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Disaster Medicine

The PsySTART Rapid Mental Health Triage System

Jasmin Tamsut MD, Kelly Young, MD, Merritt Schreiber, PhD
Harbor-UCLA Medical Center
Departments of Emergency Medicine and Pediatrics
David Geffen School of Medicine at UCLA

In the aftermath of disasters, terrorism, and other acute traumatic events there is a continuum of risk and resilience at the individual and population level. Depending on a complex dynamic of incident-specific, individual, family, and community factors, there are several different potential pathways individuals can take. Among the most common is the so-called “resilience pathway” which involves the initial development of one or more post-traumatic stress symptoms. While these symptoms may partly resemble the clinical diagnosis of Post-traumatic stress disorder (PTSD), they are transitory, sub-syndromal, and resolve without any mental health intervention.

The other most common outcome involves so-called “chronic dysfunction,” which is the development of one or more comorbid clinical conditions that are associated with functional impairment, and which require evidence-based interventions such as Prolonged Exposure Cognitive Behavioral Therapy (CBT) in the case of adults, and Trauma Focused CBT for children, to resolve. The best available epidemiological evidence (Galea et al, 2005, 2008) suggests that somewhere between 50-90% of individuals have transitory distress while 30-40% of those directly impacted develop a new clinical disorder that they did not possess pre-event. PTSD is the most common, however it is frequently comorbid with depression, anxiety, or substance abuse disorders. There is also emerging evidence that if individuals at high risk are identified early, within the first weeks after single incident trauma, and provided acute, highly truncated variants of these evidence-based interventions, subsequent development of clinical disorders may be reduced.

New therapeutic approaches are therefore focused on reducing the population level impact of disasters and traumatic events by rapidly identifying the high-risk subset of adults and children and providing them targeted, acute evidence-based interventions. Adults and children who experience traumatic injury and present to the Emergency Department (ED) or trauma center, either in the context of disaster, terrorism, or unintentional injury, are a known high-risk group, and represent an important sub-population requiring targeted risk identification and linkage to effective mental health interventions.

Traditional approaches have used symptom-based screeners to identify those with disorders. However, in the immediate aftermath of traumatic events with patients presenting to the ED or other disaster medical settings, including up to 30 to 45 days post-event, symptom-based screeners are problematic because they both fail to differentiate those with transitory distress trajectories (resilience pathway) from those with disorder trajectories, and because administration of symptom-based screening tools are impractical for ED use.

The PsySTART rapid mental health triage system was developed to address these limitations. As opposed to symptom-based PTSD screening tools, PsySTART is an evidence-based rapid mental health triage system that can be completed by non-mental health workers and responders. Instead of subjective symptoms, it relies on evidence-based, multi-variate, objective risk factors such as “being trapped, deaths of family members, displacement from home, and exposure to mutilated bodies (Theinkrua et al 2006). Once familiar, practitioners can apply PsySTART in a matter of seconds.

PsySTART is currently used in hospitals and clinics, Emergency Medical Services (EMS) pre-hospital systems, schools, and mental health response teams in Los Angeles County, Seattle and King County, the States of Tennessee and Minnesota, Lake County California, District of Columbia, and the North Central Texas Trauma Regional Advisory Council. It is a component in a new Federal Emergency Management Agency (FEMA) Pediatric Disaster Training Course and was part of the U.S. Department of Health and Human Services (HHS) field responses in the Sandy Hook, Boston Marathon, and Roseburg, Oregon terrorism and active shooter incidents.

Using a novel information technology platform, PsySTART scores are collated into a database system that provides:

  • Real-time situational awareness of a tiered system of mental health risk using a rapid triage tool completed in a few seconds by non mental health workers
  • Geo-coded information that is end user scalable at the individual site level (e.g. hospital, shelter, clinic, mobile team), as well as county, region, or statewide, depending on informational requirements
  • Real-time “decision support” at the individual/clinical and population level
    • Data-driven surveillance leveraging real-time PsySTART evidence-based metrics informs situational awareness for creation of incident action plans, gap analysis, mutual aid requests, federal Stafford Act assistance, and victims of crime funding requests
    • Metrics include, e.g. numbers at risk, sources of risk, locations, and also include separate information for children
  • Guidance in allocation of scarce mental health resources to those at greatest risk by an ethical, evidence-based risk protocol, conforming to “crisis standards of care”
    • Includes “floating triage algorithm” which matches risk to actual available resources, allowing available resources to reach those most at risk in real time
    • Novel Hospital Incident Command System (HICS) compliant job action sheets to guide response in the hospital or clinic
  • Common operating picture of population level risks specific to public health emergencies (e.g. Ebola virus disease)
    • Risks for isolated patients, quarantined (including family members, co-workers etc.), “worried well” (including neighbors, co-workers, other family members, healthcare workers), and those experiencing loss of loved ones
    • PsySTART is the first known metric to identify “worried well” trends, which can then inform targeted risk communication or other crisis management strategies specific to the health care setting and population (e.g. in Ebola virus healthcare workers)
  • Decision support tool for mental health workers who follow up on those at higher risk 
    • “Solution focused crisis intervention” using the triage information to guide practical crisis intervention and assign individuals based on need (for example those experiencing loss of loved one could be matched with chaplaincy support or trained grief counselors)
  • Stepped “continuum of care” approach to provide those at risk with early intervention to facilitate resilience

PsySTART dissemination efforts around the United States have resulted in various “disaster systems of care” (Schreiber, 2005) with pre-hospital emergency responses, emergency departments, schools, casualty collection points, and shelters serving as common population level locations to approach risk identification. This information can be shared across local disasters systems of care to inform recovery strategies and population level risk with trending by age groups and geocoded locations. Dynamic time trends for specific PsySTART risk markers can be observed. PsySTART has been used as part of comprehensive community health disaster epidemiology by the CDC in the American Samoa catastrophic earthquake and Tsunami (King et al, 2012) and in the California Napa Valley Earthquake (CDC, 2014). In the first 3 weeks after the hurricane Superstorm Sandy, the American Red Cross captured some 20,000 PsySTART triage encounters in New York state shelters (Schreiber,et al, 2012). PsySTART has also been used to estimate mental health consequences of catastrophic disasters including earthquakes in California and the New Madrid Seismic Zone (USGS, 2008).

Currently, our research is focused on pediatric trauma patients. Approximately 20% of pediatric patients develop PTSD within the first year after a traumatic injury (Mehta S., Ameratunga SN., 2012). Our efforts are aimed at refining the PsySTART prediction model with risk factor weighting and improved efficiency of risk identification in the context of life-saving trauma care. For example, a quality improvement effort at CHOC Children’s Hospital of Orange County has incorporated PsySTART into its electronic medical record for completion on every pediatric trauma activation. High- risk patients are then routed for secondary clinical assessment by the mental health team, thus leveraging the early opportunity to reduce or prevent psychological consequences. Once refined and validated, PsySTART could be incorporated into trauma assessments at EDs nationwide, potentially leading to early identification of patients at high risk for mental health disorders, and the opportunity for early therapeutic intervention.

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