Development and Validation of a Measure to Assess Patients' Threat Perceptions in the Emergency Department

Objective: Threat perceptions in the emergency department (ED; e.g., patients' subjective feelings of helplessness or lack of control) during evaluation for an acute coronary syndrome (ACS) are associated with the development of posttraumatic stress disorder (PTSD), and PTSD has been associated with medication nonadherence, cardiac event recurrence, and mortality. This study reports the development and validation of a seven-item measure of ED threat perceptions in English- and Spanish-speaking patients evaluated for ACS. Methods: Participants were drawn from an observational cohort study of 1,000 patients evaluated for ACS between 2013 and 2016 in a large New York City hospital. Participants reported on threat perceptions in the ED and during inpatient stay (using 12 items previously identified as predictive of PTSD) and reported on cardiac-induced PTSD 1 month postdischarge. Exploratory and confirmatory factor analyses were used to establish the factor structure and test measurement invariance. Validity and reliability were examined, as was the association of ED threat perceptions with cardiac-induced PTSD. Results: Factor analyses identified a seven-item measure of ED threat perceptions (e.g., I feel helpless, I am worried that I am going to die) for both English- and Spanish-speaking patients. ED threat perceptions demonstrated convergent validity, correlating with ED stress and ED crowdedness (r = 0.29 and r = 0.14), good internal consistency (alpha = 0.82), and stability (r = 0.61). Threat perceptions were associated with cardiac-induced acute stress at inpatient and PTSD symptoms at 1 month (r = 0.43 and r = 0.39). Conclusions: This brief tool assessing ED threat perceptions has clinical utility for providers to identify patients at risk for developing cardiac-induced PTSD and is critical to inform research on whether threat may be modified in-ED to reduce PTSD incidence.