Injury prevention/original research
National Survey of Emergency Department Alcohol Screening and Intervention Practices

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Study objective

We describe current alcohol screening and brief intervention practices in emergency departments (EDs) at Level I and Level II trauma centers and characterize ED directors' attitudes and perceived barriers associated with these practices among injured patients in the ED.

Methods

ED directors at Level I and Level II trauma centers were surveyed about current alcohol screening and intervention practices in the ED, as well as knowledge, attitudes, and perceived barriers to these practices.

Results

Nearly half (46.0%) of ED directors surveyed responded. The majority (64.5%) reported using a serum alcohol level to routinely screen for unhealthy alcohol use; only 23.6% routinely use standardized instruments. Sixty-five percent of ED directors support screening and 70% support intervention among injured ED patients. Only 15% reported having formal screening and intervention policies in their ED, and 9% reported offering brief alcohol intervention by trained personnel. The most commonly perceived barriers to implementation are provider time (83%) and financial resources (55%). Of injured patients identified as exhibiting alcohol misuse, few (12%) receive brief intervention conducted by trained personnel.

Conclusion

Current alcohol screening and brief intervention practices are lagging behind national guidelines. Although the majority of ED directors support the idea of alcohol screening and intervention, these beliefs have not yet been translated to routine clinical care.

Introduction

The emergency department (ED) offers a unique and essential opportunity to address the burden of alcohol misuse. ED patients are more likely than primary care patients or the general population to report misuse of alcohol.1, 2, 3 Nearly 8% of all ED visits for patients aged 15 years and older may be attributed to alcohol.4 National data consistently indicate that at least 25% of all adult ED patients screen positive for hazardous or harmful drinking.5, 6

To address the urgent need to identify patients with unhealthy alcohol use and to narrow the gap between patients in need of treatment and those actually receiving services, a comprehensive integrated public health approach for the delivery of alcohol brief interventions has been developed: screening and brief intervention. Controversy exists related to the efficacy of screening and brief intervention in ED settings: research findings have varied across studies, in part because of differences in samples, insufficient sample sizes, and inconsistent outcome measures.7, 8 Given that more research is needed, this model has nonetheless been recommended for use in many health care settings, including the ED, inpatient trauma units, and primary care settings because of the promise of the intervention model in other settings and the magnitude of the public health problem.9, 10, 11, 12, 13, 14, 15 Although not yet definitive, ED-based Screening and Brief interventions, along with referral to treatment (SBIRT), show promise at benefiting patients, including reduction in reinjury, ED readmissions, and alcohol consumption, and have begun to be put into practice nationally.6, 16, 17, 18, 19, 20, 21

In light of the promising results of brief interventions, many national organizations (eg, American Medical Association, National Institute on Alcohol Abuse and Alcoholism, Centers for Disease Control and Prevention, National Highway Traffic Safety Administration, American College of Emergency Physicians [ACEP]) have called for routine screening and intervention for alcohol problems among ED patients, and adoption of these practices by EDs is one of the Healthy People 2010 objectives.22 ACEP has a policy statement that promotes ED-based screening, intervention, and referral for alcohol misuse.23 Despite these policies, however, anecdotal evidence suggests that screening and intervention among ED patients during routine clinical care is still far from widespread but may be occurring at several sites in varying degrees. Currently, to our knowledge, no national data exist to quantify the translation of the research recommendations of the national organizations to standard routine care. Understanding the type and degree to which screening and brief interventions are in place will inform providers nationally and aid translation and efficacy research. Recently, the American College of Surgeons mandated alcohol screening among admitted trauma patients for Level I and Level II trauma centers.9 To our knowledge, no studies have been conducted to assess alcohol screening and brief intervention practices among EDs nationwide in general or specifically among EDs in Level I and Level II trauma centers.

Current rates of alcohol screening and brief intervention in EDs, as well as the attitudes of departmental decisionmakers toward alcohol screening and brief intervention and perceived barriers to implementing these practices, are unknown. The objectives of the current study are to describe current alcohol screening and brief intervention practices in the EDs at Level I and Level II trauma centers and characterize ED directors' attitudes and perceived barriers associated with these practices.

Section snippets

Study Design

A cross-sectional, anonymous survey of all 441 ED directors at Level I (n=194) and Level II (n=247) trauma centers was conducted in 2008 with self-administered questionnaires.

Selection of Participants

Level I and Level II trauma centers were identified through the American College of Surgeons. Directors of the EDs at all Level I and Level II trauma centers received a mailed notification of the survey, with a unique identifier and instructions that surveys could be returned by mail or submitted online. Follow-up with

Results

Forty-six percent (203/441) of ED directors surveyed responded, including 47% of Level I (91/194) and 45% of Level II institutions (112/247). There were no important differences between responders and nonresponders by region of country, number of beds, number of admissions, or number of outpatient visits (Table 1). In this study, 45% of ED directors represented Level I EDs. Among the respondents, 54% had a census of at least 55,000 patient visits per year.

The respondents had significant

Limitations

Our response rate is in keeping with mailed surveys of emergency physicians (Graham et al,24 46%) and trauma surgeons on the subject (Schermer et al,25 54%; Danielsson et al,26 48%), and respondents did not differ from nonrespondents in hospital characteristics. However, the possibility of response bias exists; we may have overestimated the amount of screening and brief intervention knowledge and engagement among ED directors at Level I and II trauma centers. An additional limitation of this

Discussion

To our knowledge, this study represents the first attempt to establish alcohol screening and intervention practices among the EDs in Level I and Level II trauma centers and to assess attitudes and barriers to the implementation of these practices after the American College of Surgeons mandates that admitted trauma patients at these centers be screened.

Previous studies have reported that emergency physicians do not routinely screen for alcohol misuse.25, 27, 28, 29 In a convenience sample of ED

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    Supervising editor: Debra E. Houry, MD, MPH

    Author contributions: RMC and SRH wrote the initial draft of the article. MM, MJM, and MS conceptualized the study and contributed to analysis plan. JRS and GD assisted in editing the article. All authors contributed to and have approved the final article. RMC takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This project was supported by an ACEP Trauma and Injury section grant.

    Please see page 557 for the Editor's Capsule Summary of this article.

    Reprints not available from the authors.

    Publication date: Available online April 3, 2010.

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