A 28-year-old female is brought to the emergency department (ED) by police after a sexual assault. She is visibly anxious and tearful. The police officer is waiting for the sexual assault evidence kit. What is the trauma-informed approach to care for this patient?

Introduction

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹ A significant number of patients present to the ED with concerns related to traumatic experiences. These concerns may be a direct result of trauma (e.g., injuries following an assault), or an indirect result of trauma (e.g., substance abuse as a coping mechanism following traumatic events).

Patients’ subsequent experiences in the ED may be re-traumatizing or trigger memories from past experiences.² The chaos of the ED, lack of privacy, fear, pain, physical touch, and invasive history questions may provoke a trauma response. Patients may be anxious, hypervigilant, and even combative. Conversely, they may respond to real or perceived threats by “shutting down” and not participating in their care, even refusing certain aspects of care or procedures. Trauma responses in the ED present a challenge to ED staff and may prevent the optimal provision of care. Given the prevalence of trauma among ED patients, clinicians should assume that all patients would benefit from a trauma-informed approach to care.

Trauma-informed care (TIC) is an approach to the delivery of care that includes an understanding of trauma and an awareness of the effect it may have on the individual or patient. Use of the principles of TIC improves the medical care of the patient, improves patient experience, helps survivors of trauma rebuild a sense of empowerment, and may prevent violence against ED staff.

According to SAMHSA, for an organization to provide TIC, it must abide by four principles:¹

• Realization of the widespread effect of trauma and understanding of potential paths for recovery;
• Recognition of the signs and symptoms of trauma in patients, families, staff, and others involved in the system;
• Response by fully integrating knowledge about trauma into policies, procedures, and practices; and,
• Active resistance against re-traumatization.

TIC is based on six principles: 1) safety; 2) trustworthiness and transparency; 3) peer support; 4) collaboration and mutuality; 5) empowerment, voice, and choice; and 6) cultural, historical, and gender issues.¹ There are a multitude of ways to incorporate TIC throughout the ED encounter.^3,4