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QUALITY IMPROVEMENT

Implementation of an Alcohol Screening, Brief Intervention, and a Referral Program at a Community Level II Trauma Center

Palacio, Carlos H. MD, FACS; PharmD, Bianca Cruz BCPS; Salazar, Mariselda RN; Cano, Jose R. MD; Ortega, Maria Alejandra RN; Hovorka, John W. MD, FACS

Author Information
doi: 10.1097/JTN.0000000000000520
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Abstract

Trauma is the leading cause of years of potential life lost in the United States, and alcohol and drug use is a major contributing factor (American College of Surgeons Committee on Trauma [ACS COT], 2014). In 2018, more than 1 million individuals were arrested for driving under the influence of alcohol or narcotics (Federal Bureau of Investigation, 2019). Furthermore, approximately 10,500 people died in motor vehicle accidents caused by alcohol impairment, accounting for 28% of all traffic-related deaths in the United States (National Center for Statistics and Analysis [NCSA], 2019). The annual cost of alcohol-related crashes totaled more than $44 billion (Blincoe, Miller, Zaloshnja, & Lawrence, 2015). Because of the significance of alcohol-related risk and consequences, the ACS COT (2014) required Levels I and II trauma centers to develop and implement a screening, brief Intervention, and a referral-to-treatment (SBIRT) program for alcohol use in 2006.

The SBIRT program has been has been validated as an important tool to reduce health care cost, decrease the frequency and severity of drug and alcohol abuse, and reduce the risk of trauma (Higgins-Biddle, Hungerford, & Cates-Wessel, 2009). It involves a three-step process comprising screening patients, conducting a brief intervention, and following up. Screening methods include a laboratory test for blood alcohol concentration (BAC) or a structured interview. Patients who screen positive and are determined to be at a low or moderate risk should receive a brief intervention that brings awareness of their at-risk behavior drinking (ACS COT, 2014). High-risk patients should receive a thorough intervention consisting of multiple sessions to engage and motivate individuals to reflect on their current drinking habits and change to reduce their at-risk behavior. Patients identified as having active alcohol use disorders are referred for treatment. Follow up of patients after discharge with a telephone booster to emphasize the intervention and provide additional information about services has been shown to improve outcomes (Field et al., 2014). However, limited resources may prevent some trauma centers from following up after discharge.

As a result of an internal evaluation, it was discovered that the trauma program at a community Level II trauma center was not in compliance with the ACS COT (2014) alcohol screening requirement. At the time, screening consisted of a laboratory test for BAC alone. After thoroughly assessing the available resources, a structured interview screening process for the SBIRT program was implemented. The purpose of this article is to evaluate the implementation of an SBIRT service program.

METHODS

During 2019, South Texas Health System, McAllen, a community Level II trauma center located along the U.S.–Mexico border in Texas, had approximately 3,400 emergency department (ED) visits and 1,600 trauma admissions. Before 2018, trauma patients were screened using the BAC test alone. Patients with elevated BAC levels (>0.08 g/dl) were referred to a social worker who provided an Alcoholics Anonymous brochure and encouraged them to seek assistance in the community. The screening compliance rate with this process was below 80%.

As a process improvement initiative, a more comprehensive screening process involving the injury prevention coordinator, trauma surgeons, trauma registrars, and the social worker was implemented. The Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-Concise (AUDIT-C) questionnaires were selected as screening tools. The AUDIT is a validated screening tool developed by the World Health Organization (WHO) to identify persons who have alcohol-related problems (National Institute on Drug Abuse, 2018). AUDIT-C (Table 1) is a brief three-item alcohol screening tool that identifies persons who are problem drinkers or with alcohol use disorders and scored on a scale of 0–12. The injury prevention coordinator, trauma registrars, and the social worker attended an online course for SBIRT. The training course described the background for conducting SBIRT, how to utilize the AUDIT-C and AUDIT questionnaires, and expounded on effective strategies to motivate patients to change their behavior and/or seek treatment.

TABLE 1 - Audit-C Questionnaire
Questions AUDIT-C Questionnaire
Scoring System Your Score
0 1 2 3 4
How often do you have a drink containing alcohol? Never Monthly or less Two to four times per month Two to three times per week Four + times per week
How many units do you drink on a typical day? One to two Three to four Five to six Seven to nine 10+
How often have you had six or more units if female, or eight if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily
Note. From Screening and Assessment Tools Chart, by National Institute on Drug Abuse, 2018. Retrieved from https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools

The injury prevention coordinator administered the AUDIT-C screening tool at bedside in the patient's room to all trauma patients who met the following criteria: admitted for more than 24 hr, were at least 15 years old, and medically stable and able to answer questions appropriately. The full AUDIT questionnaire was conducted on males who scored 4 or more and females who scored 3 or more on the AUDIT-C. All patients who screened positive were provided educational material by the injury prevention coordinator detailing the adverse effects of alcohol abuse and tips to assist with quitting. Patients identified as at high risk (AUDIT score >8) were referred to a social worker via a consult placed in the patient's electronic medical record. The social worker was responsible for counseling and trying to motivate the patient to seek treatment and provide a list of alcohol/drug abuse treatment centers located in the community. Parental consent was obtained for patients 15–17 years old before screening, and education was provided to both the child and the parent(s) if the child screened positive.

Activity reports for ED visits were reviewed during the workweek to identify trauma patients. The injury prevention coordinator manually updated an Excel spreadsheet with all trauma patients and reviewed their electronic medical record to see whether they met inclusion criteria for SBIRT. Screenings were attempted on all patients who met inclusion criteria and were still inpatient. Patients who met inclusion criteria but were discharged over a weekend or holiday were flagged as missed patients. These patients were included within the sample population. The trauma surgeon monitored the SBIRT program process improvement initiative closely and ensured that compliance rates were reported on a monthly basis at the institutional trauma meeting (Figure 1).

Figure 1.
Figure 1.:
Study flowchart. AUDIT-C = Alcohol Use Disorders Identification Test; AUDIT-C = AUDIT-Concise.

The University of Texas Rio Grande Valley institutional review board approval was waived because of the lack of personal identifiers and the retrospective nature of the study. All data were analyzed using descriptive statistics and χ2 analysis in Excel (Version 2016); p value was set at less than .05.

RESULTS

One year after the implementation of a structured interview screening process, a total of 1,021 trauma patients met inclusion criteria. Overall, 921 (90%) trauma patients were screened and 184 (18%) patients were referred to a social worker for an additional session and treatment referral. From 2017 to 2018, the implementation of the structured interview approach resulted in an 86% statistically significant increase in screening criteria (p < .0001) in comparison with the previous BAC screening approach (Figure 2). The SBIRT process improvement initiative within the trauma department has consistently exceeded the 80% screening compliance on a monthly basis for over a year.

Figure 2.
Figure 2.:
Rate of screened trauma patients.

DISCUSSION

During the 1960s, SBIRT was developed to identify individuals with at-risk alcohol use. In the 1980s, the WHO called for efficient methods to identify at-risk patients (WHO, 2003). Studies supporting interventions to reduce not only alcohol consumption but also injuries requiring either ED or trauma center admission first appeared in the 1990s (Gentilello et al., 1999). Therefore, Level I and II trauma centers have been mandated to implement a mechanism to identify patients who are problem drinkers with the purpose of taking advantage of a teachable moment and conduct a psychosocial intervention (ACS COT, 2014). Despite several studies showing the efficacy of SBIRT, there have been a total of 155,709 deaths in the United States caused by crashes involving alcohol-impaired drivers from 2005 to 2018 (NCSA, n.d.). According to the most recent data, Texas had the highest number of fatalities with 3,642, followed by 3,563 in California (NCSA, 2019).

Drivers with a BAC of 0.08% or higher are legally considered alcohol-impaired (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2019). Zimmermann et al. (2018) achieved an 82% screening goal by obtaining a BAC on every trauma activation and using a BAC greater than 0.02% as the threshold for alcohol screening at a Level I trauma center. Up to 50% of trauma patients are positive for BAC at the time of admission, and 10% or more will present to the same hospital with a new injury within a year (Plackett et al., 2015). In 2017, it was discovered internally that the trauma program was not achieving the minimum compliance screening rate of 80%. When BAC was the sole criterion, it was found to be unreliable because levels were not ordered in the ED or ordered several hours after presentation to the ED when BAC levels became undetectable. In addition, the trauma center is not an academic institution and lacks the resources available at a Level I trauma centers, such as surgical and emergency medicine residents.

Alcohol screening has become an important preventive measure to avoid subsequent visits. A cost analysis by Pringle et al. (2018) found that patients who received SBIRT in the ED experienced a 21% reduction in health care costs and a significant reduction in 1-year ED visits. Screening can be either a laboratory test for BAC or a structured interview, and those positive for screening should receive a brief psychosocial intervention to increase awareness of their behavior (ACS COT, 2014). Plackett et al. (2015) compared the utility of both screening methodologies as indicators of at-risk drinking in trauma patients and found the AUDIT score to be superior to BAC. After evaluating both options, it was determine the cost- and time-dependent nature of this test would not be conducive to increasing screening compliance rates. The implementation of the structured interview SBIRT program added little time and cost compared with a laboratory test.

The comprehensive screening process was spearheaded by the injury prevention coordinator. The initial AUDIT-C and full AUDIT questionnaires were administered to trauma patients who met criteria by the injury prevention coordinator and subsequently referred high-risk patients to a social worker for a psychosocial intervention. When the injury prevention coordinator was unavailable, the trauma registrars would step in and complete the screening process. Immediately after implementation, an 86% statistically significant increase in screening compliance (p < .0001) was observed and sustained in comparison with the prior BAC screening method (Figure 2). Similar results were achieved by Wagner, Garbers, Lang, Borgert, and Fisher (2016), who observed a consistent 92% increase in screening compliance by utilizing an electronic SBIRT program.

After evaluating the staffing model and available resources, an injury prevention coordinator-driven screening process was selected as the optimal method to attempt to increase our alcohol screening compliance rates. Although specific to this institution, these results support a structured interview screening process as a potential option for trauma programs facing similar barriers. The trauma program exceeded the 80% screening goal rate for more than a year because the injury prevention coordinator and the trauma surgeon closely monitored the program and were accountable for presenting these data at the institutional monthly trauma meeting.

Limitations of this study include its retrospective nature, small sample size, and lack of screening on weekends and holidays. A small portion of trauma patients met criteria but were not screened because they were admitted and discharged over weekends or holidays or were undergoing a procedure when the injury prevention coordinator made rounds. Concerns were raised regarding the screening burden placed on the injury prevention coordinator and trauma registrars. As a result of the process improvement project, the trauma department collaborated with the information and technology service department to incorporate the AUDIT-C questionnaire into the electronic medical record. The creation of an AUDIT-C electronic screening process will provide nursing the opportunity to complete the initial screenings and further increase compliance.

Future studies will be aimed at identifying the effectiveness of the structured interview SBIRT program by contacting previous trauma patients who screened positive with the AUDIT-C. Furthermore, a comparison of readmission rates for alcohol-related trauma before and after the process improvement project has also been proposed. Based on the anecdotal experiences of the injury prevention coordinator, trauma registrars, and social worker, the structured interview screening process was well received by the majority of our trauma patients.

CONCLUSION

Based on this retrospective evaluation, our Level II trauma center's adoption of a structured interview process comprising an injury prevention coordinator, trauma registrars, trauma surgeons, and social workers was an effective approach for developing a successful and sustainable SBIRT program.

KEY POINTS

  • Trauma is the leading cause of years of potential life lost in the United States. Alcohol is an important contributing factor.
  • Alcohol screening can be done via a laboratory test or using a validated questionnaire. High-risk patient should receive a thorough intervention along with a list of locations to seek help.
  • A comprehensive, well-defined screening approach involving an injury prevention coordinator, trauma surgeons, and social workers is a viable option for institutions with limited resources.
  • Monthly reporting of SBIRT compliance at trauma meeting provided accountability and an opportunity to discuss concerns openly.

REFERENCES

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National Institute on Drug Abuse. (2018). Screening and assessment tools chart. Retrieved from https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools
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Keywords:

Alcohol; Audit-C; SBIRT; Trauma

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