ED Nurses Set the Stage for Alcohol Screening
Monday July 28, 2008
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"It's quick, it's easy, and it makes a difference because there are a lot of people who don't understand what at-risk drinking is," says Patricia Kunz Howard, RN, PhD, CEN, a member of the ENA's SBIRT toolkit team.
Current research shows a single alcohol-related ED visit is a predictor of continued problem drinking, alcohol-impaired driving, and possible premature death, according to compiled research available from the ENA. The ENA believes ED nurses are key players in an alcohol-related injury prevention strategy that also includes DUI legislation and alcohol checkpoints on the nation's roads. ED nurses are in a prime position to jump on "teachable moments" — brief slices of time when a person whose drinking has led to an injury is more receptive to the idea of reducing his or her alcohol intake.
"Just gaining awareness that, by virtue of their drinking patterns, they are considered at risk is a huge wake-up call for many patients," says Howard. "It gives them insight into changes they need to make."
The SBIRT process is based on motivational interviewing, a non-confrontational counseling approach that tries to influence a person's intrinsic desire to modify potentially dangerous behavior. Evidence suggests acute subcritical injuries, such as a sprained ankle or minor head injury, may be an important motivator for patients to disclose drinking habits and reduce drinking, according to the ENA.
"It's not a treatment but a motivational technique to reduce alcohol consumption," says Pierre Desy, MPH, director of the ENA's Injury Prevention Institute. "It's about getting people to see the link between their alcohol use and their injuries."
SBIRT is intended for use in all levels of drinkers (social to heavy) who have alcohol-related ED visits. Typical injuries that might be seen include falls, motor vehicle crashes, domestic violence, and police requests for a DUI blood draw. Illnesses that may be alcohol-related include altered pancreatitis, gastritis, gastrointestional bleeding, and altered level of consciousness.
SBIRT begins with a rapid screening that includes open-ended questions such as "On a typical day when you drink, how many drinks do you have?" or "Have you ever felt guilty about your drinking?"
For patients who have a positive screen, a brief intervention and referral include providing information about the connection between drinking and injury, discussing how the patient perceives the connection between drinking and his or her ED visit, discussing a patient's readiness to change drinking behavior, and providing alcohol treatment referrals as needed.
SBIRT has been shown to be so effective in earlier ED pilot studies (as reported in the December 2007 Annals of Emergency Medicine), the procedure qualifies for reimbursement from Medicare, Medicaid, and commercial insurers. Plus, data collected from a pilot SBIRT project at University of Kentucky Chandler Medical Center in Lexington, Ky., was compelling enough to convince administrators to hire an ED alcohol counselor.
"There's a significant difference between the SBIRT intervention group and the control group in terms of the reduction of alcohol use," says Howard, operations manager for Emergency and Trauma Services at Chandler Medical Center.
Patients in the study's control group, which did not receive SBIRT, drank about 10 drinks per drinking event before the study and eight drinks after the study. In comparison, the intervention group drank as much as 28 drinks per drinking event before receiving SBIRT and had cut their alcohol intake to about eight drinks after the intervention, according to Howard.
In addition, the study reported in the December 2007 Annals of Emergency Medicine found ED patients who underwent a regimen of SBIRT reported lower rates of risky drinking at the three-month follow-up than those who received only written information about reducing their drinking.
The ENA's goal is to expand the number of EDs and facilities using the SBIRT process, which is already required of EDs for designation as level I or II trauma centers by the American College of Surgeons. The Joint Commission is in the process of developing standards for alcohol screening and intervention as well, according to Desy.
Currently each SBIRT-participating ED develops a procedure that fits its patient population and resources. The screening piece is often done in triage and the intervention is completed in the treatment area. It is generally done by the nurses, although in some EDs there are SBIRT teams that may include social workers, substance-abuse counselors, medical residents, or a chaplain.
For busy ED nurses who fear they don't have the time to fit yet another procedure into their day, Howard says the SBIRT intervention can be completed in as little as three to five minutes. It also is important to have a staff champion who understands SBIRT is a time-saver and an investment in reducing alcohol-related visits and ED overcrowding.
"Fewer alcohol- and substance-related patients means shorter waits, reduced staff workloads, safer emergency departments, and a safer community as a whole," says 2008 ENA president Denise King, RN, MSN, CEN.
The ENA's free SBIRT toolkit is available at www.ena.org/ipinstitute/SBIRT/default.asp.
Catherine Spader is a contributing writer for Nursing Spectrum/NurseWeek. To comment, e-mail editorNTL@gannetthg.com.
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