Implementing the ACE and PCL-5 Screening Tools to Improve Trauma-Informed Care at an Outpatient Mental Health Clinic

Background: Post-traumatic stress disorder (PTSD) is a trauma response that leads to adverse psychological and physical symptoms. Post-traumatic stress disorder is frequently underdiagnosed by providers, resulting in unrecognized and untreated trauma symptoms. Experts recommend screening patients with the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5) for PTSD symptoms and the Adverse Childhood Experiences (ACE) tool for childhood trauma exposure. Increased rates of trauma screening with the ACE and PCL-5 can help providers identify individuals with PTSD and refer them to appropriate resources to improve trauma-informed care. Local Problem: Despite evidence-based recommendations for trauma screening, the South Jordan Health Center (SJHC) outpatient psychiatric clinic demonstrated low trauma screening rates. This quality improvement project aimed to increase trauma screening rates by integrating the ACE and PCL-5 screening tools into patient evaluations to enhance trauma-informed care. Methods: This project included a needs assessment conducted through chart review and standardized interviews to determine protocols and procedures for trauma screening. Clinic staff received an educational presentation about trauma screening, a clinical practice guideline, and a patient handout of local trauma resources. Providers utilized the ACE and PCL-5 screeners to help determine when to diagnose PTSD and refer patients to appropriate resources. Analysis of chart review and standardized interviews following project implementation evaluated the intervention's effectiveness. Results: Retrospective chart review of 54 patient evaluations before project implementation revealed that providers screened 0% of patients with the ACE and 9.3% (n=5) with the PCL-5. This data established baseline trauma screening rates with the ACE and PCL-5 tools at SJHC before project implementation. Data obtained from chart reviews showed that after project implementation, the provider screened 84.8% (n=56) of new patients with the ACE and 84.8% (n=57) with the PCL-5, indicating a statistically significant increase in screening rates (p<0.001). In addition, interviews with participants showed that the ACE and PCL-5 screening tools workflow demonstrated high feasibility, usability, satisfaction, and sustainability. Providers indicated high satisfaction rates with the brief trauma education, referral resources, and patient educational handout they received. Conclusion: This project demonstrated that an outpatient psychiatric clinic with low trauma screening rates effectively integrated the ACE and PCL-5 screening tools into patient evaluations. This project led to a statistically significant increase in trauma screening rates and an increased number of patients provided with trauma resources. Future implications of this project include implementing trauma screening at other outpatient psychiatric clinics and in primary care.