Scott Steinbach, MD

Posttraumatic stress disorder (PTSD) is a syndrome that occurs after exposure to a significant traumatic event and is characterized by persistent, debilitating symptoms that fall into four “diagnostic clusters” as outlined in the Diagnostic and Statistical Manual of Mental Disorders-Version V (DSM-V). Patients may experience intrusive thoughts, avoidance of distressing stimuli, persistent negative mood, and hypervigilance, all of which last longer than 1 month.¹

A national survey of United States households conducted during 2001-2003 estimated the 12-month prevalence of PTSD among adults to be 3.5%.² Lifetime prevalence has been found to be between 6.8%³ and 7.8%.⁴ PTSD is more common in veterans. The prevalence of PTSD in veterans differs depending on the conflict in which the veteran participated. Vietnam veterans have an estimated lifetime prevalence of approximately 30%,^5,6 Gulf War veterans approximately 15%,⁷ and veterans of more recent conflicts in Afghanistan and Iraq of approximately 21%.⁸ With the MISSION Act moving more veteran care into the private sector, non-VA inpatient providers will need to become better versed in PTSD.⁹

Patients with PTSD have more contact with the healthcare system, even for non–mental health problems,^8,10-13 and a significantly higher burden of medical comorbities,¹⁴ such as diabetes mellitus, liver disease, gastritis and gastric ulcers, HIV, arthritis,¹⁵ and coronary heart disease.¹⁶ Veterans with PTSD are hospitalized three times more often than are those with no mental health diagnoses,⁸ and patients with psychiatric comorbidities have higher lengths of stay.¹⁷ More than 1.4 million hospitalizations occurring during 2002-2011 had either a primary or secondary associated diagnosis of PTSD, with total inflation-­adjusted charges of 34.9 billion dollars.¹⁸ In the inpatient sample from this study, greater than half were admitted for a primary diagnosis of mental diseases and disorders (Major Diagnostic Category [MDC] 19). Following mental illness, the most common primary diagnoses for men were MDC 5 (Circulatory System, 12.1%), MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 9.2%), and MDC 4 (Respiratory System, 7.4%), while the most common categories for women were MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 5.8%), MDC 21 (Injuries, Poison, and Toxic Effect of Drugs, 4.9%), and MDC 6 (Digestive System, 4.5%).¹⁸

In both the inpatient and outpatient settings, a fundamental challenge to comprehensive PTSD management is correctly diagnosing this condition.¹⁹ Confounding the difficulties in diagnosis are numerous comorbidities. In addition to the physical comorbidities described above, more than 70% of patients with PTSD have another psychological comorbidity such as affective disorders, anxiety disorders, or substance use disorder/dependency.²⁰

Given that PTSD may be an underrecognized burden on the healthcare system, we sought to better understand how PTSD could affect hospitalized patients admitted for medical problems by conducting this narrative review. Additionally, three of the authors collaborated with the VA Employee Education Service to conduct a needs assessment of VA hospitalists in 2013. Respondents identified managing and educating patients and families about PTSD as a major educational need (unpublished data available upon request from the corresponding author). Therefore, our aims were to present a synthesis of existing literature, familiarize readers with the tenets of trauma-­informed care as a framework to guide care for these patients, and generate ideas for changes that inpatient providers could implement now. We began by consulting a research librarian at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, who searched the following databases: PsycInfo, CINAHL, MEDLINE, and PILOTS (a PTSD/trauma specific database). Search terms included hospital, hospitalized, and hospitalization, as well as traumatic stress, posttraumatic stress, and PTSD. Pertinent guidelines and the reference lists from included papers were examined. We focused on papers that described patients admitted for medical problems other than PTSD because those patients who are admitted for PTSD-­related problems should be primarily ma­naged by psychiatry (not hospitalists) with the primary focus of their hospitalization being their PTSD. We also excluded papers about patients developing PTSD secondary to hospitalization, which already has a well-developed literature.^21-23

The literature is sparse describing frequency or type of problems encountered by hospitalized medical patients with PTSD. A recent small survey study reported that 40% of patients anticipated triggers for their PTSD symptoms in the hospital; such triggers included loud noises and being shaken awake.²⁴ Two papers describe case vignettes of patients who had exacerbations of their PTSD while in the Intensive Care Unit (ICU), although neither contain frequency or severity data.^25,26 Approximately 8% of patients in VA ICUs have PTSD,²⁷ and a published abstract suggests that they appear to require more sedation than do patients without PTSD.²⁸ Another published case report describes a patient with recurrent PTSD symptoms (nightmares) after moving into a nursing home.²⁹ These papers suggest other providers have recognized and are concerned about hospitalized patients with PTSD. At present, there are no data to quantify how often hospitalized patients have PTSD exacerbations or how troublesome such exacerbations are to these patients.

Given that there is little empiric literature to guide inpatient management of PTSD as a comorbidity in hospitalized medical patients, we extrapolate some information from the outpatient setting. PTSD is often underdiagnosed and underreported by individual patients in the outpatient setting.³⁰ Failure to have an associated diagnosis of PTSD may lead to underrecognition and undertreatment of these patients by inpatient providers in the hospital setting. Additionally, the numerous psychological and physical comorbidities in PTSD can create unique challenges in properly managing any single problem in these patients.²⁰ Armed with this knowledge, providers should be vigilant in the recognition, assessment, and treatment of PTSD.

Trauma-Informed Care: A Conceptual Model

Trauma-informed care is a mindful and sensitive approach to caring for patients who have suffered trauma.³¹ It requires understanding that many people have suffered trauma in their lives and that the trauma continues to impact many aspects of their lives.³² Trauma-informed care has many advocates and has been implemented across myriad health and social services settings.³³ Its principles can be applied in both the inpatient and outpatient hospital settings. While it is an appropriate approach to patients with PTSD, it is not specific to PTSD. People who have suffered sexual trauma, intimate partner violence, child abuse, or other exposures would also be included in the group of people for whom trauma-informed care is a suitable approach. There are four key assumptions to a trauma-­informed approach to care (the 4 R’s): (1) realization that trauma affects an individual’s coping strategies, relationships, and health; (2) recognition of the signs of trauma; (3) having an appropriate, planned response to patients identified as having suffered a trauma; and (4) resisting retraumatization in the care setting.^31,32

General Approach to Treating Medical Patients With PTSD in the Inpatient Setting

Recognition

Consistent with a trauma-informed care approach, inpatient providers should be able to recognize patients who may have PTSD. First, careful review of the past medical history may show some patients already carry this diagnosis. Second, patients with PTSD often have other comorbidities that could offer a clue that PTSD could be present as well; for example, risk for PTSD is increased when mood, anxiety, or substance use disorders are present.²⁰ When PTSD is suspected, screening is a reasonable next step.

The Primary Care-PTSD-5 (PC-PTSD-5) is a validated screening tool used in the outpatient setting.³⁴ It is easily administered and has good predictive validity (positive likelihood ratio [LR+] of 6.33 and LR– of 0.06). It begins with a question of whether the patient has ever experienced a trauma. A positive initial response triggers a series of five yes/no questions. Answering “yes” to three or more questions is a positive screen. A positive screen should result in consultation to psychiatry to conduct more formal evaluation and guide longer-term management.

Collaboration

Individual trauma-focused psychotherapy is the primary treatment of choice for PTSD with strong evidence supporting its practice.³⁵ This treatment is administered by a psychiatrist or psychologist and will be limited in the inpatient medical setting. Current recommendations suggest pharmacotherapy only when individualized trauma-focused psychotherapy is not available, the patient declines it, or as an adjunct when psychotherapy alone is not effective.³⁶ Therefore, inpatient providers may see patients who are prescribed selective serotonin reuptake inhibitors (eg, paroxetine, fluoxetine) or serotonin and norepinephrine reuptake inhibitors (eg, venlafaxine).³⁶ In the past, PTSD-related nightmares were often treated with prazosin.³⁷ However, a recent randomized controlled trial of prazosin in veterans with PTSD failed to show significant improvement in nightmares.³⁸ Hence, current guidelines do not recommend prazosin as a first-line therapy.³⁹ For hospitalized patients with PTSD symptoms refractory to the interventions outlined herein, particularly those patients with possible borderline personality traits (as suggested by severe anger and impulsivity), we strongly recommend partnering with psychiatry. Finally, given the high prevalence of substance use disorders (SUDs) in PTSD patients, awareness and treatment of comorbidities such as opioid and alcohol dependence must be concurrently addressed.

Individualizing Care

It is essential for the healthcare team to identify ways to meet each patient’s immediate needs. Many of the ideas proposed below are not specific to PTSD; many require an interprofessional approach to care.⁴⁰ From a trauma-informed care standpoint, this is akin to having a planned response for patients who have suffered trauma. Assessing the individual’s needs and incorporating therapeutic modalities such as reflective listening, broadening safe opportunities for control, and providing complementary and integrative medicine (IM) therapies may help manage symptoms and establish rapport.⁴¹ Through reflective listening, a collaborative approach can be established to identify background, triggers, and a safe approach for managing PTSD and its comorbid conditions. Ensuring frequent communication and allowing the patient to be at the center of decision-making establishes a safe environment and promotes positive rapport between the patient and healthcare team.³⁶ Providing a sense of control by involving the patients in their healthcare decisions and in the structure of care delivery may benefit the patients’ well-being. Furthermore, incorporating IM encourages rest and relaxation in the chaotic hospital environment. Suggested IM interventions include deep breathing, aromatherapy, guided imagery, muscle relaxation, and music therapy.^42,43

Key Inpatient Issues Affecting PTSD

In the following sections, we outline common clinical situations that may exacerbate PTSD symptoms and propose some evidence-based responses (Table). In general, nonpharmacologic approaches are favored over pharmacologic approaches for patients with PTSD.

Sleep Hygiene

Sleep problems are very common in patients with PTSD, with nightmares occurring in more than 70% of patients and insomnia in 80%.⁴⁴ In PTSD, sleep problems are linked to poor physical health and other health outcomes^45,46 and may exacerbate other PTSD symptoms.⁴

Treating the sleep problems that occur with PTSD is an important aspect of PTSD care. Usually administered in the outpatient setting, the treatment of choice is cognitive-behavioral therapy (CBT).⁴⁸ Sleep-specific CBT focuses, among other things, on strategies that encourage good sleep hygiene,⁴⁹ which includes promoting regular sleep/wake-up times and specific bedtime routines, avoiding stimulation (eg, light, noise, TV) or excessive liquids before bed, refraining from daytime naps, and using relaxation techniques. Many of these recommendations seem at odds with hospital routines, which may contribute to decompensation of hospitalized patients with PTSD.

While starting sleep-specific CBT in the hospital may not be realistic, we suggest the following goals and strategies as a starting place for promoting healthy sleep for hospitalized patients with PTSD. To begin, factors affecting sleep hygiene should be addressed. Inpatient providers could pay more attention to intravenous (IV) fluid orders, perhaps adjusting them to run only during the daytime hours. Medications can be scheduled at times conducive to maintaining home routines. Avoiding the administration of diuretics close to bedtime may decrease the likelihood of frequent nighttime wakening. Grouping patient care activities, such as bathing or wound care, during daytime hours may allow more opportunities for rest at night. Incorporating uninterrupted sleep protocols, such as quiet hours between 10pm and 6am, may enhance sleep quality in the appropriately selected patient.⁵⁰ Although pharmacological interventions to improve sleep in the hospital may be initially beneficial, nonpharmacological interventions as described above should be incorporated for long-term maintenance of enhanced sleep quality.

Second, providers need to ask about established home bedtime routines and facilitate implementation in the hospital. Through collaboration with patients, providers can incorporate an individualized plan of care for sleep early in hospitalization.⁵⁰ Partnering with nurses is also essential to creating a sleep-friendly environment that can improve patient experiences.⁵¹ Breathing exercises, meditating, listening to music and praying are all examples of “bedtime wind down” strategies recommended in sleep-specific CBT.⁴⁹ Many of these could be successfully implemented in the hospital and may benefit other hospitalized patients too.⁵² In patients with PTSD and obstructive sleep apnea, continuous positive airway pressure (CPAP) reduces nightmares, and if inpatients are on CPAP at home, it should be continued in the hospital.⁵³

Pain

If sleep disturbance is the hallmark of PTSD,⁴⁷ chronic pain is its coconspirator.¹⁵ Uncontrolled pain can make it much more difficult to treat patients with PTSD, which in turn may lead to further decompensation from a mental health standpoint.⁵⁴ SUDs such as alcohol or opioid dependencies are highly comorbid with PTSD⁴⁵ and introduce a layer of complexity when managing painin these patients. Providers should be thoughtful when electing to treat acute or chronic pain with opioids and take particular care to establish realistic therapeutic goals if doing so. While patients with PTSD have a greater likelihood of having an SUD, undertreating pain risks exacerbating underlying PTSD symptoms.

Nonpharmacologic therapies, which include communicating, listening, and expressing compassion and understanding, should be utilized by inpatient providers as a first-line treatment in patients with PTSD who suffer from pain. Additionally, relaxation techniques, physical therapy, and physical activity⁵⁵ can be offered. Pharmacologically, nonopioid medications such as acetaminophen or NSAIDs should always be considered first. Should the use of opioids be deemed necessary, inpatient providers should preferentially use oral over intravenous medications and consider establishing a fixed timeframe for short-term opioids, which should be limited to a few days. Providers should communicate clear expectations with their patients to maximize the desired effect of any specific treatment while minimizing the risk of medication side effects with the goal of agreeing on a short yet effective treatment course.

Anxiety and Anger

One of the most challenging situations for the inpatient provider is encountering a patient who is anxious, angry, or hypervigilant. Mismatch between actual and expected communication between the provider and the patient can lead to frustration and anxiety. A trauma-informed care approach would suggest that frequent and thorough communication with patients may prevent or ameliorate the stresses and anxieties of hospitalization that may manifest as anger because of retraumatization. Hospitalizations usually lead to disruption of normal routine (eg, unpredictable meal times or medication administration), interrupted sleep (eg, woken up for blood draws or provider evaluation), and lack of control of schedule (eg, unsure of exact time when a procedure may be occurring), any of which may trigger symptoms of anxiety and anger in patients with PTSD and lead to hypervigilance.

If situations involving patient anxiety do arise, employ compassion and communication. Extra time spent with the patient, while challenging in the hectic hospital environment, is critical, and nonpharmacological treatments should be the priority. Engaging patients by asking about their PTSD triggers²⁴ may help prevent exacerbations. For example, some patients may specify how they prefer to be woken up to prevent startle reactions. PTSD triggers can be reduced via effective communication with the entire healthcare team. Some immediate yet effective strategies are listening, validation, and negotiation. Benzodiazepine or antipsychotic usage should be avoided.³⁶ Inpatient social work and comanagement with psychiatry involvement may be helpful in more severe exacerbations. A small observational study of patients hospitalized for severe PTSD found an association between walking more during hospitalization and fewer PTSD symptoms,⁵⁶ suggesting that staying active could be helpful for inpatients with PTSD who are able to safely ambulate.

PTSD is a common comorbidity among hospitalized patients in the United States. Typical hospital routines may exacerbate symptoms of PTSD such as anxiety and anger. Inpatient providers can play an important role in making hospitalizations go more smoothly for these patients by using principles consistent with trauma-informed care. Specifically, partnering with patients to construct a plan that preserves their sleep routines and accounts for potential triggers for decompensation can improve the hospital experience for patients with PTSD. Some PTSD interventions require additional investment from the healthcare system to deploy, such as staff training in trauma-­informed care and reflective listening techniques. Electronic health record–based protocols and order sets for patients with PTSD can leverage available resources. Further research should evaluate hospital outcomes that result from a more tailored approach to the care of patients with PTSD. More effective, patient-centered PTSD care could lower rates of leaving against medical advice and improve the inpatient experience for patients and providers alike.

Posttraumatic stress disorder (PTSD) is a syndrome that occurs after exposure to a significant traumatic event and is characterized by persistent, debilitating symptoms that fall into four “diagnostic clusters” as outlined in the Diagnostic and Statistical Manual of Mental Disorders-Version V (DSM-V). Patients may experience intrusive thoughts, avoidance of distressing stimuli, persistent negative mood, and hypervigilance, all of which last longer than 1 month.¹

A national survey of United States households conducted during 2001-2003 estimated the 12-month prevalence of PTSD among adults to be 3.5%.² Lifetime prevalence has been found to be between 6.8%³ and 7.8%.⁴ PTSD is more common in veterans. The prevalence of PTSD in veterans differs depending on the conflict in which the veteran participated. Vietnam veterans have an estimated lifetime prevalence of approximately 30%,^5,6 Gulf War veterans approximately 15%,⁷ and veterans of more recent conflicts in Afghanistan and Iraq of approximately 21%.⁸ With the MISSION Act moving more veteran care into the private sector, non-VA inpatient providers will need to become better versed in PTSD.⁹

Patients with PTSD have more contact with the healthcare system, even for non–mental health problems,^8,10-13 and a significantly higher burden of medical comorbities,¹⁴ such as diabetes mellitus, liver disease, gastritis and gastric ulcers, HIV, arthritis,¹⁵ and coronary heart disease.¹⁶ Veterans with PTSD are hospitalized three times more often than are those with no mental health diagnoses,⁸ and patients with psychiatric comorbidities have higher lengths of stay.¹⁷ More than 1.4 million hospitalizations occurring during 2002-2011 had either a primary or secondary associated diagnosis of PTSD, with total inflation-­adjusted charges of 34.9 billion dollars.¹⁸ In the inpatient sample from this study, greater than half were admitted for a primary diagnosis of mental diseases and disorders (Major Diagnostic Category [MDC] 19). Following mental illness, the most common primary diagnoses for men were MDC 5 (Circulatory System, 12.1%), MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 9.2%), and MDC 4 (Respiratory System, 7.4%), while the most common categories for women were MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 5.8%), MDC 21 (Injuries, Poison, and Toxic Effect of Drugs, 4.9%), and MDC 6 (Digestive System, 4.5%).¹⁸

In both the inpatient and outpatient settings, a fundamental challenge to comprehensive PTSD management is correctly diagnosing this condition.¹⁹ Confounding the difficulties in diagnosis are numerous comorbidities. In addition to the physical comorbidities described above, more than 70% of patients with PTSD have another psychological comorbidity such as affective disorders, anxiety disorders, or substance use disorder/dependency.²⁰

Given that PTSD may be an underrecognized burden on the healthcare system, we sought to better understand how PTSD could affect hospitalized patients admitted for medical problems by conducting this narrative review. Additionally, three of the authors collaborated with the VA Employee Education Service to conduct a needs assessment of VA hospitalists in 2013. Respondents identified managing and educating patients and families about PTSD as a major educational need (unpublished data available upon request from the corresponding author). Therefore, our aims were to present a synthesis of existing literature, familiarize readers with the tenets of trauma-­informed care as a framework to guide care for these patients, and generate ideas for changes that inpatient providers could implement now. We began by consulting a research librarian at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, who searched the following databases: PsycInfo, CINAHL, MEDLINE, and PILOTS (a PTSD/trauma specific database). Search terms included hospital, hospitalized, and hospitalization, as well as traumatic stress, posttraumatic stress, and PTSD. Pertinent guidelines and the reference lists from included papers were examined. We focused on papers that described patients admitted for medical problems other than PTSD because those patients who are admitted for PTSD-­related problems should be primarily ma­naged by psychiatry (not hospitalists) with the primary focus of their hospitalization being their PTSD. We also excluded papers about patients developing PTSD secondary to hospitalization, which already has a well-developed literature.^21-23

The literature is sparse describing frequency or type of problems encountered by hospitalized medical patients with PTSD. A recent small survey study reported that 40% of patients anticipated triggers for their PTSD symptoms in the hospital; such triggers included loud noises and being shaken awake.²⁴ Two papers describe case vignettes of patients who had exacerbations of their PTSD while in the Intensive Care Unit (ICU), although neither contain frequency or severity data.^25,26 Approximately 8% of patients in VA ICUs have PTSD,²⁷ and a published abstract suggests that they appear to require more sedation than do patients without PTSD.²⁸ Another published case report describes a patient with recurrent PTSD symptoms (nightmares) after moving into a nursing home.²⁹ These papers suggest other providers have recognized and are concerned about hospitalized patients with PTSD. At present, there are no data to quantify how often hospitalized patients have PTSD exacerbations or how troublesome such exacerbations are to these patients.

Given that there is little empiric literature to guide inpatient management of PTSD as a comorbidity in hospitalized medical patients, we extrapolate some information from the outpatient setting. PTSD is often underdiagnosed and underreported by individual patients in the outpatient setting.³⁰ Failure to have an associated diagnosis of PTSD may lead to underrecognition and undertreatment of these patients by inpatient providers in the hospital setting. Additionally, the numerous psychological and physical comorbidities in PTSD can create unique challenges in properly managing any single problem in these patients.²⁰ Armed with this knowledge, providers should be vigilant in the recognition, assessment, and treatment of PTSD.

Trauma-Informed Care: A Conceptual Model

Trauma-informed care is a mindful and sensitive approach to caring for patients who have suffered trauma.³¹ It requires understanding that many people have suffered trauma in their lives and that the trauma continues to impact many aspects of their lives.³² Trauma-informed care has many advocates and has been implemented across myriad health and social services settings.³³ Its principles can be applied in both the inpatient and outpatient hospital settings. While it is an appropriate approach to patients with PTSD, it is not specific to PTSD. People who have suffered sexual trauma, intimate partner violence, child abuse, or other exposures would also be included in the group of people for whom trauma-informed care is a suitable approach. There are four key assumptions to a trauma-­informed approach to care (the 4 R’s): (1) realization that trauma affects an individual’s coping strategies, relationships, and health; (2) recognition of the signs of trauma; (3) having an appropriate, planned response to patients identified as having suffered a trauma; and (4) resisting retraumatization in the care setting.^31,32

General Approach to Treating Medical Patients With PTSD in the Inpatient Setting

Recognition

Consistent with a trauma-informed care approach, inpatient providers should be able to recognize patients who may have PTSD. First, careful review of the past medical history may show some patients already carry this diagnosis. Second, patients with PTSD often have other comorbidities that could offer a clue that PTSD could be present as well; for example, risk for PTSD is increased when mood, anxiety, or substance use disorders are present.²⁰ When PTSD is suspected, screening is a reasonable next step.

The Primary Care-PTSD-5 (PC-PTSD-5) is a validated screening tool used in the outpatient setting.³⁴ It is easily administered and has good predictive validity (positive likelihood ratio [LR+] of 6.33 and LR– of 0.06). It begins with a question of whether the patient has ever experienced a trauma. A positive initial response triggers a series of five yes/no questions. Answering “yes” to three or more questions is a positive screen. A positive screen should result in consultation to psychiatry to conduct more formal evaluation and guide longer-term management.

Collaboration

Individual trauma-focused psychotherapy is the primary treatment of choice for PTSD with strong evidence supporting its practice.³⁵ This treatment is administered by a psychiatrist or psychologist and will be limited in the inpatient medical setting. Current recommendations suggest pharmacotherapy only when individualized trauma-focused psychotherapy is not available, the patient declines it, or as an adjunct when psychotherapy alone is not effective.³⁶ Therefore, inpatient providers may see patients who are prescribed selective serotonin reuptake inhibitors (eg, paroxetine, fluoxetine) or serotonin and norepinephrine reuptake inhibitors (eg, venlafaxine).³⁶ In the past, PTSD-related nightmares were often treated with prazosin.³⁷ However, a recent randomized controlled trial of prazosin in veterans with PTSD failed to show significant improvement in nightmares.³⁸ Hence, current guidelines do not recommend prazosin as a first-line therapy.³⁹ For hospitalized patients with PTSD symptoms refractory to the interventions outlined herein, particularly those patients with possible borderline personality traits (as suggested by severe anger and impulsivity), we strongly recommend partnering with psychiatry. Finally, given the high prevalence of substance use disorders (SUDs) in PTSD patients, awareness and treatment of comorbidities such as opioid and alcohol dependence must be concurrently addressed.

Individualizing Care

It is essential for the healthcare team to identify ways to meet each patient’s immediate needs. Many of the ideas proposed below are not specific to PTSD; many require an interprofessional approach to care.⁴⁰ From a trauma-informed care standpoint, this is akin to having a planned response for patients who have suffered trauma. Assessing the individual’s needs and incorporating therapeutic modalities such as reflective listening, broadening safe opportunities for control, and providing complementary and integrative medicine (IM) therapies may help manage symptoms and establish rapport.⁴¹ Through reflective listening, a collaborative approach can be established to identify background, triggers, and a safe approach for managing PTSD and its comorbid conditions. Ensuring frequent communication and allowing the patient to be at the center of decision-making establishes a safe environment and promotes positive rapport between the patient and healthcare team.³⁶ Providing a sense of control by involving the patients in their healthcare decisions and in the structure of care delivery may benefit the patients’ well-being. Furthermore, incorporating IM encourages rest and relaxation in the chaotic hospital environment. Suggested IM interventions include deep breathing, aromatherapy, guided imagery, muscle relaxation, and music therapy.^42,43

Key Inpatient Issues Affecting PTSD

In the following sections, we outline common clinical situations that may exacerbate PTSD symptoms and propose some evidence-based responses (Table). In general, nonpharmacologic approaches are favored over pharmacologic approaches for patients with PTSD.

Sleep Hygiene

Sleep problems are very common in patients with PTSD, with nightmares occurring in more than 70% of patients and insomnia in 80%.⁴⁴ In PTSD, sleep problems are linked to poor physical health and other health outcomes^45,46 and may exacerbate other PTSD symptoms.⁴

Treating the sleep problems that occur with PTSD is an important aspect of PTSD care. Usually administered in the outpatient setting, the treatment of choice is cognitive-behavioral therapy (CBT).⁴⁸ Sleep-specific CBT focuses, among other things, on strategies that encourage good sleep hygiene,⁴⁹ which includes promoting regular sleep/wake-up times and specific bedtime routines, avoiding stimulation (eg, light, noise, TV) or excessive liquids before bed, refraining from daytime naps, and using relaxation techniques. Many of these recommendations seem at odds with hospital routines, which may contribute to decompensation of hospitalized patients with PTSD.

While starting sleep-specific CBT in the hospital may not be realistic, we suggest the following goals and strategies as a starting place for promoting healthy sleep for hospitalized patients with PTSD. To begin, factors affecting sleep hygiene should be addressed. Inpatient providers could pay more attention to intravenous (IV) fluid orders, perhaps adjusting them to run only during the daytime hours. Medications can be scheduled at times conducive to maintaining home routines. Avoiding the administration of diuretics close to bedtime may decrease the likelihood of frequent nighttime wakening. Grouping patient care activities, such as bathing or wound care, during daytime hours may allow more opportunities for rest at night. Incorporating uninterrupted sleep protocols, such as quiet hours between 10pm and 6am, may enhance sleep quality in the appropriately selected patient.⁵⁰ Although pharmacological interventions to improve sleep in the hospital may be initially beneficial, nonpharmacological interventions as described above should be incorporated for long-term maintenance of enhanced sleep quality.

Second, providers need to ask about established home bedtime routines and facilitate implementation in the hospital. Through collaboration with patients, providers can incorporate an individualized plan of care for sleep early in hospitalization.⁵⁰ Partnering with nurses is also essential to creating a sleep-friendly environment that can improve patient experiences.⁵¹ Breathing exercises, meditating, listening to music and praying are all examples of “bedtime wind down” strategies recommended in sleep-specific CBT.⁴⁹ Many of these could be successfully implemented in the hospital and may benefit other hospitalized patients too.⁵² In patients with PTSD and obstructive sleep apnea, continuous positive airway pressure (CPAP) reduces nightmares, and if inpatients are on CPAP at home, it should be continued in the hospital.⁵³

Pain

If sleep disturbance is the hallmark of PTSD,⁴⁷ chronic pain is its coconspirator.¹⁵ Uncontrolled pain can make it much more difficult to treat patients with PTSD, which in turn may lead to further decompensation from a mental health standpoint.⁵⁴ SUDs such as alcohol or opioid dependencies are highly comorbid with PTSD⁴⁵ and introduce a layer of complexity when managing painin these patients. Providers should be thoughtful when electing to treat acute or chronic pain with opioids and take particular care to establish realistic therapeutic goals if doing so. While patients with PTSD have a greater likelihood of having an SUD, undertreating pain risks exacerbating underlying PTSD symptoms.

Nonpharmacologic therapies, which include communicating, listening, and expressing compassion and understanding, should be utilized by inpatient providers as a first-line treatment in patients with PTSD who suffer from pain. Additionally, relaxation techniques, physical therapy, and physical activity⁵⁵ can be offered. Pharmacologically, nonopioid medications such as acetaminophen or NSAIDs should always be considered first. Should the use of opioids be deemed necessary, inpatient providers should preferentially use oral over intravenous medications and consider establishing a fixed timeframe for short-term opioids, which should be limited to a few days. Providers should communicate clear expectations with their patients to maximize the desired effect of any specific treatment while minimizing the risk of medication side effects with the goal of agreeing on a short yet effective treatment course.

Anxiety and Anger

One of the most challenging situations for the inpatient provider is encountering a patient who is anxious, angry, or hypervigilant. Mismatch between actual and expected communication between the provider and the patient can lead to frustration and anxiety. A trauma-informed care approach would suggest that frequent and thorough communication with patients may prevent or ameliorate the stresses and anxieties of hospitalization that may manifest as anger because of retraumatization. Hospitalizations usually lead to disruption of normal routine (eg, unpredictable meal times or medication administration), interrupted sleep (eg, woken up for blood draws or provider evaluation), and lack of control of schedule (eg, unsure of exact time when a procedure may be occurring), any of which may trigger symptoms of anxiety and anger in patients with PTSD and lead to hypervigilance.

If situations involving patient anxiety do arise, employ compassion and communication. Extra time spent with the patient, while challenging in the hectic hospital environment, is critical, and nonpharmacological treatments should be the priority. Engaging patients by asking about their PTSD triggers²⁴ may help prevent exacerbations. For example, some patients may specify how they prefer to be woken up to prevent startle reactions. PTSD triggers can be reduced via effective communication with the entire healthcare team. Some immediate yet effective strategies are listening, validation, and negotiation. Benzodiazepine or antipsychotic usage should be avoided.³⁶ Inpatient social work and comanagement with psychiatry involvement may be helpful in more severe exacerbations. A small observational study of patients hospitalized for severe PTSD found an association between walking more during hospitalization and fewer PTSD symptoms,⁵⁶ suggesting that staying active could be helpful for inpatients with PTSD who are able to safely ambulate.

PTSD is a common comorbidity among hospitalized patients in the United States. Typical hospital routines may exacerbate symptoms of PTSD such as anxiety and anger. Inpatient providers can play an important role in making hospitalizations go more smoothly for these patients by using principles consistent with trauma-informed care. Specifically, partnering with patients to construct a plan that preserves their sleep routines and accounts for potential triggers for decompensation can improve the hospital experience for patients with PTSD. Some PTSD interventions require additional investment from the healthcare system to deploy, such as staff training in trauma-­informed care and reflective listening techniques. Electronic health record–based protocols and order sets for patients with PTSD can leverage available resources. Further research should evaluate hospital outcomes that result from a more tailored approach to the care of patients with PTSD. More effective, patient-centered PTSD care could lower rates of leaving against medical advice and improve the inpatient experience for patients and providers alike.

Posttraumatic stress disorder (PTSD) is a syndrome that occurs after exposure to a significant traumatic event and is characterized by persistent, debilitating symptoms that fall into four “diagnostic clusters” as outlined in the Diagnostic and Statistical Manual of Mental Disorders-Version V (DSM-V). Patients may experience intrusive thoughts, avoidance of distressing stimuli, persistent negative mood, and hypervigilance, all of which last longer than 1 month.¹

A national survey of United States households conducted during 2001-2003 estimated the 12-month prevalence of PTSD among adults to be 3.5%.² Lifetime prevalence has been found to be between 6.8%³ and 7.8%.⁴ PTSD is more common in veterans. The prevalence of PTSD in veterans differs depending on the conflict in which the veteran participated. Vietnam veterans have an estimated lifetime prevalence of approximately 30%,^5,6 Gulf War veterans approximately 15%,⁷ and veterans of more recent conflicts in Afghanistan and Iraq of approximately 21%.⁸ With the MISSION Act moving more veteran care into the private sector, non-VA inpatient providers will need to become better versed in PTSD.⁹

Patients with PTSD have more contact with the healthcare system, even for non–mental health problems,^8,10-13 and a significantly higher burden of medical comorbities,¹⁴ such as diabetes mellitus, liver disease, gastritis and gastric ulcers, HIV, arthritis,¹⁵ and coronary heart disease.¹⁶ Veterans with PTSD are hospitalized three times more often than are those with no mental health diagnoses,⁸ and patients with psychiatric comorbidities have higher lengths of stay.¹⁷ More than 1.4 million hospitalizations occurring during 2002-2011 had either a primary or secondary associated diagnosis of PTSD, with total inflation-­adjusted charges of 34.9 billion dollars.¹⁸ In the inpatient sample from this study, greater than half were admitted for a primary diagnosis of mental diseases and disorders (Major Diagnostic Category [MDC] 19). Following mental illness, the most common primary diagnoses for men were MDC 5 (Circulatory System, 12.1%), MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 9.2%), and MDC 4 (Respiratory System, 7.4%), while the most common categories for women were MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 5.8%), MDC 21 (Injuries, Poison, and Toxic Effect of Drugs, 4.9%), and MDC 6 (Digestive System, 4.5%).¹⁸

In both the inpatient and outpatient settings, a fundamental challenge to comprehensive PTSD management is correctly diagnosing this condition.¹⁹ Confounding the difficulties in diagnosis are numerous comorbidities. In addition to the physical comorbidities described above, more than 70% of patients with PTSD have another psychological comorbidity such as affective disorders, anxiety disorders, or substance use disorder/dependency.²⁰

Given that PTSD may be an underrecognized burden on the healthcare system, we sought to better understand how PTSD could affect hospitalized patients admitted for medical problems by conducting this narrative review. Additionally, three of the authors collaborated with the VA Employee Education Service to conduct a needs assessment of VA hospitalists in 2013. Respondents identified managing and educating patients and families about PTSD as a major educational need (unpublished data available upon request from the corresponding author). Therefore, our aims were to present a synthesis of existing literature, familiarize readers with the tenets of trauma-­informed care as a framework to guide care for these patients, and generate ideas for changes that inpatient providers could implement now. We began by consulting a research librarian at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, who searched the following databases: PsycInfo, CINAHL, MEDLINE, and PILOTS (a PTSD/trauma specific database). Search terms included hospital, hospitalized, and hospitalization, as well as traumatic stress, posttraumatic stress, and PTSD. Pertinent guidelines and the reference lists from included papers were examined. We focused on papers that described patients admitted for medical problems other than PTSD because those patients who are admitted for PTSD-­related problems should be primarily ma­naged by psychiatry (not hospitalists) with the primary focus of their hospitalization being their PTSD. We also excluded papers about patients developing PTSD secondary to hospitalization, which already has a well-developed literature.^21-23

The literature is sparse describing frequency or type of problems encountered by hospitalized medical patients with PTSD. A recent small survey study reported that 40% of patients anticipated triggers for their PTSD symptoms in the hospital; such triggers included loud noises and being shaken awake.²⁴ Two papers describe case vignettes of patients who had exacerbations of their PTSD while in the Intensive Care Unit (ICU), although neither contain frequency or severity data.^25,26 Approximately 8% of patients in VA ICUs have PTSD,²⁷ and a published abstract suggests that they appear to require more sedation than do patients without PTSD.²⁸ Another published case report describes a patient with recurrent PTSD symptoms (nightmares) after moving into a nursing home.²⁹ These papers suggest other providers have recognized and are concerned about hospitalized patients with PTSD. At present, there are no data to quantify how often hospitalized patients have PTSD exacerbations or how troublesome such exacerbations are to these patients.

Given that there is little empiric literature to guide inpatient management of PTSD as a comorbidity in hospitalized medical patients, we extrapolate some information from the outpatient setting. PTSD is often underdiagnosed and underreported by individual patients in the outpatient setting.³⁰ Failure to have an associated diagnosis of PTSD may lead to underrecognition and undertreatment of these patients by inpatient providers in the hospital setting. Additionally, the numerous psychological and physical comorbidities in PTSD can create unique challenges in properly managing any single problem in these patients.²⁰ Armed with this knowledge, providers should be vigilant in the recognition, assessment, and treatment of PTSD.

Trauma-Informed Care: A Conceptual Model

Trauma-informed care is a mindful and sensitive approach to caring for patients who have suffered trauma.³¹ It requires understanding that many people have suffered trauma in their lives and that the trauma continues to impact many aspects of their lives.³² Trauma-informed care has many advocates and has been implemented across myriad health and social services settings.³³ Its principles can be applied in both the inpatient and outpatient hospital settings. While it is an appropriate approach to patients with PTSD, it is not specific to PTSD. People who have suffered sexual trauma, intimate partner violence, child abuse, or other exposures would also be included in the group of people for whom trauma-informed care is a suitable approach. There are four key assumptions to a trauma-­informed approach to care (the 4 R’s): (1) realization that trauma affects an individual’s coping strategies, relationships, and health; (2) recognition of the signs of trauma; (3) having an appropriate, planned response to patients identified as having suffered a trauma; and (4) resisting retraumatization in the care setting.^31,32

General Approach to Treating Medical Patients With PTSD in the Inpatient Setting

Recognition

Consistent with a trauma-informed care approach, inpatient providers should be able to recognize patients who may have PTSD. First, careful review of the past medical history may show some patients already carry this diagnosis. Second, patients with PTSD often have other comorbidities that could offer a clue that PTSD could be present as well; for example, risk for PTSD is increased when mood, anxiety, or substance use disorders are present.²⁰ When PTSD is suspected, screening is a reasonable next step.

The Primary Care-PTSD-5 (PC-PTSD-5) is a validated screening tool used in the outpatient setting.³⁴ It is easily administered and has good predictive validity (positive likelihood ratio [LR+] of 6.33 and LR– of 0.06). It begins with a question of whether the patient has ever experienced a trauma. A positive initial response triggers a series of five yes/no questions. Answering “yes” to three or more questions is a positive screen. A positive screen should result in consultation to psychiatry to conduct more formal evaluation and guide longer-term management.

Collaboration

Individual trauma-focused psychotherapy is the primary treatment of choice for PTSD with strong evidence supporting its practice.³⁵ This treatment is administered by a psychiatrist or psychologist and will be limited in the inpatient medical setting. Current recommendations suggest pharmacotherapy only when individualized trauma-focused psychotherapy is not available, the patient declines it, or as an adjunct when psychotherapy alone is not effective.³⁶ Therefore, inpatient providers may see patients who are prescribed selective serotonin reuptake inhibitors (eg, paroxetine, fluoxetine) or serotonin and norepinephrine reuptake inhibitors (eg, venlafaxine).³⁶ In the past, PTSD-related nightmares were often treated with prazosin.³⁷ However, a recent randomized controlled trial of prazosin in veterans with PTSD failed to show significant improvement in nightmares.³⁸ Hence, current guidelines do not recommend prazosin as a first-line therapy.³⁹ For hospitalized patients with PTSD symptoms refractory to the interventions outlined herein, particularly those patients with possible borderline personality traits (as suggested by severe anger and impulsivity), we strongly recommend partnering with psychiatry. Finally, given the high prevalence of substance use disorders (SUDs) in PTSD patients, awareness and treatment of comorbidities such as opioid and alcohol dependence must be concurrently addressed.

Individualizing Care

It is essential for the healthcare team to identify ways to meet each patient’s immediate needs. Many of the ideas proposed below are not specific to PTSD; many require an interprofessional approach to care.⁴⁰ From a trauma-informed care standpoint, this is akin to having a planned response for patients who have suffered trauma. Assessing the individual’s needs and incorporating therapeutic modalities such as reflective listening, broadening safe opportunities for control, and providing complementary and integrative medicine (IM) therapies may help manage symptoms and establish rapport.⁴¹ Through reflective listening, a collaborative approach can be established to identify background, triggers, and a safe approach for managing PTSD and its comorbid conditions. Ensuring frequent communication and allowing the patient to be at the center of decision-making establishes a safe environment and promotes positive rapport between the patient and healthcare team.³⁶ Providing a sense of control by involving the patients in their healthcare decisions and in the structure of care delivery may benefit the patients’ well-being. Furthermore, incorporating IM encourages rest and relaxation in the chaotic hospital environment. Suggested IM interventions include deep breathing, aromatherapy, guided imagery, muscle relaxation, and music therapy.^42,43

Key Inpatient Issues Affecting PTSD

In the following sections, we outline common clinical situations that may exacerbate PTSD symptoms and propose some evidence-based responses (Table). In general, nonpharmacologic approaches are favored over pharmacologic approaches for patients with PTSD.

Sleep Hygiene

Sleep problems are very common in patients with PTSD, with nightmares occurring in more than 70% of patients and insomnia in 80%.⁴⁴ In PTSD, sleep problems are linked to poor physical health and other health outcomes^45,46 and may exacerbate other PTSD symptoms.⁴

Treating the sleep problems that occur with PTSD is an important aspect of PTSD care. Usually administered in the outpatient setting, the treatment of choice is cognitive-behavioral therapy (CBT).⁴⁸ Sleep-specific CBT focuses, among other things, on strategies that encourage good sleep hygiene,⁴⁹ which includes promoting regular sleep/wake-up times and specific bedtime routines, avoiding stimulation (eg, light, noise, TV) or excessive liquids before bed, refraining from daytime naps, and using relaxation techniques. Many of these recommendations seem at odds with hospital routines, which may contribute to decompensation of hospitalized patients with PTSD.

While starting sleep-specific CBT in the hospital may not be realistic, we suggest the following goals and strategies as a starting place for promoting healthy sleep for hospitalized patients with PTSD. To begin, factors affecting sleep hygiene should be addressed. Inpatient providers could pay more attention to intravenous (IV) fluid orders, perhaps adjusting them to run only during the daytime hours. Medications can be scheduled at times conducive to maintaining home routines. Avoiding the administration of diuretics close to bedtime may decrease the likelihood of frequent nighttime wakening. Grouping patient care activities, such as bathing or wound care, during daytime hours may allow more opportunities for rest at night. Incorporating uninterrupted sleep protocols, such as quiet hours between 10pm and 6am, may enhance sleep quality in the appropriately selected patient.⁵⁰ Although pharmacological interventions to improve sleep in the hospital may be initially beneficial, nonpharmacological interventions as described above should be incorporated for long-term maintenance of enhanced sleep quality.

Second, providers need to ask about established home bedtime routines and facilitate implementation in the hospital. Through collaboration with patients, providers can incorporate an individualized plan of care for sleep early in hospitalization.⁵⁰ Partnering with nurses is also essential to creating a sleep-friendly environment that can improve patient experiences.⁵¹ Breathing exercises, meditating, listening to music and praying are all examples of “bedtime wind down” strategies recommended in sleep-specific CBT.⁴⁹ Many of these could be successfully implemented in the hospital and may benefit other hospitalized patients too.⁵² In patients with PTSD and obstructive sleep apnea, continuous positive airway pressure (CPAP) reduces nightmares, and if inpatients are on CPAP at home, it should be continued in the hospital.⁵³

Pain

If sleep disturbance is the hallmark of PTSD,⁴⁷ chronic pain is its coconspirator.¹⁵ Uncontrolled pain can make it much more difficult to treat patients with PTSD, which in turn may lead to further decompensation from a mental health standpoint.⁵⁴ SUDs such as alcohol or opioid dependencies are highly comorbid with PTSD⁴⁵ and introduce a layer of complexity when managing painin these patients. Providers should be thoughtful when electing to treat acute or chronic pain with opioids and take particular care to establish realistic therapeutic goals if doing so. While patients with PTSD have a greater likelihood of having an SUD, undertreating pain risks exacerbating underlying PTSD symptoms.

Nonpharmacologic therapies, which include communicating, listening, and expressing compassion and understanding, should be utilized by inpatient providers as a first-line treatment in patients with PTSD who suffer from pain. Additionally, relaxation techniques, physical therapy, and physical activity⁵⁵ can be offered. Pharmacologically, nonopioid medications such as acetaminophen or NSAIDs should always be considered first. Should the use of opioids be deemed necessary, inpatient providers should preferentially use oral over intravenous medications and consider establishing a fixed timeframe for short-term opioids, which should be limited to a few days. Providers should communicate clear expectations with their patients to maximize the desired effect of any specific treatment while minimizing the risk of medication side effects with the goal of agreeing on a short yet effective treatment course.

Anxiety and Anger

One of the most challenging situations for the inpatient provider is encountering a patient who is anxious, angry, or hypervigilant. Mismatch between actual and expected communication between the provider and the patient can lead to frustration and anxiety. A trauma-informed care approach would suggest that frequent and thorough communication with patients may prevent or ameliorate the stresses and anxieties of hospitalization that may manifest as anger because of retraumatization. Hospitalizations usually lead to disruption of normal routine (eg, unpredictable meal times or medication administration), interrupted sleep (eg, woken up for blood draws or provider evaluation), and lack of control of schedule (eg, unsure of exact time when a procedure may be occurring), any of which may trigger symptoms of anxiety and anger in patients with PTSD and lead to hypervigilance.

If situations involving patient anxiety do arise, employ compassion and communication. Extra time spent with the patient, while challenging in the hectic hospital environment, is critical, and nonpharmacological treatments should be the priority. Engaging patients by asking about their PTSD triggers²⁴ may help prevent exacerbations. For example, some patients may specify how they prefer to be woken up to prevent startle reactions. PTSD triggers can be reduced via effective communication with the entire healthcare team. Some immediate yet effective strategies are listening, validation, and negotiation. Benzodiazepine or antipsychotic usage should be avoided.³⁶ Inpatient social work and comanagement with psychiatry involvement may be helpful in more severe exacerbations. A small observational study of patients hospitalized for severe PTSD found an association between walking more during hospitalization and fewer PTSD symptoms,⁵⁶ suggesting that staying active could be helpful for inpatients with PTSD who are able to safely ambulate.

PTSD is a common comorbidity among hospitalized patients in the United States. Typical hospital routines may exacerbate symptoms of PTSD such as anxiety and anger. Inpatient providers can play an important role in making hospitalizations go more smoothly for these patients by using principles consistent with trauma-informed care. Specifically, partnering with patients to construct a plan that preserves their sleep routines and accounts for potential triggers for decompensation can improve the hospital experience for patients with PTSD. Some PTSD interventions require additional investment from the healthcare system to deploy, such as staff training in trauma-­informed care and reflective listening techniques. Electronic health record–based protocols and order sets for patients with PTSD can leverage available resources. Further research should evaluate hospital outcomes that result from a more tailored approach to the care of patients with PTSD. More effective, patient-centered PTSD care could lower rates of leaving against medical advice and improve the inpatient experience for patients and providers alike.

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

The journey toward patient and family centered care (PFCC) has been one of the hallmarks of early twenty-first century healthcare transformation. The Veterans Health Administration (VHA, including all of its VAMC hospitals) understands the critical importance of PFCC and has fully embraced—indeed, extended—its tenets as a core foundational structure going into the future. As full participants in the collaborative VHA care model, hospitalists and collaborating care teams are enhancing best care/best treatment practices with PFCC modalities.

Transformation is not new to VHA. Starting in the late 1990s, the organization expanded from a hospital-based, specialty care-only institution to one that adopted primary care in a wheel-and-spoke design: a centralized medical center with surrounding community-based primary care clinics. This brought about the infrastructure necessary to create the fully integrated national network that is VHA today. The current PFCC transformation aims to grow VHA a step further by restyling the culture of VHA care to a model that completely focuses the system around the needs of the veterans. VHA’s Blueprint for Excellence, a prescient guiding document for VHA transformation today, explains that the direction to Whole Health encompasses “support for both care needs and health into a coherent experience of veteran-centered care that maximizes well-being.”

The Whole Health program is the sum of patient self-care; personalized, proactive, patient-driven care (PPPDC); and environmental (relationship and community-based) care. The VHA is serious about PFCC: In 2010, the organization created a top-ranking office, aptly named the Office of Patient-Centered Care & Cultural Transformation (OPCC&CT); the office reports directly to national leadership and has as its founding objective the support of this latest transformation.

The VHA’s ambitious adoption of PFCC and the Whole Health program involves fully embracing PPPDC. VHA partners work with each veteran to create a personal health plan (PHP), supported by health coaching, motivational interviewing, and other clinical tools, as a living document aimed at optimizing health and well-being; best practice, evidence-based disease intervention and management provide the chronic and acute care needs.

A veteran’s PHP, essentially a mission and goal-planning document, is founded on what matters most to the veteran and on the aspects of the veteran’s health that are keeping him or her from meeting current and future life goals. Hospitalist providers, including those at VHA, academic, and private sector hospitals, can use the essence of the PHP to guide inpatient care. It is powerful to ask each of our patients what matters most to him or her, to understand a patient’s situational life goal. To partner with patients, helping each one to focus on and realize a pressing individual goal, not only centers us but humanizes an often destabilizing and stressful time for our patients.

Hippocrates is quoted as saying that we “cure sometimes, treat often, and comfort always.” This is true today. We rarely cure, but we can offer treatment with maximal comfort during a hospitalization, assisting our patients in returning to the health they had established prior to their admission. Hospital medicine providers and hospital-based teams act as a safety net, caring for our acutely ill patients, working with them to bring them back to their baseline, and getting them back on track to be able to enjoy what really matters to them, their “mission” at the moment. PFCC and PPPDC provide the culture and tools to meet our patients’ goals.

The VHA’s number one strategic goal has been to provide veterans PPPDC. Hospitalists and hospitals have adopted—and will continue to adopt—practices that move toward this goal. PFCC is at its essence patient empowerment, and its primary benefits are enhancement of patient safety, quality of care, and patient satisfaction. PFCC is one innovation necessary to reach the “triple aim” all healthcare systems strive toward: better health, better care, better value.

Dr. Steinbach is chief of hospital medicine at the Atlanta VAMC and assistant professor of medicine in the division of hospital medicine at Emory University School of Medicine in Atlanta.

The journey toward patient and family centered care (PFCC) has been one of the hallmarks of early twenty-first century healthcare transformation. The Veterans Health Administration (VHA, including all of its VAMC hospitals) understands the critical importance of PFCC and has fully embraced—indeed, extended—its tenets as a core foundational structure going into the future. As full participants in the collaborative VHA care model, hospitalists and collaborating care teams are enhancing best care/best treatment practices with PFCC modalities.

Transformation is not new to VHA. Starting in the late 1990s, the organization expanded from a hospital-based, specialty care-only institution to one that adopted primary care in a wheel-and-spoke design: a centralized medical center with surrounding community-based primary care clinics. This brought about the infrastructure necessary to create the fully integrated national network that is VHA today. The current PFCC transformation aims to grow VHA a step further by restyling the culture of VHA care to a model that completely focuses the system around the needs of the veterans. VHA’s Blueprint for Excellence, a prescient guiding document for VHA transformation today, explains that the direction to Whole Health encompasses “support for both care needs and health into a coherent experience of veteran-centered care that maximizes well-being.”

The Whole Health program is the sum of patient self-care; personalized, proactive, patient-driven care (PPPDC); and environmental (relationship and community-based) care. The VHA is serious about PFCC: In 2010, the organization created a top-ranking office, aptly named the Office of Patient-Centered Care & Cultural Transformation (OPCC&CT); the office reports directly to national leadership and has as its founding objective the support of this latest transformation.

The VHA’s ambitious adoption of PFCC and the Whole Health program involves fully embracing PPPDC. VHA partners work with each veteran to create a personal health plan (PHP), supported by health coaching, motivational interviewing, and other clinical tools, as a living document aimed at optimizing health and well-being; best practice, evidence-based disease intervention and management provide the chronic and acute care needs.

A veteran’s PHP, essentially a mission and goal-planning document, is founded on what matters most to the veteran and on the aspects of the veteran’s health that are keeping him or her from meeting current and future life goals. Hospitalist providers, including those at VHA, academic, and private sector hospitals, can use the essence of the PHP to guide inpatient care. It is powerful to ask each of our patients what matters most to him or her, to understand a patient’s situational life goal. To partner with patients, helping each one to focus on and realize a pressing individual goal, not only centers us but humanizes an often destabilizing and stressful time for our patients.

Hippocrates is quoted as saying that we “cure sometimes, treat often, and comfort always.” This is true today. We rarely cure, but we can offer treatment with maximal comfort during a hospitalization, assisting our patients in returning to the health they had established prior to their admission. Hospital medicine providers and hospital-based teams act as a safety net, caring for our acutely ill patients, working with them to bring them back to their baseline, and getting them back on track to be able to enjoy what really matters to them, their “mission” at the moment. PFCC and PPPDC provide the culture and tools to meet our patients’ goals.

The VHA’s number one strategic goal has been to provide veterans PPPDC. Hospitalists and hospitals have adopted—and will continue to adopt—practices that move toward this goal. PFCC is at its essence patient empowerment, and its primary benefits are enhancement of patient safety, quality of care, and patient satisfaction. PFCC is one innovation necessary to reach the “triple aim” all healthcare systems strive toward: better health, better care, better value.

Dr. Steinbach is chief of hospital medicine at the Atlanta VAMC and assistant professor of medicine in the division of hospital medicine at Emory University School of Medicine in Atlanta.

The journey toward patient and family centered care (PFCC) has been one of the hallmarks of early twenty-first century healthcare transformation. The Veterans Health Administration (VHA, including all of its VAMC hospitals) understands the critical importance of PFCC and has fully embraced—indeed, extended—its tenets as a core foundational structure going into the future. As full participants in the collaborative VHA care model, hospitalists and collaborating care teams are enhancing best care/best treatment practices with PFCC modalities.

Transformation is not new to VHA. Starting in the late 1990s, the organization expanded from a hospital-based, specialty care-only institution to one that adopted primary care in a wheel-and-spoke design: a centralized medical center with surrounding community-based primary care clinics. This brought about the infrastructure necessary to create the fully integrated national network that is VHA today. The current PFCC transformation aims to grow VHA a step further by restyling the culture of VHA care to a model that completely focuses the system around the needs of the veterans. VHA’s Blueprint for Excellence, a prescient guiding document for VHA transformation today, explains that the direction to Whole Health encompasses “support for both care needs and health into a coherent experience of veteran-centered care that maximizes well-being.”

The Whole Health program is the sum of patient self-care; personalized, proactive, patient-driven care (PPPDC); and environmental (relationship and community-based) care. The VHA is serious about PFCC: In 2010, the organization created a top-ranking office, aptly named the Office of Patient-Centered Care & Cultural Transformation (OPCC&CT); the office reports directly to national leadership and has as its founding objective the support of this latest transformation.

The VHA’s ambitious adoption of PFCC and the Whole Health program involves fully embracing PPPDC. VHA partners work with each veteran to create a personal health plan (PHP), supported by health coaching, motivational interviewing, and other clinical tools, as a living document aimed at optimizing health and well-being; best practice, evidence-based disease intervention and management provide the chronic and acute care needs.

A veteran’s PHP, essentially a mission and goal-planning document, is founded on what matters most to the veteran and on the aspects of the veteran’s health that are keeping him or her from meeting current and future life goals. Hospitalist providers, including those at VHA, academic, and private sector hospitals, can use the essence of the PHP to guide inpatient care. It is powerful to ask each of our patients what matters most to him or her, to understand a patient’s situational life goal. To partner with patients, helping each one to focus on and realize a pressing individual goal, not only centers us but humanizes an often destabilizing and stressful time for our patients.

Hippocrates is quoted as saying that we “cure sometimes, treat often, and comfort always.” This is true today. We rarely cure, but we can offer treatment with maximal comfort during a hospitalization, assisting our patients in returning to the health they had established prior to their admission. Hospital medicine providers and hospital-based teams act as a safety net, caring for our acutely ill patients, working with them to bring them back to their baseline, and getting them back on track to be able to enjoy what really matters to them, their “mission” at the moment. PFCC and PPPDC provide the culture and tools to meet our patients’ goals.

The VHA’s number one strategic goal has been to provide veterans PPPDC. Hospitalists and hospitals have adopted—and will continue to adopt—practices that move toward this goal. PFCC is at its essence patient empowerment, and its primary benefits are enhancement of patient safety, quality of care, and patient satisfaction. PFCC is one innovation necessary to reach the “triple aim” all healthcare systems strive toward: better health, better care, better value.

Dr. Steinbach is chief of hospital medicine at the Atlanta VAMC and assistant professor of medicine in the division of hospital medicine at Emory University School of Medicine in Atlanta.