though common sources of trauma include neighborhood violence, intimate partner violence, sexual assault, physical abuse, a household member’s substance use disorder, or a family member’s mental illness. Traumatic events may sometimes be the direct cause of ICU admission, such as when a patient is admitted after a violent physical assault. However, traumatic experiences also may be more distant in a patient’s history, such as an adult patient admitted with septic shock who was sexually assaulted during childhood.

Trauma potentially has lifelong effects that can influence a patient’s experience with healthcare. Advances in neuroscience have illumined trauma’s physiological, neuroendocrine, behavioral, and psychosocial impact (Hughes et al., 2017; Pacella, Hruska, & Delahanty, 2013). Health effects include increased risk for chronic conditions such as cardiovascular disease, cancer, type II diabetes, depression, anxiety, and substance use disorder. Neuroendocrine effects include lasting hypothalamic-pituitary-adrenal dysregulation, resulting in heightened stress reactivity, hypervigilance, difficulty assessing threats, and challenges responding to perceived stressors. Trauma’s psychosocial and behavioral effects can hinder cognitive function, regulation of emotions, and interpersonal interactions. In the ICU, a trauma history may manifest as agitation, excessive restlessness, panic, resistance to care, and challenges engaging with the clinical team.

Individuals who have experienced trauma are often highly sensitive to their environment. The ICU environment may be perceived as particularly threatening, with great potential to trigger trauma-related symptoms such as anxiety, hyper-arousal, or re-experiencing events via flashbacks and nightmares. For example, the ICU has disruptive ambient sound and light intensities and intermittent alarms, which may promote feelings of apprehension. Patients are often connected to monitors, tubes, drains, and physical restraints, making a patient feel a lack of control over their own body. Multiple clinicians frequently enter the room and touch the patient as part of care, which may violate a sense of safety. Privacy is limited, given the need for body exposure during invasive procedures and personal care. The physiological effects of critical illness as well as sedative/analgesic agents hinder a patient’s perception of their situation, increasing feelings of fear. Traumatizing aspects of the ICU environment have been magnified during the COVID-19 pandemic, with healthcare providers hidden by personal protective equipment, and patients being in isolation rooms without visitors.

Trauma-informed Intensive Care

A trauma-informed care approach recognizes the widespread prevalence and impact of trauma on physical and mental health and psychosocial function, and strives to deliver care in a manner to promote healing and avoid re-traumatization (Substance Abuse and Mental Health Services Administration, 2014). Trauma-informed care centers on six principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues (Substance Abuse and Mental Health Services Administration, 2014). Such principles are meant to inform approaches to care, rather than dictate specific prescribed practices.

Trauma-informed approaches in intensive care may decrease potential for re-traumatization during hospitalization, thereby minimizing distress and challenges experienced by patients, families, and clinical staff (Kuehn, 2020). A trauma-informed care approach could be implemented in the ICU setting in multiple ways. For example, reducing ambient sound and light intensities, minimizing alarm frequency/loudness, finding alternatives to physical restraints when able, and creation of a healing physical space with natural light could increase feelings of safety. Efforts to provide privacy and carefully explain invasive procedures to all patients (even those who are sedated or minimally responsive) could foster trust, as could assigning the same healthcare provider to a patient across multiple days. Peer support could be fostered through flexible visitation policies and offering availability of team members who provide psychosocial support, such as palliative and pastoral care. In addition, efforts to ask for a patient’s perspective and provide autonomy during care activities, when possible, could promote feelings of empowerment. Cultural, historical, and gender issues could be fostered by staff training in how power dynamics around race, class, and gender impact clinical encounters.

Trauma-informed care has been widely implemented in settings such as behavioral health and child protective services. Attention to trauma is increasing in medical settings such as emergency departments. However there exists a largely untapped opportunity to apply trauma-informed approaches in the ICU. Importantly, a trauma-informed approach in the ICU (“trauma-informed intensive care”) would directly align with - rather than hinder - a focus on recovery from critical illness. The decreased physiological stress, agitation, and restlessness from trauma-informed strategies may support recovery both directly (e.g., reduced tachycardia, hypertension, exhaustion) and indirectly (e.g., reduced risk of self-extubation or unplanned removal of devices due to decreased agitation). Further, many trauma-informed intensive care strategies overlap with efforts to promote patient-centered care. Trauma-informed intensive care would align with best practices for preventing delirium and minimizing use of sedatives and restraints. Such an approach would also support care provided by interdisciplinary team members, including mental health professionals.

Creating a trauma-informed culture in an ICU would require staff education and training, policy change, and environmental modifications. Training would be integral to ensuring that staff understand the long lasting effects and diverse manifestations of trauma, and would need to involve all members of the interdisciplinary team. Further, training would need to be ongoing, relevant to all disciplines, and delivered in a way that accounts for staff’s potential trauma history. Efforts to promote trauma-informed intensive care could be optimized and costs reduced by joining efforts with other clinical units, such as the emergency department, that may share similar goals related to address trauma. Patient and family involvement in conceptualizing a trauma-informed ICU would be crucial, to ensure their perspectives, experiences, and values are reflected in implementation and outcomes.

Research is needed to explore aspects of trauma-informed intensive care, including which staff, patient, and environmental factors would contribute to a healing environment and how to implement trauma-informed care in a way that is acceptable and effective in the ICU setting. Metrics relevant to measuring trauma-informed intensive care implementation and outcomes must be identified. Importantly, future research must maintain a conceptual clarity about the focus on trauma and its separation from related but different concepts such as patient-centered care and Post-intensive Care Syndrome prevention.

Conclusion

Given the high prevalence of trauma, it is evident that trauma-informed approaches merit greater attention in ICU care delivery. Now is an ideal time to advance such efforts, given heightened public attention to the ICU experience as a result of the COVID-19 pandemic. Collaborative efforts among experts in trauma, critical care providers and staff, and patients and families are needed, as are research-driven approaches to understanding how to translate trauma-informed care principles to the ICU. Considered collectively. trauma-informed intensive care may promote more positive patient experiences and support patient recovery from critical illness.

Highlights.

• Many intensive care unit (ICU) patients have a history of trauma.

• The ICU setting can be perceived as threatening for those with a trauma history.

• Trauma-informed approaches merit great attention in delivery of critical care.

• Research is needed to explore inform trauma-informed care policies and practices.

• Trauma-informed intensive care may support patient recovery from critical illness.

Abbreviations:

ICU

intensive care unit