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Journal of Trauma-Injury Infection & Critical Care:
doi: 10.1097/01.ta.0000174769.80839.12
Session 4

Are We the Problem? Overcoming Obstacles to Implementing Intervention Programs

Hoyt, David B. MD, FACS

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From the Department of Surgery, Division of Trauma, University of California, San Diego, California.

Submitted for publication December 21, 2004.

Accepted for publication December 21, 2004.

This article was written for the proceedings from a conference entitled “Alcohol and Other Drug Problems Among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism” in Washington, DC, May 28–30, 2003. It does not reflect the official policy or opinions of the Centers for Disease Control and Prevention (CDC) or the U.S. Department of Health and Human Services (HHS) and does not constitute an endorsement of the individuals or their programs—by CDC, HHS, or the federal government—and none should be inferred.

Address for reprints: David B. Hoyt, MD, FACS, UCSD Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8896; email:

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Alcohol-related injuries comprise a large percentage of injuries in the United States. As the impact of these injuries on society increases, a well-functioning trauma system becomes increasingly important. During the last decade, evidence-based guidelines to reduce alcohol-related injuries have emerged. Further, evidence supports the effectiveness of brief intervention programs to reduce alcohol-related injuries and demonstrates that trauma centers can improve patient outcomes by integrating them into care. Although many obstacles have inhibited progress and made implementing preventive interventions a difficult task, economic constraints are among the biggest challenges to implementing intervention programs as part of routine trauma care.

A trauma system provides organized and coordinated health care services within a defined geographic area and improves patient outcomes by integrating appropriate health care resources into care of the injured patient. A well-functioning trauma system with an arsenal of resources is essential to reducing the burden of injuries on society.1 These resources range from prevention programs to rehabilitation programs that take place after hospital treatment.

Within the trauma system, each trauma center focuses primarily on acute care problems to prevent deaths from early exsanguination or head injury.2 Despite the documented improvement in mortality since trauma systems were implemented, the number of preventable deaths after injury has changed very little using current quality improvement methods.3 It seems that prevention programs provide the greatest opportunity for reducing morbidity and mortality after injury, but only recently has a serious commitment to these programs become evident.

The last decade in medicine has been characterized by an emergence of evidence-based guidelines, a renewed commitment to quality and safety, and the failure of managed care. Multiple external pressures have shifted health care decisions to value-based consumerism. These pressures have arisen in part as a result of skyrocketing health care costs and a growing awareness that current health care systems do not always lead to optimal quality. Before making purchasing decisions, purchasers of health care, such as large corporations and other conglomerate entities, are increasingly interested in obtaining information on steps taken to reduce or eliminate medical errors and measures of quality. As consumers push to hold costs in check but increase health care quality, it is likely that medical professionals and decision makers will act on data that clearly show the efficacy of brief intervention programs in preventing alcohol-related injuries.

Inconsistencies in our beliefs and, to a certain extent, the erroneous belief that drinking behavior is something that cannot be changed have made the movement toward preventive interventions that focus on alcohol difficult to implement. Even insurance policies contain clauses that deny benefits when injuries are related to drinking, reflecting the attitude that alcohol use disorders are founded in misbehavior, rather than in disease.4 These denials are particularly striking given the existence of data that suggest that brief intervention programs are effective in reducing alcohol use and subsequent alcohol-related injuries.4,5 Although recent surveys of current trauma center practices show that more trauma centers are screening patients for alcohol-related problems than in the past,6 trauma centers still face significant barriers to implementing interventions that will require ongoing physician education to overcome.7

The American College of Surgeons (ACS) has developed standards of care for trauma centers that are upheld through a well-organized evaluation system.8 These standards ensure that injured patients receive timely diagnostic, therapeutic, and surgical care. Evidence supports this approach. By maintaining and ensuring standards, the overall quality of patient care is increased, and lives are saved. Many trauma centers that have implemented these standards have shown improved patient outcomes. When a trauma center adheres to ACS standards of care, studies suggest that mortality rates plateau.9

What will it take to include brief alcohol intervention programs in the accreditation criteria for trauma centers? Clearly, additional data will be helpful. But lack of data is not the major obstacle. To be considered a standard trauma center service by the Verification Review Committee or Executive Committee of the ACS, an intervention program has to be reasonable and evidence based. When possible, there needs to be consensus among surgeons. For more than 25 years, this has proven to be a valid process for revising standards of care. Brief intervention programs meet the criteria set by the ACS and should be considered an integral part of routine trauma care.

Adequate funding remains the biggest obstacle to implementing intervention programs. Recent studies by Schermer et al.10 evaluate the resources required to implement a brief alcohol intervention program. In large trauma centers where routine alcohol screening was performed by one half-time employee, most at-risk patients were identified. In another intervention model, contract employees successfully captured most patients and identified those who would benefit from intervention. When compared with the overall costs of a trauma center, the cost of conducting screening and brief intervention programs is quite small. Currently, however, trauma centers are threatened by decreased reimbursement, malpractice issues, and failure of physicians to commit to these services When resources are strained, maintaining the trauma center as an injury management facility takes priority over public health issues, including intervention programs.

Although at-risk patients need brief alcohol intervention programs, such programs will never be implemented unless we—the medical community—become less of an obstacle. Our belief system must broaden to acknowledge alcohol problems as a treatable disease. Given its treatable nature, insurance laws should not deny payment if injury is alcohol related. It does no good for physicians to personally commit their efforts to screening and intervention services if trauma centers cannot obtain financing. Adequate funding to implement and sustain these programs can be obtained only through the combined efforts of trauma practitioners, public health workers, and local, state, and federal authorities. Let us join forces and support the integration of new clinical preventive services into trauma care. We can overcome financial obstacles by doubling our efforts to secure adequate resources to support these essential prevention programs.

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1. Fildes JJ, ed. National Trauma Data Bank Report 2004. Chicago, Ill: American College of Surgeons; 2004. Available at: Accessed October 14, 2004.

2. Acosta JA, Yang JC, Winchell RJ, et al. Lethal injuries and time to death in a level I trauma center. J Am Coll Surg. 1998;186:528–533.

3. Potenza BM, Hoyt DB, Coimbra R, et al. The epidemiology of serious and fatal injury in San Diego County over an 11-year period. J Trauma. 2004;56:68–75.

4. Rivara FP, Tollefson S, Tesh E, Gentilello LM. Screening trauma patients for alcohol problems: are insurance companies barriers? J Trauma. 2000;48:115–118.

5. Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473–480.

6. Schermer CR, Bloomfield LA, Lu SW, Demarest GB. Trauma patient willingness to participate in alcohol screening and intervention. J Trauma. 2003;54:701–706.

7. Schermer CR, Gentilello LM, Hoyt DB, et al. National survey of trauma surgeons' use of alcohol screening and brief intervention. J Trauma. 2003;55:849–856.

8. Fabian TC, Gamelli RL, Heilman JE, et al. Resources for Optimal Care of the Injured Patient: 1999. Chicago, Ill: American College of Surgeons; 1998.

9. Hoyt DB. Use of panel study methods. J Trauma. 1999;47:S42–S43.

10. Schermer CR, Gentilello LM, Hoyt DB, et al. National survey of trauma surgeons' use of alcohol screening and brief intervention. J Trauma. 2003;55:849–856.

Cited By:

This article has been cited 1 time(s).

Journal of the American College of Surgeons
Nationwide Survey of Alcohol Screening and Brief Intervention Practices at US Level I Trauma Centers
Terrell, F; Zatzick, DF; Jurkovich, GJ; Rivara, FP; Donovan, DM; Dunn, CW; Schermer, C; Meredith, JW; Gentilello, LM
Journal of the American College of Surgeons, 207(5): 630-638.
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Alcohol-related injuries; Intervention programs; Prevention

© 2005 Lippincott Williams & Wilkins, Inc.

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