Larry M. Gentilello
There are over 1,675 trauma centers in the United States. Although there are still gaps in coverage, particularly in rural areas, 82% of the U.S. population has rapid access to a trauma center. And, there is a 25% reduction in mortality after injury with trauma center care compared to treatment at a nontrauma center. The rapid development of trauma centers and systems across the United States is one of the most important developments in the history of surgery.1
Despite this success, injuries are still the fifth leading cause of death. This figure actually understates their impact. Years of Potential Life Lost (YPLL), which subtracts the age a person dies from their life expectancy, is a better measure of burden of disease. When a man in the United States dies from an injury at the age of 20, the YPLL is 58 because the average life expectancy for a man in the United States is 78. If he dies of heart disease at the age of 77, there is only one YPLL.
Heart disease causes five times the number of deaths as injuries, but injuries account for one and one half times as many years of life lost, and more than the amount attributable to all malignant neoplasms.2Thus, the task of reducing injury-related mortality is far from complete.
In a 12-year longitudinal study that tested the impact of a rigorous emphasis on continuous quality improvements, the center involved was unable to reduce major complications or mortality during the entire study period, despite implementation of numerous protocols.3 The authors concluded that mature trauma centers have already reached the limits of their effectiveness at reducing injury-related deaths. Further reductions in trauma mortality will require new strategies.
The reasons for this were demonstrated in a study that looked at 753 consecutive deaths in a trauma center.4 Over 40% of those who died received cardiopulmonary resuscitation in the field and had nonsurvivable injuries. The leading cause of death was severe traumatic brain injuries. Roughly 90% of patients who died had such severe organ damage and destruction that no current or conceivable future treatments would ever be able to prevent their death.
Late deaths due to multiple organ failure, secondary brain injury, sepsis, and pulmonary emboli accounted for only 6% of deaths. The preventable death rate was 2.6%. Thus, a research breakthrough that prevents all deaths due to complications and eliminates all medical errors would have only a marginal effect on survival rates in trauma centers. The actual reductions would be much less than that. Up to 75% of injury-related deaths occur in the field. Autopsy reports suggest that most field deaths probably occur within minutes of injury before help has a chance to arrive. These patients will not benefit from improvements in care.
The most promising way to reduce trauma mortality is to implement evidence-based injury prevention programs. Numerous studies have documented that misuse of alcohol and other drugs is the leading risk factor for injury, and there are highly effective methods to reduce these problems. In 1990, a report by the Institute of Medicine declared that the scientific basis for implementing routine screening for alcohol problems in medical settings and for providing brief interventions to those who screen positive was well-established and should now be adopted into routine practice.5
There have been over 100 clinical trials, most of them prospective controlled trials enrolling more than one-half million patients, demonstrating the positive effects of interventions. Given the relationship between alcohol and injury, trauma centers are ideal sites for establishing such programs.6 Studies conducted specifically in trauma centers have demonstrated their ability to reduce alcohol intake, injury recidivism, and drunk driving arrests. Such programs are not only cost-effective, but result in cost-savings to the hospital also.7–9
In 2006, the American College of Surgeons Committee on Trauma (COT) added two new requirements for trauma center verification. Level I and Level II centers must have a mechanism in place to identify injured patients who have a drinking problem, and Level I centers must have a mechanism in place to offer an intervention to those who screen positive, as well.
This pioneering COT mandate was the first time in the history of health care in the United States that any regulatory organization required that patients with a substance use problem, or any type of mental health problem, receive necessary counseling.
The purposes of this chapter are as follows: (1) to review the scientific basis for the recommendation for routine provision of Screening, Brief Intervention, and Referral to Treatment (SBIRT) in a trauma center; (2) to provide guidance on optimal screening methods for alcohol and drug use disorders; (3) to review the key elements of a brief intervention; (4) to provide step-by-step guidance on how to establish an evidence-based SBI program in a trauma center, and (5) to review relevant legal, billing, and confidentiality concerns.
MAGNITUDE OF THE PROBLEM
Between 35 and 50% of patients admitted to a trauma center are under the influence of alcohol. The number of drivers using illicit drugs has recently been revealed to be as large, if not larger, than the problem of drunk drivers. In the 2007 roadside survey conducted by the National Highway Traffic Safety Administration, the percentage of weekend nighttime drivers testing positive for alcohol dropped from 36.1% in 1973 to 12.4% in 2007. Drivers with a blood alcohol concentration (BAC) over the legal limit of 0.08 g/dL dropped from 7.5% in 1974 to 2.2% in 2007; however, 16.3% of drivers tested positive for drugs. Of these, 11.3% were positive for illegal drugs, and 1.1% tested positive for a combination of illegal drugs and prescription narcotics or psychoactive medications.10
In 2001, alcohol misuse resulted in 34,833 deaths by causing or exacerbating 70 associated medical disorders such as cirrhosis, hepatitis, oropharyngeal cancers, gastrointestinal disorders, and other chronic diseases. In contrast, there were 40,933 alcohol-related injury deaths, which was more than all deaths due to alcohol-related chronic medical problems. Also, alcohol misuse also caused 788,005 YPPL as a result of all of its associated medical diseases, whereas the YPLL due to alcohol-related injuries alone was nearly four times as high at 3,279,322.
The only medical settings with as high a proportion of patients with substance use problems as trauma centers are inpatient psychiatry units.
It is far more common for these patients to receive treatment for an injury than for any other medical or psychiatric problem. Thus, addressing substance misuse, which particularly overburdens trauma centers, is a natural part of a trauma center’s mission.
NATURE OF THE PROBLEM
Since the beginning of the 20th century, the prevailing belief was that people who use alcohol could be divided into two types. One type was considered social drinkers, even if they drank heavily. The others passed a certain irreversible threshold and became known as “alcoholics.” In the early 1980s, the Diagnostic and Statistics Manual III (DSM III) replaced the word alcoholism with the terms alcohol abuse and alcohol dependence syndrome. Alcohol abuse referred to patients who experienced repeated adverse consequences of their drinking, but displayed no signs of addiction or dependence. Such patients can quit ingesting alcohol on their own if they are sufficiently motivated. Patients with dependence syndrome demonstrate tolerance, withdrawal symptoms, and such loss of control that they are usually, but not always, unable to stop drinking without treatment. This is true despite experiencing repeated, often catastrophic, social, legal, and medical consequences. Alcohol abuse and alcohol dependence are mutually exclusive terms.
This classification system will be replaced in DSM-V, scheduled for publication in 2013, to reflect more recent research about the nature of unhealthy substance use. Alcohol and drug problems are similar to hypertension; that is, their severity can be measured along a continuous scale of problem severity. The severity in any single individual varies over time from no problem, to a mild, moderate, or severe problem, based on a variety of environmental and social stresses that interact with genetic and other factors. The term “alcohol abuse” will be dropped because it is stigmatizing and clinically detrimental.
The Spectrum of Severity
In the United States, approximately 30% of people do not use alcohol. Another 45% use it in a way that poses no risk to their health (Fig. 42-1). The remaining 25% use alcohol in ways that can damage their health in one of the two following ways: (1) acute intoxication that causes an injury (often referred to as binge drinking); or (2) long-term excessive use that results in chronic medical diseases. These two types of problems can together be called “unhealthy alcohol use,” a nonstigmatizing, nonjudgmental term that reflects a physician’s appropriate concern about his or her patient’s health.
FIGURE 42-1 Matching interventions to problem severity for trauma patients who use alcohol or drugs. (Reproduced with permission from Daniel Hungerford, PhD, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention).
The threshold for unhealthy alcohol use is defined as more than four drinks for a male or three drinks for a female on any single drinking occasion. Such intake in average sized individuals would result in a BAC above the legal limit for driving and is associated with a greater than 2-fold risk of being injured due to intoxication. An additional definition is more than 14 drinks per week in a male or more than seven in a female. Even if the drinking episodes are spread out over a week and the person never reaches intoxication, alcohol is toxic to virtually every organ system. Therefore, exceeding these amounts over time will significantly increase the likelihood of developing a chronic alcohol-related medical disease.
In recent years, there has been an unprecedented increase in drug overdoses. Deaths due to drug overdose are included as a form of unintentional injury in the International Classification of Disease Version 9(ICD-9) codes. For decades, motor vehicle crashes were the leading cause of unintentional injury death, followed by falls. The problem has become so severe that deaths from drug overdoses have surpassed falls and are now the second leading cause of unintentional injury-related death. In 15 states, deaths due to drug overdoses have surpassed motor vehicle crashes and are the leading cause of death due to unintentional injury.
The death rate from drug overdose is now seven times higher than it was at the height of the heroin epidemic in the early 1970s, and three and one half times as high as it was at the height of the crack cocaine epidemic in the 1980s. Illicit “street drugs” are not the primary cause of these fatal drug overdoses. More than half are due to misuse of legal prescription drugs, most often obtained from a physician. The exploding overdose rate closely corresponds to a 6-fold increase in the amount of opiates and benzodiazepines prescribed since 1997 (Fig. 42-2).
FIGURE 42-2 Unintentional drug poisoning death rates, United States, 1970–2004. (Courtesy of Leon J. Paulozzi, MD, MPH, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.)
The appropriate goal of an intervention at the trauma center is to capitalize on the effects of the injury to increase a patient’s motivation to change their pattern of usage of intoxicants and to refer the smaller proportion with chronic dependence to available community treatment resources or support systems. Most patients with unhealthy alcohol use will respond to appropriately and skillfully delivered “brief interventions.” Research has demonstrated that even in dependent patients brief interventions more than double the likelihood that they will follow through on a treatment referral.
Brief interventions, which will be further described below, are time-limited (10–30 minute), focused, nonconfrontational discussions between the patient and doctor or other health care professional. They are designed to raise the patient’s level of awareness of their need for behavioral change and their commitment to pursue it. They have specific elements and can be provided by anyone who is able to speak to patients with unhealthful alcohol use in a nonjudgmental, nonconfrontational manner. They are not, however, adequate as a stand-alone treatment for most patients with dependence.
The largest study to date of Screening, Brief Intervention, and for patients who need it, Referral to Treatment (SBIRT), was a multistate program delivered across six states and several tribal nations.11 It was conducted in trauma centers, primary care clinics, emergency departments, general medical and surgery wards, and college health clinics, and enrolled a diverse population. Screening was administered to all adult patients who presented to the study sites for care, unless they were too severely ill or injured.
There were 459,599 patients screened using standardized questionnaires, making it the largest study of its kind. Nearly one out of four patients who presented for medical care (22.7%) screened positive for unhealthy alcohol or drug use; however, screening results indicated that 15.9% of patients were considered nondependent, and in need of a brief intervention only. An additional 3.2% would benefit from having two to three additional sessions that could be administered during return visits. Only 3.7% of patients, or one out of six patients who screened positive, were considered dependent and in need of formal treatment.
Studies show that the majority of patients with unhealthy alcohol use that results in encounters with the medical system, including studies conducted in trauma centers, are appropriate candidates for a brief intervention.
ALCOHOL DEPENDENCE SYNDROMES
The relatively small percentage of patients with dependence require more than a brief intervention. Although alcohol use begins as a choice, for some patients it has become a disease that they have little control over, and they require medical treatment. Trauma centers are not able to act as treatment centers; however, they should have a list of treatment resources available in the community to provide to patients. Brief interventions have been shown to cause a greater than 2-fold increase in the probability that patients will follow through with a referral.
Whether or not these patients require prophylaxis or treatment for withdrawal syndromes is an important consideration. The goals of prophylaxis and treatment are to minimize the risk of serious complications such as seizures, delirium tremens, and the cardiovascular morbidity that occurs as a result of sympathetic overload. Clinicians should consider treating withdrawal as the first step in a comprehensive plan aimed at referring these patients to treatment.
Withdrawal is characterized by signs and symptoms that are the opposite of the pharmacologic effects of the drug that is the cause of the addiction. The four primary categories of addicting agents are alcohol, sedative-hypnotics (benzodiazepines, barbiturates), opiates, and stimulants. All drugs in each category are associated with similar withdrawal syndromes, but they differ in their intensity, timing of onset, and duration. Symptoms from cessation of short-acting drugs such as alcohol may emerge within 6–24 hours, whereas withdrawal from long-acting benzodiazepines may not emerge for several days. Alcohol and sedative-hypnotic drugs have similar pharmacologic effects and similar withdrawal symptoms. Cessation of stimulant use is characterized by depression and a risk of suicidal behavior.
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Evidence of Effect in Trauma Settings
One study of brief interventions analyzed their efficacy at reducing the recurrence of injury in injured adolescents by randomly assigning patients age 18 or 19 years to receive either a 30-minute brief intervention or standard care. At 6-month follow-up, the intervention group had a significant reduction in drinking and driving, moving violations, alcohol-related problems, and less than half as many alcohol-related injuries as patients in the control group.12
Another randomized, prospective, controlled trial was performed on 762 patients admitted to a Level 1 Trauma Center.7 Patients who screened positive were randomized to a single 15–30 minute brief intervention or to a no-intervention control group. At 1-year follow-up, the intervention group decreased their alcohol intake by 22 drinks per week compared to a 2, drink reduction in the conventional care group. A statewide registry was used to detect readmission to any hospital for treatment of an injury over a 3-year follow-up period. There was a 47% reduction in trauma readmissions in the intervention group compared to controls. There was also a 48% reduction in returns to the emergency department for treatment of another injury (Fig. 42-3).
FIGURE 42-3 Risk of repeat injury requiring treatment in the Harborview Medical Center, Emergency Department, Seattle Washington (hazard ratio 0.53, 95% CI 0.26–1.07). (Reproduced with permission from 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(4):473–483.)
Another randomized, prospective trial of brief interventions showed that one driving under the influence (DUI) was prevented for every nine brief interventions performed at 3-year follow-up.13 Through their effect on reducing trauma recurrence, brief interventions have also been shown to result in cost-savings to trauma centers.8 The savings in health care costs over 3 years were $320 per intervention performed and $3.81 for every dollar invested in the screening and brief intervention program.
A best-practice screening model combines both a standardized questionnaire with a laboratory test (urine toxicology screen or blood alcohol test). Patients with a very high BAC or positive toxicology screen should be considered as screening positive. Many physicians are mistrustful of patient self-report, but patients with an alcohol problem do not typically underreport their drinking when asked in a respectful, concerned, and confidential manner.14 Toxicology testing may be a better means of detecting drug use, as patients may be less willing to disclose use of an illegal substance.
A screening questionnaire must be sensitive enough to detect the full spectrum of alcohol problems from mild unhealthy drinking to severe dependence. The Cut down on drinking, Angry when criticized about drinking, Guilty feelings about drinking, Eye-opening morning drinking (CAGE) and Michigan Alcohol Screening Test (MAST) questionnaires have been used for decades, but were primarily designed to detect dependence and are less sensitive to more moderate drinking problems.
The Alcohol Use Disorders Identification Test (AUDIT) is a 10-question, self-report screening tool developed by the World Health Organization, and it has been validated in trauma patients and in numerous languages and cultures15(Table 42-1). It was designed to be sensitive to a broad spectrum of harmful drinking levels. It assesses drinking quantity and frequency (three questions), problems caused by drinking (two questions), and symptoms of dependence (five questions). It takes less than 2–4 minutes to administer and seconds to score the results.
TABLE 42-1 The Alcohol Use Disorders Identification Test (AUDIT) Was Designed to Detect Alcohol Problems Across a Range of Severity, Including Harmful or Nondependent Drinking.
A score of 8 or more is considered to be a positive screen. Because the safe recommended level of alcohol intake is different between males and females, the three quantity and frequency questions decrease the sensitivity of the AUDIT in females, and a lower cutoff score of five points has been recommended.16 Patients who score over 20 points should be considered as being likely to have alcohol dependence and require further assessment and, most likely, a referral to treatment. The AUDIT can often be abbreviated because many patients drink infrequently or not at all. If the answer to question one is zero concerning frequency of use, no further questioning is necessary. The AUDIT is quickly becoming the standard of care in most clinical settings and is widely available in downloadable form.17
At a minimum, reasonably effective screening for drinking above safe guidelines can be performed by asking only one question. In a study of 1,537 patients who presented to the emergency department with an injury, researchers asked the question, “when was the last time you had five or more drinks in one day (more than four drinks for women)?” Formal interviews by trained staff were then conducted to determine if an alcohol problem was present. This single question had sensitivities and specificities of 85 and 70% in males and 82 and 77% in females. This indicates that asking only one straightforward question can be used as a brief screening method. If the patient answers “within the past three months,” then the full AUDIT should be administered.18 Although more time-consuming, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is another instrument that was designed to detect and score problems with alcohol, drugs, and tobacco.19
Guidelines for Brief Interventions for Trauma Patients
Most studies of successful brief interventions have used a patient-centered style of motivational counseling derived from Motivational Interviewing. Healthy change occurs when people perceive a large enough discrepancy between the status quo and how they would prefer things to be. It is the clinician’s behavior during the intervention that strongly influences how the patient talks about his or her drinking. An interviewing style of polite and genuine curiosity facilitates change. On the other hand, an interviewing style that the patient experiences as attacking or confrontational provokes resistance and slows down the process.
Research has failed to support the concept that patients with alcohol problems have personality traits such as poor motivation and rigid defense mechanisms such as denial. Rather, these factors are an outcome of the style of interaction between the clinician and patient. When patients “in denial” are heard to argue in favor of the status quo (more drinking), it is usually because he or she has encountered a confrontational or authoritarian counselor. Confrontational tactics are particularly counterproductive in a trauma center because the “denial” they provoke requires too much time and skill to undo.
Application of Brief Intervention
FRAMES. The basic elements of a brief intervention can be summarized by the acronym FRAMES. They consist of providing nonpersonal, concerned Feedback of the patient’s personal risk or impairment related to alcohol consumption; emphasizing their personal Responsibility to change; giving clear Advice that change is needed; and presenting a Menu of alternative strategies that may be appropriate and helpful. This material is presented in an Empathetic manner intended to increase the patient’s sense of Self-efficacy, optimism, and confidence that change is possible.
SUM. Another acronym that has been used to summarize the key components of a brief intervention is SUM or Screening feedback, Understanding the patient’s views, and providing a Menu of change options.
The two main sources of feedback for trauma patients are their BAC upon admission and how their score on a questionnaire compares to established standards. This information can be presented on personalized feedback forms or verbally.
For giving feedback about their BAC a simple five-step acronym is “RANGE.” Tell patients the Range of possible BAC results, from 0 (sober) to 0.6 (fatal). State that All drivers know that 0.08 is the beginning of drunk driving. Normal drinkers stay under 0.05, even when not driving. Then, Give the patient his or her BAC result in relation to 0.08; for example, “Your BAC was 0.16, which is twice the 0.08 figure for drunk driving.” Elicit the patient’s reaction and do not argue. If the patient challenges the validity of the BAC test, the clinician might state, “The best way to explain this is to show you an illustration that indicates that at your blood alcohol concentration of 0.14, you are 48 times more likely to have a serious crash than if you had not been drinking.” It is important for clinicians to tell patients that they are not concerned with labels (alcoholism), “but I am concerned if alcohol is hurting you.”
The goal of an intervention is to establish empathy, not to administer blame. Empathy is the clinician’s primary tool in avoiding resistance or denial. Studies demonstrate that drinking is more likely to be reduced when the counseling style is empathetic, rather than confrontational.
Understanding (from SUM) the patient’s views can be done by asking them about the “pros and cons” of their drinking. After the clinician has listened to and summarized what the patient believes are benefits such as “It helps me to relax,” “It makes it easier to interact with others,” or “It helps me to have a good time,” he or she may ask the patient to explore the “cons” by asking, “What are some of the things you don’t like about drinking?” For example, if the patient indicates that one of the negative aspects of drinking has been frequent arguments with family members, the clinician might ask, “How does your alcohol use affect your ability to have a stable family life?” The goal is to raise doubt by having the patient, rather than the clinician, articulate how alcohol use is having an adverse effect on their family, health, work, finances, driving record, or legal status.
Asking for and then summarizing the pros and cons is a central brief intervention technique. It allows the patient to state the ways that their use of alcohol is adversely affecting them so that recommendations for change are based upon the goals and values that are important to them.
Menus of strategies are offered when the SUMS technique is used. When given a choice the patient is more likely to find an approach that is acceptable to his or her own particular situation. For example, a patient may refuse a referral to formal treatment or to a self-help group, but may be willing to accept an incremental change. Examples would be setting specific limits on their alcohol intake and agreeing to seek further help if they are unable to stay within the negotiated limit. Or, the patient may only be willing to agree to avoid drinking and driving and agree to become involved with a self-help group if they are unable to do so.
The “menu of options” list is most often presented in ascending order of commitment as follows: no change whatsoever, merely think about it and notice more about your drinking in the future, cut down, or quit. If the patient is able to select one of these options, then a plan for obtaining this goal can be discussed. Giving advice is also an important part of the menu. It is appropriate for the clinician to weigh in with an opinion. This usually means offering clear advice to the patient regarding the need to change his or her drinking pattern.
Most studies of brief interventions with positive outcomes have used non–substance abuse specialists. This means that to successfully use these techniques a clinician does not have to have special training and expertise in managing unhealthy substance use. Brief interventions can be performed by anyone who is willing to learn the methods and who is capable of showing respect and concern for injured patients who sometimes drink too much and take dangerous risks.
There are multiple individuals in every trauma center who meet these criteria. The list includes but is not limited to nurses, social workers, physician assistants, psychologists, chaplains, peer-counselors, health educators, and physicians. Although trauma surgeons may obtain the training necessary to perform brief interventions and should have the skills needed to screen and counsel patients with a problem, time demands and staffing constraints will usually prevent them from being the primary providers of this service. The role of the trauma surgeon, however, is critical in providing administrative support through education and advocacy for these services.
Ask, Advise, Assist, Arrange
This acronym is recommended by the National Institute of Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. If the patient is ready to change, the clinician assists in setting goals and agreeing on plans to arrange mechanisms to support these efforts. There is a wealth of information online, including scripts, manuals, and videos.20,21
HOW TO ESTABLISH AN EVIDENCE-BASED SBIRT PROGRAM
When considering starting an SBIRT program many feel that their first and only concern is to assign willing individuals to obtain the required training. In reality, training is the last step in the process. If there is little administrative support for the SBIRT program within the hospital and among those in positions of leadership and decision making, it is unlikely that the program will succeed, even if there are several enthusiastic supporters.
The first step is to make a case for establishing the SBIRT program. Hundreds of studies have established effectiveness, and some concisely summarize these results and will help to make the case.22,23 The message should be concise and simple. In appealing to potentially interested colleagues, research, and evidence of patient benefits should be provided and an attempt made to recruit additional stakeholders into the process.
Once buy-in is achieved, the next step is to organize implementation. A team approach works best, and this involves recruiting people from multiple departments such as the following: psychiatry, addiction medicine, social work, nursing, trauma leadership, surgery and emergency medicine colleagues and chairs, clergy, pain medicine staff, hospital executives, billing personnel, and anyone else who might contribute. It is important to gain their respect and trust and the authority to carry out the project.
At meetings of interested parties key decisions can be made such as whether the program will require recruiting additional staff or changes in the responsibilities of the existing staff. The key to establishing the need for an SBIRT program is to convey concern, to provide everyone involved with information about what it is and how it works, to establish goals and plans to work together, and to develop timelines and responsibilities.
The fourth step is to determine who will provide the intervention. Someone on staff may be able provide the entire service. Alternatively, screening may be performed by one individual and the intervention provided by another. Time, availability, background knowledge and experience, interpersonal skills, and willingness to participate will help determine the appropriate candidates. Other factors need to be considered such as typical length of stay, how to handle early discharges, how many patients will need to be screened, and how many interventions are likely to be needed.
The type of intervention should then be chosen based upon a variety of available models. These range from 5 minutes of brief advice to more extensive motivational interviews that consist of 15–20 minute sessions. Ideally, all patients should be screened, but this may not be practical. Policies and procedures to determine who should be screened should be established in order to train staff and for subsequent evaluation of the program.
Next, screening procedures should be established. A single question followed by a full AUDIT if indicated is only one of many evidence-based screening procedures. Screening for drugs can be accomplished when using the single question initial screen. The patient is asked whether they have exceeded safe alcohol intake limits in the past three months “or used street drugs or prescription drugs to get high.”
As with screening, step seven is a determination of how to establish the intervention procedures that follow. This will include when the intervention will be delivered, how the person who is to deliver the intervention is to be notified of a positive screening result, and the development of forms, handouts, and other materials that will be used during the intervention. Step eight is to establish procedures to manage patients who are dependent and who will require a referral to treatment. This will involve developing a list of resources in the community that can be provided to patients. Included would be contact numbers for self-help groups, formal treatment, and for determining insurance coverage and health plans.
The next step before initiation of the process is to seek long-term buy-in for the plan by reviewing it with all levels of employees. Finally, it is time to train staff who will provide the screening and the intervention service. It is useful to try to include others such as supervisors and administrators, who will not provide the service, but who need a better understanding of what SBIRT is and why it is important. There are a variety of training programs available at conferences, on websites, and videos, and at a variety of ongoing training seminars.
Once ongoing means of support and a mechanism of troubleshooting are available, the program is initiated. It is also important to develop a monitoring system and quality improvement process. This monitoring would include the percentage of patients screened, number of interventions performed per positive screen, patients referred, and other possible measures. A complete program with information on how to navigate the above steps has been specifically designed for trauma centers and is available in a format that can be downloaded from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.24
Billing for SBIRT
In 2008, the American Medical Association, the group responsible for maintaining the Common Procedural Terminology (CPT) codes used for billing, passed and established new CPT codes for SBIRT. There are two codes, 99408 and 99409, for SBIRT lasting greater than 15 or 30 minutes. Most insurers have agreed to pay for these codes, and a requirement that insurers cover SBIRT in their plans is written into the health care reform bill that will be implemented throughout the United States over the next 5 years. Nonphysician providers such as nurse practitioners, physician’s assistants, and others who provide services “incident” to a physician may use these codes also.
The Center for Medicare and Medicaid Services (CMS) passed similar codes (G0396 and G0397) in 2008 to cover SBIRT services in Medicare patients. Medicaid also passed billing codes (H0049 and H0050); however, Medicaid is a joint federal and state program that requires cost sharing. As of 2010, approximately 15 states have adopted the Medicaid codes. A complete primer and web-based source on how to use these codes is available in an on-line form that includes webinars and recordings.25
Uniform Policy and Provision Laws
In 1948, the National Association of Insurance Commissioners (NAIC) adopted a model law that stated that if a patient is injured while under the influence of any intoxicant, the insurance company is not liable for any resulting hospital or medical charges. This law was adopted in some form in 42 states and provided a strong disincentive to determine a patient’s BAC, which can be an important tool when provided as a part of feedback during a brief intervention.26
Since 2001, nearly half of the states that had these laws have repealed them. In states that still have these laws, none of the screening questionnaires such as the AUDIT can be used as a basis to deny a claim. This is because they discuss alcohol use over a period of months and do not determine if the patient was intoxicated at the time of injury. Trauma centers in states that still have these laws may wish to avoid BAC measurements and rely solely on questionnaires.
The Code of Federal Regulations known as 42 CFR Part 2 “Confidentiality of Alcohol and Drug Abuse Patients Records” governs the management and disclosure of any information related to screening, treatment, or referral of patients with unhealthy alcohol use for treatment. Patients with substance use are still subject to stigma, with potential loss of employment, insurance, loss of child custody, housing, and other requirements of life. The purpose of the law was to ensure that patients who were willing to receive help do not suffer losses that other patients with a problem can avoid by denying their need for help.
The “Part 2” statute is much more restrictive than the Health Insurance Portability and Accountability Act, which allows for disclosure of health information to other health care workers within the same facility without written authorization from the patient. CFR 42, Part 2, allows disclosures concerning substance use only to other staff within the same facility who have a need for the information to perform their duties.
With only several exceptions trauma centers that screen and provide interventions or referrals or who employ staff whose primary responsibility is to perform such procedures must abide by this law. They have an ethical and legal duty to ensure that information on alcohol and drug use is not disseminated to those who do not have a right to know.27
The United States Preventive Services Task Force provides guidelines to Congress and payers concerning evidence-based preventive services. In a cost–benefit ranking based on the magnitude of the disease burden and the evidence of benefit that highlighted which preventive services should be prioritized, alcohol screening and brief intervention were tied at second place with colorectal cancer and screening for hypertension. Also, it was ranked ahead of cervical Pap smears, cholesterol measurements, mammograms to detect breast cancer, screening for diabetes mellitus, education for injury prevention, and other services.28
The brief intervention procedures discussed in this chapter have been tested and applied in a variety of health care settings, and a large number of research studies have established their effectiveness. When receiving medical care, patients have the right to expect that the underlying causes of their disease will be sought and addressed. The field of trauma surgery has taken the lead in ensuring that this is being done.
1. MacKenzie EJ, Rivara P, Jurkovich G, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366–378.
2. WISQARS (Web-based Injury Statistics Query and Reporting System), National Center for Injury Prevention and Control, Centers for Disease Control. Available at: http://www.cdc.gov/injury/wisqars/index.html.
3. Hoyt DB, Coimbra R, Potenza B, et al. A twelve-year analysis of disease and provider complications on an organized level I trauma service: as good as it gets? J Trauma. 2003;54:26–36.
4. Stewart RM, Myers JG, Dent DL, et al. Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention. J Trauma. 2003;54:66–70.
5. Broadening the Base of Treatment for Alcohol Problems. Institute of Medicine. Washington, DC: National Academy Press; 1990.
6. Developing Best Practices of Emergency Care of the Alcohol-impaired Patient. Recommendations from the National Conference. National Highway Traffic Safety Administration. Washington, DC: S Department of Transportation; 2000.
7. 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;230:473–483.
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