Trauma-Informed Psychosocial Screening and Care Planning: A Patient-Centered Improvement Project in a Midwife Clinic

Traumatic stress is associated with increases in preterm birth, low birth weight, and other perinatal complications. Yet the identification of patients with traumatic stress and intervention for traumatic stress prevention or treatment remain low. Locally in this university hospital-based midwife clinic, a health records review found that trauma exposure was documented in 5% of patient records, and no records had a diagnosis of posttraumatic stress disorder (PTSD). This is lower than research-based population estimates of 25% to 50% for trauma exposure and 8% for PTSD during pregnancy. The clinic staff did not screen for posttraumatic stress, and exposure screening was limited to intimate personal violence. Staff had not been trained in trauma-informed care (TIC) as defined by the Substance Abuse and Mental Health Services Administration. The aim for this improvement project was to provide trauma screening and trauma-related care planning, collectively referred to as trauma-informed psychosocial care, to midwifery patients 85% of the time.

Interventions were implemented over 4 plan-do-study-act (PDSA) cycles. These included staff training in TIC; written screening at the new prenatal, third trimester, and postpartum visits; verbal broad inquiry at every visit; and bidirectional trauma-specific care planning emphasizing patient and provider input into treatment choice. The clinic flow was changed to create privacy for patient-staff interaction at every visit. Field notes and data were analyzed every 2 weeks and iterative changes applied.

Trauma disclosure increased from 5% to 30% and identification of PTSD from 0% to 7%. Bidirectional care plan documentation increased from 8% to 67%. Staff rated the workload as reasonable.

Redesigning psychosocial screening to align with TIC principles increased the discovery of trauma to levels consistent with research-based population estimates. Gains were made in bidirectional care planning. This project illustrates practical methods of implementing TIC principles.