Appendix D: Technical detail on the criteria for audit

Possible objectives for an audit

One or more audits could be carried out in different care settings to ensure that:

  • individuals with PTSD are involved in their care

  • treatment options, including psychological interventions, are

appropriately offered and provided for individuals with PTSD.

People who could be included in an audit

A single audit could include all individuals with PTSD. Alternatively, individual audits could be undertaken on specific groups of individuals such as:

  • people with a specific type of PTSD (for example, to study early intervention)

  • a sample of patients from particular populations in primary care.

Measures that could be used as a basis for an audit

Recommendation

Measured by

Exception

Definition of terms

1. Brief, single-session interventions (debriefing)

For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief, single-session interventions (often referred to as debriefing) that focus on the traumatic incident, should not be routine practice when delivering services.

100% of individuals who have experienced a traumatic event should not be offered single-session interventions (often referred to as debriefing).

None

Operational policies of relevant organisations should contain copies of relevant protocols and implementation plans, which specify that single-session debriefing should not be routinely provided.

2. Watchful waiting

Where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a way of managing the difficulties presented by individual sufferers, should be considered by healthcare professionals. A follow-up contact should be arranged within 1 month.

100% of patients identified as suffering from PTSD who are not offered or who decline an active intervention should have arranged a follow-up contact within 4 weeks.

Individuals who are offered the follow-up but who, for personal or practical reasons, are not able to attend within 4 weeks.

The notes should indicate that the healthcare professional responsible has discussed the need for follow-up and an arrangement has been made for a contact to be made.

3. Trauma-focused psychological treatment

Trauma-focused cognitive behavioural therapy should be offered to those with severe posttraumatic symptoms or with severe PTSD in the first month after the traumatic event. These treatments should normally be provided on an individual outpatient basis.

All people with PTSD should be offered a course of trauma-focused psychological treatment (trauma-focused CBT or EMDR). These treatments should normally be provided on an individual outpatient basis.

100% of PTSD sufferers with symptoms present for more than 3 months should be considered for trauma-focused psychological treatment.

Those who request or have taken up the offer of another intervention.

The notes should indicate that the patient was informed of the possibility of trauma-focused CBT.

The notes should record if the patient completes a full course of treatment.

4. Trauma-focused cognitive behavioural therapy for older children with PTSD

Trauma-focused cognitive behavioural therapy should be offered to older children with severe post-traumatic symptoms or with severe PTSD in the first month after the traumatic event.

100% of children and young people with severe post-traumatic symptoms seen within 1 month of the traumatic event should be considered for trauma-focused CBT.

Those who request or have taken up the offer of another intervention.

The notes should indicate that the patient was informed of the possibility of trauma-focused CBT.

The notes should record if the patient completes a full course of treatment.

5. Trauma-focused cognitive behavioural therapy for chronic PTSD in children and young people

Children and young people with PTSD, including those who have been sexually abused, should be offered a course of trauma-focused cognitive behavioural therapy adapted as needed to suit their age, circumstances and level of development.

100% of children and young people with PTSD should be offered a course for trauma-focused CBT.

Those who request or have taken up the offer of another intervention.

The notes should indicate that the patient was offered trauma-focused CBT.

The notes should record if the patient completes a full course of treatment.

6. Drug treatments for PTSD

Drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy.

Drugs should not routinely be used in the treatment of PTSD. The option of trauma-focused psychological treatment should be considered.

Exceptions include:

a. patients who refuse psychological treatment

b. patients who have not responded to psychological interventions

c. patients who have significant sleep or related problems of hyperarousal

d. patients where safety issues prevent the use of psychological interventions.

The notes should indicate for all patients in receipt of medication that they were considered for psychological interventions and the reason that this was not taken up – the exceptions set out in this audit apply.

The notes should record if the patient completes a full course of treatment.

7. Drug treatments for PTSD when a patient declines psychological interventions

Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or phenelzine for initiation only by mental health specialists) should be considered for the treatment of PTSD in adults who express a preference not to engage in a trauma-focused psychological treatment.

Drugs should be considered in the treatment of PTSD where a sufferer declines the offer of trauma-focused psychological treatment.

None

The notes should indicate for all patients who declined psychological interventions that the option of prescribing appropriate medication was considered. The reason that this was not taken up should be recorded in the notes, which should also record if the patient completes a full course of treatment.

8. Disaster screening

For individuals at high risk of developing PTSD following a major disaster, consideration should be given (by those responsible for coordination of the disaster plan) to the routine use of a brief screening instrument for PTSD 1 month after the disaster.

100% of individuals who have been involved in a major disaster should be screened 1 month after the disaster.

Those who refuse to participate in the screening or who are not contactable despite reasonable efforts by those responsible for the screening.

Operational policies of relevant organisations should contain copies of relevant protocols and implementation plans that specify the requirement for screening. Where screening occurs, records should be reviewed to establish the numbers screened.

Calculation of compliance

Compliance (%) with each measure described in the table above is calculated as follows.

Number of patients whose care is consistent with the criterion plus number of patients who meet any exception listed

/

Number of patients to whom the measure applies

× 100

Clinicians should review the findings of measurement, identify whether practice can be improved, agree on a plan to achieve any desired improvement and repeat the measurement of actual practice to confirm that the desired improvement is being achieved.