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Journal of Trauma-Injury Infection & Critical Care:
doi: 10.1097/01.ta.0000176045.95492.01
Session 3

Implementing Screening, Brief Intervention, and Referral for Alcohol and Drug Use: The Trauma Service Perspective

Sise, Michael J. MD; Sise, C Beth MSN, JD; Kelley, Dorothy M. MSN; Simmons, Charles W. MD; Kelso, Dennis J. PhD

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Author Information

From the Division of Trauma (M.J.S., C.B.S., D.M.K.) and Emergency Medicine (C.W.S.), Scripps Mercy Hospital, San Diego, California, and Altam Associates, San Diego, California (D.J.K.).

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: Michael J. Sise, MD, 550 Washington Street, Suite 641, San Diego, CA 92103; email: sise.mike@scrippshealth.org.

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Abstract

Background: Most trauma surgeons are unfamiliar with screening, brief intervention, and referral (SBIR) programs for substance use disorders, and few trauma centers provide them. This report describes how an urban private-teaching hospital adapted a protocol from an existing emergency department-based program to include patients treated by the trauma service.

Methods: We recorded the rates of SBIR completion and reasons for failure during each phase of the implementation, interviewed trauma service staff and health educators to assess attitudes toward the program, and evaluated patient satisfaction surveys.

Results: By adding SBIR staff to the trauma outpatient clinic and to trauma morning rounds, the capture rate increased from 12 to 71%. Most screened patients (59%) were found at risk for problems or probably dependent on alcohol or drugs. Trauma service staff and health educators reported high satisfaction with the program. Patients reported higher satisfaction with SBIR.

Conclusion: SBIR services can be effectively integrated into all components of a busy, urban trauma service by adding specially trained health educators to the trauma service staff. This collaboration provides effective SBIR services to both trauma and emergency service patients without interfering with patient flow or medical procedures. The relatively high percentage of patients at risk for alcohol or drug problems supports the inclusion of routine alcohol and drug screening for all eligible trauma patients.

To effectively prevent injury, we must first address its root causes. In America, alcohol and drug use are among the most common contributing factors in traumatic injury and death.1–3 Although dependent drinkers and drug users are at high risk for causing injury to themselves and others, four to five times as many people are only moderate users, yet they are responsible for most alcohol- and drug-related injuries and traumatic deaths.4–9 Simple, inexpensive, and easily-delivered screening, brief intervention, and referral (SBIR) programs for alcohol and drug use are readily acceptable to patients and staff and are effective in changing these high-risk behaviors.10–14 Despite the prevalence of alcohol and drug problems among injured patients, trauma centers have done little to address this issue.11,14–17 Although most trauma surgeons have extensive experience with intoxicated patients, they are not always able to detect alcohol and drug use. Most trauma surgeons feel they don’t have adequate time to address substance use disorders, and they lack a basic understanding of SBIR.15

This article describes how Scripps Mercy Hospital partnered with Altam Associates to supplement an existing emergency department (ED)-based SBIR program to include the trauma center of an urban teaching hospital. The program was implemented in phases so that earlier protocols could be improved, obstacles could be overcome, and the impact of this program on trauma service staff could be assessed.

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Background

Scripps Mercy Hospital is a large urban privately owned teaching hospital that offers a graduate medical education program affiliated with the University of California, San Diego. The hospital’s ED staff evaluates over 60,000 patients each year. The trauma service includes surgical residents and is staffed 24 hours a day by in-house attending surgeons who are board-certified in surgical critical care.

Annually, the trauma center evaluates over 2,000 patients and admits over 1,600 patients. More than 300 of these patients have an injury severity score of 15 or greater. Approximately 50% of trauma patients are in the self-pay financial category or are enrolled in county and state government programs that do not sufficiently reimburse the cost of care. Although the ED and trauma patient population speaks numerous languages, Spanish is spoken by 20 to 40% of patients. Length of stay for trauma patients is generally brief. Overall, 21% are discharged from the ED after evaluation and a short observation period. Discharge from the medical-surgical floors occurs throughout the day and into the late evening hours. All discharged patients are scheduled for follow-up at the hospital’s outpatient trauma clinic, a freestanding facility located near the hospital. Trauma service physicians and nurse practitioners staff the outpatient clinic one afternoon per week. Self-reports and serum and urine tests show that alcohol and drug use by trauma patients at the time of injury varies between 30 and 50%.

Scripps Mercy Hospital ED first implemented SBIR in 1999. The hospital’s director of Trauma Prevention Programs (C.B.S.) became aware of the SBIR program through her leadership of the San Diego County Methamphetamine Strike Force Research Committee. This was a community effort involving government and nongovernment organizations focused on strategies to prevent substance use disorders. With the support of the Scripps Health System and the San Diego County Department of Health and Human Services, the ED at Scripps Mercy Hospital implemented the first SBIR program at a large urban hospital in Southern California.

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Preparation and Program Administration

Implementation of the program included a 6-month preparation period. The external SBIR agency director (D.J.K.) and the trauma medical director (M.J.S.) explained the proposed program and reviewed the scientific basis for SBIR with physician governance and quality improvement committees of the medical staff and to nursing and administrative leadership groups. These staff committees and groups then distributed screening questionnaires, interview techniques, and educational materials to all staff members who would be affected by the program.

Clinical settings for the pilot program included the main ED, chest pain center, urgent care center, and trauma resuscitation room. Because these areas are located near each other with common access through the ED entrance, the same bilingual health educators (employed and managed by the external SBIR agency Altam Associates) could provide program services to each area. These health educators were introduced to hospital staff, were oriented to the hospital environment, and were provided 80 hours of training in screening, intervention, and referral techniques. During the first 2 weeks after training, they provided SBIR to patients alongside an experienced colleague. During the balance of the first 3 months of the project, they conducted SBIR independently but under close supervision by the external agency.

The SBIR agency collected data on eligible patients, refusal rates, and screening rates and submitted quarterly reports to the ED and trauma service supervisory committees. The agency also examined variations in the rate of screening throughout the week, ease of access to patients, and reasons for failing to access and screen patients. The SBIR agency director (D.J.K.), the trauma medical director (M.J.S.), the ED medical director (C.W.S.), and the Trauma Prevention Program director (C.B.S.) reviewed progress reports, program development, and related issues at quarterly meetings. Throughout implementation, the SBIR agency director maintained close coordination with the Trauma Prevention Program director. The results of these assessments were included in the Trauma Program yearly report and in the Scripps system annual report. Additionally, reports were submitted to the San Diego County Department of Health and Human Services.

Integration of SBIR services for Scripps Mercy trauma patients evolved in three phases during 3 1/2 years. In Phase 1 (January 1999–June 2000), SBIR services implemented in the ED captured trauma patients. In Phase 2 (July 2000–August 2001), these services were augmented with an additional SBIR service module at the follow-up trauma clinic, which was a once-a-week, 4-hour clinic provided at an offsite facility. In Phase 3 (September 2001–July 2002), SBIR services continued in the ED but were discontinued at the follow-up trauma clinic. In addition, SBIR services were systematically added for admitted trauma patients. These phases represent an evolution of the integration of SBIR services for trauma patients during actual practice, not an a priori implementation design. The purpose was to devise an effective and efficient SBIR service integration system that would meet the needs of all types of trauma patients and be consistent with the structure of trauma services provided at Scripps Mercy Hospital.

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Phase 1: ED Screening

In the first years of the program, all patients older than 18 years who were treated in the ED were eligible for screening. Patients were not screened if illness, injury, severe intoxication, or drug overdose would hinder the screening interview. Health educators conducted face-to-face, structured interviews to screen patients using the Alcohol Use Disorders Identification Test (AUDIT; score, 0–40) and Drug Abuse Screening Test (DAST; score, 0–10).18,19 Patients who met at least one of the following conditions were categorized as at-risk drinkers: 1) total AUDIT scores of 8 to17; 2) patients who drank excessively or frequently (scores on AUDIT questions one and two totaling ≥5 for men or ≥4 for women); or 3) patients who binge drank (on any single occasion in the past 30 days: ≥5 drinks for men or ≥4 drinks for women). These thresholds are similar to those proposed by the Department of Health and Human Services in the Dietary Guidelines for Americans.20 Patients with a DAST score of 1 to 2 were categorized as at-risk drug users. If patients had AUDIT scores ≥18 or DAST scores ≥3, they were categorized as probably alcohol or drug dependent. When health educators detected dependent patterns of alcohol or drug use, patients were referred to the appropriate treatment program. Immediately after screening, nondrinkers, nondrug users, and low-risk drinkers (AUDIT total scores 0–7; DAST score 0) received an educational intervention (prevention dose), which provided positive reinforcement for their behavior, and a brochure explaining recommended limits for alcohol consumption. In contrast, health educators provided brief interventions for at-risk drinkers or drug users, using principles from motivational interviewing, the FRAMES method (Feedback, Responsibility, Advice to change, Menu of options, Empathy, and Self-efficacy),21 and readiness to change theory.22 For no-risk and low-risk patients, the time for screening and intervention was 5 to 10 minutes. For at-risk patients, the process took 10 to 13 minutes, and for patients who were probably dependent, the time required was approximately 20 minutes, including referral to specialized alcohol or drug treatment. Findings for each patient were shared with the emergency medicine physician, who then reinforced the advice given during the intervention. Patients were screened only once within a 3-month period; patients returning to the trauma service for a second time within a 3-month period were ineligible for repeat screening.

Two health educators performed SBIR between 9:30 am and 11:30 pm, 7 days a week. They recorded results and placed temporary reports in ED charts for review by the emergency medicine physician. Upon completion of the patient’s visit, this report was destroyed. However, results of screenings were also recorded in a confidential registry maintained by the external SBIR agency. During screening hours, health educators assisted ED physicians and nurses by interpreting for Spanish-speaking patients and families as an adjunct to their primary SBIR function.

In 2001, the SBIR program was expanded to include: screening and intervention among adolescents 12 to 17 years of age for tobacco use, in addition to alcohol and drug use; screening parents of pediatric patients for alcohol and drug use; and screening patients age 65 or older for alcohol and drug use, in addition to the appropriate use of prescription drugs.

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Evaluating SBIR Results in the ED

Scripps Mercy Hospital ED program screened more than 61,000 patients (adolescents, adults, and older adults) between July 1999 and June 2003. This total represented 88% of eligible patients; the screening refusal rate was less than 1%. Among adults ages 18 to 64 who were screened, 34% of men and 19% of women were considered at-risk drinkers; 5% of men and 2% of women were probable dependent drinkers; 13% reported illicit drug use (17% of men and 9% of women), with 4% classified as probable dependent drug users. Compared with pre-SBIR periods, when ED physicians used only patient history and physical examination to identify patients with alcohol and drug problems, SBIR increased identification of at-risk patients 16-fold. This important result was determined by comparing the number of intoxicated ED patients (those likely to be identified during normal clinical practice as having an alcohol problem) to the number of patients at risk or probably dependent (identified through screening by health educators during the same hours of operation). Per service protocol, peer health educators did not screen intoxicated patients but did refer and arrange transportation for patients to sobering services and documented their actions.

Patient satisfaction was significantly higher for patients who received SBIR. Six months after the start of SBIR services, patient surveys were obtained during a 14-day period through in-person interviews at the time of discharge. Patients were asked to rate satisfaction with various elements of their visit, including being asked about alcohol and drug use. On alternate days, SBIR services were suspended to allow time for data collection from a comparison group of patients who did not receive SBIR services and from a similar group of patients who did receive SBIR services. Seventy-six percent of the group receiving SBIR rated overall satisfaction with the ED visit as excellent or very good compared with 66% in the group that did not receive SBIR; SBIR patients also had a higher level of satisfaction with communication from their physician (78%) than did non-SBIR patients (68%) (p < 0.05). In the category ‘thoroughness of physicians,’ 86% of the SBIR group scored physicians high compared with 79% of non-SBIR patients; in the category ‘explanations provided by physicians,’ there was a similar result—77% of SBIR patients gave physicians a high score compared with 63% of the group that received no screening; patients’ satisfaction with the amount of time spent with them by their ED physician was also higher in the SBIR group (67%) than in the comparison group (54%) (p < 0.05).

Pretest and posttest surveys of ED physicians, nurses, and other staff showed a high level of staff satisfaction with the SBIR program and the use of health educators. ED staff felt that SBIR improved patient services and their ability to thoroughly address patient needs. Job satisfaction among ED staff also increased. The program was frequently rated as very important to completing the mission of the ED. Informal interviews were conducted (M.J.S.) with numerous ED physicians and nurses to assess the perceived value of the service and the integration of health educators into the ED staff. All agreed that the program was extremely valuable to patient care and that health educators were essential members of the ED team.

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Phase 2: ED and Trauma Outpatient Clinic Screening

During Phase 1, only 12% of all trauma patients were screened (238 of 1,987 patients) as part of the operation of SBIR services in emergency services (including urgent care and chest pain services). Explanations for this small rate of capture include the short stays in the ED for most trauma patients—their conditions were quickly assessed or they were moved to other departments (radiology, intensive care unit, medical-surgical floors, or operating room); those who remained in the trauma room long enough to be approached could not be interviewed because they were unconscious, intoxicated, or in acute pain; and, the higher volume of emergency service patients created conflicting demands on time of health educators during the more occasional trauma patient visits.

To increase the capture rate of trauma patients screened, an SBIR screening module was added to the Scripps Mercy Hospital Trauma Outpatient Clinic for Phase 2. The addition of the trauma outpatient clinic module, however, added relatively few patients to the total screened, increasing the total trauma patient screening rate from 12% in Phase 1 to 20% in Phase 2 (201 of 1,012 patients). Analysis of trauma patient flow revealed the potential for increasing access to more patients if screening could be conducted for admitted patients on the medical surgical floors after morning turnover rounds.

The Scripps Mercy Trauma Service categorizes trauma patients into three groups: 1) “trauma admits,” which comprise 76% of trauma cases, may access trauma services as a direct trauma patient or through emergency services, including urgent care and chest pain. Of this group, 16% were admitted for less than 24 hours, and 84% were admitted for more than 24 hours. 2) “Hold and release” are regular trauma patients treated and observed but not admitted and comprise 18% of the cases. 3) Two percent of the remaining patients entered through emergency, urgent care, or chest pain services or after receiving a ‘trauma consult.’ The flow of each of these groups of patients through medical services, the severity of injury, and the physical location of services affects the routine integration of SBIR services in trauma services.

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Phase 3: Expanding Screening to the Trauma Service

In Phase 3, the trauma service began to routinely evaluate all patients for drug and alcohol levels using blood alcohol concentration tests and urine assays. Results were entered in the trauma registry as part of the routine data collection. At daily morning turnover rounds, attending trauma surgeons, trauma residents, and other members of the trauma team (nurses, case managers, and social workers) discussed the screening data. In addition, an SBIR health educator from the ED SBIR operations joined the trauma service for these rounds. Trauma residents were instructed to make certain that health educators had an opportunity to complete the AUDIT and DAST interviews on all available patients not previously screened in the trauma resuscitation room before discharge. Available screening results were shared with all members of the trauma service during turnover rounds or by direct communication with trauma physicians. Health educators spent 3 hours a day, 7 days a week, performing SBIR—the equivalent of one half-time employee.

After health educators began providing SBIR and participating in trauma rounds, and the screening rate for trauma patients increased from 20% in Phase 2 to 60% in Phase 3 (300 of 503 patients; Table 1.) This rate is based on the denominator of all trauma patients eligible for screening, although in practice, not all trauma patients are eligible for screening for several reasons. When we excluded patients who died, patients with head injuries, the disabled, or those transferred to an acute care facility while still intubated, the adjusted screening rate (based on a denominator of those eligible for screening) was 71% (300 of 422 patients; Table 2.) The most common reasons for failure to screen the remaining 29% were discharge from the ED or medical-surgical floor before the health educator could see the patient or lack of health educators on duty. Overall, 21% of patients were discharged directly from the ED within 4 to 6 hours of initial evaluation by the trauma service. When discharge from the ED occurred after hours, the health educator was unable to screen these patients. The screening rate for trauma patients increased to an adjusted rate of 71% in Phase 3, but this rate was lower than the adjusted screening rate of 88% for patients in the ED. This was because of the higher volume of ED patients, the consistency of patient volume during peak hours, the hours health educators were on duty, and the central location of patients in a common area compared with the lower volume of trauma patients, unpredictable time of admissions, and wider distribution of patients in various medical settings in separated locations.

Table 1
Table 1
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Table 2
Table 2
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The screening results showed that 59% of screened patients were at risk for problems or were probably dependent on alcohol or drugs. For men, the combined figure was 66%, compared with 42% for women (Table 3). Nineteen percent of all patients were screened as having a low risk for developing alcohol or drug problems (men, 17%; women, 24%); 21% did not use alcohol or drugs (men, 17%; women, 33%). Men (52%) and women (31%) were almost twice as likely to be at risk for alcohol-use problems compared with drug-use problems (men, 28%; women, 16%). Although men were more likely to be classified as ‘probably dependent’ for alcohol use compared with drug use (7% for alcohol use; 4% drug use), women were equally likely to be in this category (3%) (Table 3). The relatively high percentages of patients—both men and women at risk for alcohol or drug problems—justify routine screening of all eligible trauma patients.

Table 3
Table 3
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During Phase 3, the external SBIR agency Altam Associates informally interviewed trauma service staff to evaluate both their acceptance of SBIR and the presence of health educators in a patient-care environment. Interview results clearly showed that trauma staff readily accepted the program. These new employees were viewed as part of the trauma team on an equal basis with other nonmedical staff. Health educators were easily oriented to trauma areas, new health educators were introduced to all supervisors during orientation, and trauma resident physicians viewed screening as an essential part of the discharge checklist. Health educators became an integral part of morning turnover rounds and frequently interpreted for Spanish-speaking trauma patients and their families. After completion of morning rounds in the trauma service, health educators returned to continue SBIR in the ED. In November 2002, the deputy director for demand reduction, White House Office of National Drug Control Policy, visited Scripps Mercy Hospital to evaluate the health educator model for providing SBIR. In its 2003 annual report, the White House Office of National Drug Control Policy featured the Scripps Mercy ED and Trauma SBIR Service program as a best practice program that works.23

An SBIR leadership group was formed to ensure the quality and consistency of screening services. The leadership group comprised the authors, the program coordinator from Altam Associates, health educators, and other trauma staff. The directors of the ED, the Trauma Service, and the SBIR program monitored the project on a continual basis and evaluated the need for additional modules. The most recently added modules (screening adolescents, older adults, and the parents of pediatric patients) required ongoing monitoring and evaluation. The leadership group has committed to a feasibility study to determine whether screening modules for depression and domestic violence should be added to the current SBIR program. Proven and promising screening tools for these two problems are being selected for evaluation. During the 4-year SBIR program, the leadership group recognized that an increasing number of seniors were presenting to the ED and trauma service. Because health educators provide easier access to older adults, the leadership group sees this as a unique opportunity for assessing the complex medical and social problems many seniors face and is evaluating new screening and intervention tools for older adults.

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DISCUSSION

The expanded SBIR program at Scripps Mercy Hospital Trauma Service has demonstrated the feasibility of using dedicated part-time health educators to screen large numbers of trauma patients. Patients and staff embraced SBIR, and the program was easily integrated into the normal flow of patient care. Successful implementation required program elements that went beyond the ED-based effort. For example, adding a trauma morning rounds component significantly increased the screening capture rate to 71% of all trauma patients, after adjusting for patients not able to be screened.

The original ED-based SBIR program reached few trauma patients (approximately 12%), which reflects the unique nature of the flow of care for trauma patients. A stay in the ED is intentionally short. While there, patients are the center of a flurry of diagnostic tests and treatment for the first 30 to 60 minutes and then are quickly moved to other areas of the hospital for further evaluation and more definitive care. Usually, patients in the trauma resuscitation room cannot be screened because most are in too much pain, are unconscious, or are intoxicated. Consequently, there are few opportunities to complete SBIR for trauma patients during their stay in the ED. We found that adding an SBIR module in the trauma outpatient clinic only increased the overall screening rate for trauma patients from 12 to 20%. In retrospect, this is not surprising given that many trauma patients do not keep follow-up appointments, even when compensation for returning to the trauma outpatient clinic is offered.24 Among stable patients who are no longer intoxicated or are in pain, the window of opportunity for screening is apparently open just before discharge from the ED or the medical-surgical floor. Combining the efforts of health educators in the ED and on the trauma team morning rounds led to a much larger increase in the overall screening rate.

The San Diego County SBIR model uses bilingual, bicultural health educators who provide direct patient services, record keeping, and information transfer to physicians and nurses. Because the external agency handles all personnel issues for health educators, the burden on the ED and trauma center is minimal. We found this approach particularly useful and effective for our trauma service. Because of time constraints, attending and resident physicians are unlikely to achieve the consistency and quality of SBIR that the health educators can provide. Further, the workload of all nurses, especially advanced practitioner nurses, has steadily increased over the last decade. Burdening them with the added role of providing SBIR is neither practical nor desirable.

Unlike other members of the trauma team, health educators can focus on screening as their primary role. We were able to hire health educators with outstanding interviewing skills who were well versed in the challenges of ED and trauma care environments. Plus, their bilingual skills were extremely valuable to overall patient care.

By outsourcing SBIR, the trauma service was able to provide high-quality, consistent services to trauma patients with substance use disorders. Although ED and trauma nursing services at Scripps Mercy Hospital’s ED underwent numerous organizational and personnel changes during the 4-year program, the external SBIR agency underwent remarkably few changes despite a steady increase in the number of venues in which SBIR programs were being implemented.

The trauma service staff embraced the program and welcomed health educators to the trauma team. Within weeks, SBIR was viewed as an essential part of routine care for injured patients. It was commonplace to overhear first-year residents ‘running the list’ of work to accomplish after morning rounds, and to notify the health educator was always on the list.

The presence of health educators on the trauma team during morning rounds added a significant educational component to the meeting. Over 60 residents (surgery, emergency medicine, and transitional interns) rotate through Scripps Mercy Hospital Trauma Service each year; another 60 to 70 residents from other programs also rotate through the hospital’s ED. All of these residents receive in-depth exposure to the SBIR program. Each resident gets to know the health educator on a close professional basis. It becomes routine for residents to review screening and intervention results and provide positive reinforcement to patients who drink sensibly and abstain from drug use. This protocol creates an intense personal experience for both resident and patient. Exposure to SBIR is a valuable educational tool for young physicians who are now well versed in the scientific basis and practical application of screening, brief intervention, and referral of trauma patients.

As of late 2003, the San Diego County SBIR program had grown to include 17 health care sites. In fiscal year 2002, the program screened 68,000 patients, and an estimated 125,000 patients were expected to be screened before the close of fiscal year 2003. Since 1995, over 360,000 screenings have been performed. The program is scheduled to expand in 2004 to include other hospital and clinic venues.

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CONCLUSION

Having a well-established preexisting ED-based SBIR program in the ED at Scripps Mercy Hospital ensured, in large part, the success of SBIR for trauma patients because they represent less than 4% of all hospital patients evaluated in the hospital’s ED, chest pain center, urgent care center, and trauma resuscitation room. Expanding the preexisting ED program ensured consistency, quality, and feasibility. However, the success of the SBIR program must also be viewed within the context of the partnership with San Diego County Department of Health and Human Services—the government and private agencies cooperating to improve overall health for San Diego County residents. A broad collaboration was essential to successfully address the alcohol and drug problems our community faces. As a participant in numerous community-based prevention activities over the past two decades, the Scripps Mercy Hospital Trauma Service was a key element in establishing this cooperative effort. Urban trauma centers must take a leadership role in injury prevention. If trauma centers do not embrace this role, prevention efforts cannot succeed.

The future of SBIR as part of trauma services in the United States depends on the willingness of trauma surgeons to see beyond their familiar world of trauma resuscitation, surgery, and intensive care. For them, SBIR represents new territory. To the experienced trauma surgeon, it may seem counterintuitive that a 9- to 12-minute session with a health educator could have a greater overall impact on the life of their patient than much of the treatment given in the trauma room or the operating room. However, there is compelling evidence that SBIR is effective. If we are to reduce trauma recidivism, prolong life, and improve community health, reducing high-risk behavior has to be our first priority. SBIR should be an essential part of the care we provide to the injured.

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Keywords:

Trauma centers; Alcohol screening; Brief intervention; Alcohol and injury; At-risk drinking; Alcoholism; ED screening; Preventive health services

© 2005 Lippincott Williams & Wilkins, Inc.

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