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Emergency Department Screening and Intervention for Patients with Alcohol-Related Disorders: a Pilot Study

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Emergency Department Screening and Intervention for Patients with Alcohol-Related Disorders: a Pilot Study ORIGINAL CONTRIBUTION Emergency Department Screening and Intervention for Patients With Alcohol-Related Disorders: A Pilot Study Aaron Craig Love, DO; Marna Rayl Greenberg, DO; Matthew Brice, DO; and Michael Weinstock, MD Context: Physicians in emergency departments (EDs) treat n estimated 40 million adults in the United States are con- more patients with alcohol-related disorders than do those in Asidered “heavy drinkers” of alcohol, with 10 million primary care settings. dependent on the substance, according to the National Insti- tute on Alcohol Abuse and Alcoholism (NIAAA).1 Misuse of Objectives: To implement an effective screening, brief inter- alcohol contributes to a wide range of harmful effects in vention, and referral (SBIR) program for use in EDs. Further, society. For example, the prevalence of alcohol abuse and to evaluate the impact of the program on alcohol-consump- dependency in individuals involved in motor vehicle acci- tion levels. dents is estimated to be 23%.1 In addition, there are Methods: A prospective cohort pilot study was conducted at 66.9 alcohol-related diagnoses per 10,000 adults annually in a suburban community teaching hospital using a convenience the United States.1 The economic costs of alcohol abuse were sample of ED patients and an original seven-question estimated at $184.6 billion annually in 1998.2 screening tool based on well-known guidelines. Subjects Based on probability sample comparisons of noninjured screening positive for possible alcohol abuse were given treat- patients seen in emergency departments (EDs) versus nonin- ment referrals. Follow-up telephone interviews were con- jured patients in primary care settings, it was found that physi- ducted 6 months later. cians in EDs treat a larger percentage of patients who misuse alcohol.3 Thus, there exists great potential for physicians in Results: Of the 1556 enrolled subjects, 251 (16%) were clas- EDs to have a beneficial impact on intervention efforts. sified as at-risk drinkers. Seventy-nine at-risk subjects The US Centers for Disease Control and Prevention, the (32% [95% CI, 26%-37%]) screened positive on CAGE-based National Highway Traffic Safety Administration (NHTSA), questions (Cut down, Annoyed, Guilty, Eye opener). At and the American College of Emergency Physicians (ACEP) follow-up, 20 (25% [95% CI, 16%-35%]) were successfully have spearheaded a nationwide effort to incorporate patient contacted. Of these 20 subjects, 5 (25%) refused to partici- screening for alcohol misuse into a broad-based program of pate in follow-up screening. For the remaining 15 individuals, injury prevention.4 In addition, the ACEP has received an follow-up screening indicated that the mean (SD) number of NHTSA grant to develop an alcohol-screening and brief inter- drinks consumed per week decreased from 28 (14) on study vention tool to help ED physicians address alcohol-related enrollment to 10 (10) at 6-month follow-up (PϽ.001). Max- injuries.4 A randomized controlled trial by Crawford et al5 imum number of drinks per occasion decreased from 12 (8) found reduced alcohol-consumption levels and ED visits in at enrollment to 6 (7) on follow-up (P=.008). Subject scores on alcohol-misusing patients who were screened and referred to the CAGE-based questions decreased from pre- to post- follow-up care with alcohol-abuse treatment specialists. Nev- intervention, though not significantly, with an average of ertheless, there remain considerable barriers to establishing and 2.1 (1) affirmative answers on enrollment and 1.5 (1.4) at evaluating the effectiveness of alcohol-screening programs. follow-up (P=.108). Although there have been more than 30 studies revealing Conclusion: Implementation of an effective SBIR program the beneficial impact of brief intervention in various clinical set- for alcohol-related disorders can be accomplished in the ED. tings for patients with alcohol-related disorders, there have J Am Osteopath Assoc. 2008;108:12-20 been few studies on the effectiveness of brief intervention under conditions commonly encountered in an ED.6 The goals of the present pilot study were to develop a brief alcohol- From the Department of Emergency Medicine at Lehigh Valley Hospital in screening and referral program for this patient population, to Bethlehem, Pa. investigate the feasibility of telephone follow-up after inter- Address correspondence to Aaron Craig Love, DO, 7437 Beaver Valley Rd, vention, and to determine the 6-month self-reported change in Prescott Valley, AZ 86314-1412. E-mail: [email protected] patients’ alcohol-consumption levels and CAGE scores. The CAGE questionnaire is an internationally used assessment Submitted August 31, 2006; revision received October 30, 2006; accepted instrument for identifying people who misuse alcohol. The November 1, 2006. 12 • JAOA • Vol 108 • No 1 • January 2008 Love et al • Original Contribution ORIGINAL CONTRIBUTION letters in the acronym represent the standard four questions disorders conducted the training session. Pocket reference used in the test7: cards were developed and distributed to ED staff. An incen- tive program offering retail gift cards was used to increase Ⅲ Have you felt you ought to Cut down on your drinking? staff participation. Local newspapers were contacted and Ⅲ Have you been Annoyed by people criticizing your encouraged to publish articles about the SBIR program, further drinking? contributing to staff interest and participation. Ⅲ Have you felt Guilty about your drinking? Staff determined which patients to screen, being encour- Ⅲ Have you had a drink first thing in the morning (ie, an Eye aged to perform screening on any patient who answered “yes” opener) to steady your nerves, get rid of a hangover, or get or “yes, socially” to the question, “Do you drink alcohol?” your day started? This question is part of the standard social history obtained at triage in the ED of our hospital. Subjects who answered with Methods either affirmative response to this question were screened— We conducted a prospective cohort pilot study using conve- regardless of whether their presenting complaints were related nience sampling in a screening, brief intervention, and to alcohol consumption. We adopted this strategy because referral (SBIR) program for alcohol-use disorders in noncritical other researchers have recommended similar screening for care patients seeking treatment in the ED at Lehigh Valley Hos- any ED patient who consumes alcohol.8,9 In addition, it has pital in Allentown, Pa. Patients’ reasons for seeking ED treatment been shown that self-reporting of recent drinking is not a good may or may not have been related to alcohol consumption. indicator of alcohol abuse in ED populations.10 Subject The present project was referred to the institutional review screening was conducted by ED staff, depending on the avail- board at Lehigh Valley Hospital. The board deemed the project able time and resources, workload, and staff motivation. to be exempt from full review because it was designated a quality- We developed our SBIR tool (Appendix) based on the improvement initiative. Because of the social nuances of alcohol NIAAA at-risk drinking guidelines (“at-risk drinking” defined abuse, there was considerable concern that requiring written con- as >14 drinks/wk or >4 drinks per occasion for men age sent from the patients would diminish participation. Therefore, р65 years; >7 drinks/wk or >3 drinks per occasion for women verbal consent was obtained from patients for ED screening and of all ages and men older than 65 years) and the CAGE ques- postintervention telephone follow-up. Verbal consent was logged tionnaire.7 One standard drink was defined as 142 mL (5 oz) for subjects who could be contacted for follow-up. of wine; 43 mL (1.5 oz), spirits; or 341 mL (12 oz), regular beer. The NIAAA at-risk drinking guidelines have previously been Study Participants and Setting shown to result in the best balance of sensitivity and specificity Patients were eligible for and included in the present pilot for screening patients with alcohol-related disorders.10,11 To study if they were cognitively alert, cooperative, medically increase the selectivity for subjects’ current drinking patterns, stable, at least 14 years of age, and presented with a condition we added the phrase, “Within the past year...” to the beginning that did not result in hospital admission. Subjects were enrolled of each of the four standard CAGE questions. During the in the study at the hospital’s ED during a 6-month period, study period, the SBIR tool was placed on each new ED patient from April 2004 to October 2004. Patients who were excluded record. from study participation were customarily cared for at the Subjects who answered “yes” or “yes, socially” to the discretion of physicians and nurses. Physicians, nurses, and question, “Do you drink alcohol?” were screened first with the physician assistants in the ED performed the initial patient three NIAAA at-risk questions evaluating current drinking screening for alcohol misuse. A research assistant conducted habits. Subjects who screened positive according to these the telephone follow-up of subjects 6 months after intervention. guidelines were then screened with the four-question CAGE- Lehigh Valley Hospital is a suburban community teaching based portion of our SBIR tool. A positive result on this section hospital with approximately 30,000 visits to its ED every year. of the SBIR was defined as one affirmative answer to any of the The hospital is part of a three-site, tertiary care
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