There are an estimated 7.6 million alcohol-related emergency department (ED) visits each year in the country. A first step in identifying an alcohol problem is screening all ED patients utilizing two well-researched screening tests. Once identified, one technique that has proven successful is motivationally-based brief interviews focused on reducing alcohol use. The research to date, however, has been focused on an academic medical environment and not within the more common environment of the community hospital ED, where 56 percent of all ED visits occur.
As a result, physicians and researchers at Rhode Island Hospital's Injury Prevention Center set out to identify a model that could integrate screening and brief interventions (SBI) for alcohol misuse into a community hospital environment. The study was published in the August 2009 issue of the journal Substance Abuse. Their goal was to develop, implement and evaluate the adoption of a model of SBI, using feedback from the community hospital ED. This would then allow them to create a delivery method for the toolkit for SBI developed by the American College of Emergency Physicians (ACEP) and the National Highway Traffic Safety Administration.
Under the direction of lead author Michael Mello, MD, MPH, director of the Injury Prevention Center and an emergency medicine physician at Rhode Island and The Miriam hospitals, the researchers worked with Robert Dinwoodie, DO, MBA, an emergency medicine physician at Kent Hospital as a pilot site.
The project was divided into two phases over a year. The first phase involved meeting with key stakeholders to gather information and feedback on the SBI delivery model design and implementation. The feedback was then used to adapt the proposed SBI model design for the community hospital and train the staff. Phase two focused on the implementation and adoption of the SBI into the ED setting in the community hospital over a 6-month period. The research study design team included ED physicians, a clinical psychologist, experimental psychologist and project coordinator, along with a research assistant who was present in the ED to record the extent of adoption into the ED's practice.
Mello says, "Our research identified numerous barriers, with key stakeholders expressing concern over potential disruption to the clinical practice and patient flow; the burden of SBI on staff time, particularly nurses; the willingness of nursing and physician staff to accept the SBI; and staff reluctance to speak to patients about alcohol-related issues when not directly related to a patient's chief complaint. These are all understandable concerns."
As a result, the SBI model was modified to address the concerns. The implementation was limited to an area of the ED for non-critical patients, active participation was limited to physicians only who would evaluate using the screening tool and then refer patients screening positive to a research assistant who would then perform the 5- to 10-minute brief intervention.
Prior to the adoption of the SBI model in the community hospital ED, a medical record review revealed that alcohol screening only occurred in 50 percent of patients, and of those, only 23 percent of the positive screens were referred for an alcohol intervention. In the study, during the time period when the research assistant was present in the ED, 90 percent of eligible patients were screened, and 71 percent of those patients were then evaluated by ED staff. Further, 38 percent of screened patients met the screening criteria, with 77 percent of the patients who met the criteria being correctly identified by ED staff and referred to the research assistant for the brief intervention. One month after the research assistant was no longer present in the ED, a repeat medical record review found documented alcohol screening had returned to the 50 percent level.
Dinwoodie, of Kent Hospital, says, "The research was done to look at the feasibility and impact of implementing an alcohol abuse screening and brief intervention program into a community hospital emergency department setting. The results of the study suggest that implementing such a program is possible by training staff such as emergency department nursing personnel, however, implementation will potentially be more successful if additional staff trained to conduct the screening and intervention are utilized."
Mello and the researchers comment that the return of the alcohol screenings to the 50 percent level when the research assistant was no longer in the ED suggests that the program did not create a sustainable change. Mello says, "Our study shows, however, that with the appropriate training and tools, combined with additional resources devoted to this effort, SBI can be successfully transitioned and integrated into community hospital EDs. Additional research would help to further refine the SBI model so that it would work in different types of community hospitals."
Mello concludes, "In the end, if the identified barriers can be overcome, we believe that a refined model will result in higher levels of screening for alcohol problems and appropriate referrals for help with many patients."
The study was funded by a grant from the Emergency Medicine Foundation through a grant from the Highway Traffic Safety Administration. Other researchers involved in the study with Mello and Dinwoodie include Janette Baird, PhD, Ted Nirenberg, PhD, Jennifer Smith, EdM of the Injury Prevent Center at Rhode Island Hospital and Robert Woolard, MD, of Texas Tech University Health Sciences Center, and formerly of Rhode Island Hospital.
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