Every year, emergency departments across the nation get about 7.6 million visits related to alcohol abuse. To identify patients with alcohol problems, researchers have developed two screening tests, and they have found brief motivation-oriented interviews to work well in getting people to seek help.
So far, however, the research has focused on academic medical centers, not community hospitals, which handle 56 percent of emergency-room visits. Dr. Michael Mello, director of the Rhode Island Hospital Injury Prevention Center, is now testing a model for screening and brief interventions to be used in community hospitals.
In this month’s issue of the journal Substance Abuse, Mello described the results of a pilot test of that model at Kent Hospital in Warwick. Mello answered questions about the project.
PBN: What do the screenings and interventions entail, and when do you do them?
MELLO: It can be done in a variety of ways, but there’s a formal method of doing it; it’s not just asking someone, “Do you drink?” but quantifying it, and seeing if they drink at levels that are risky by defined standards. … We use a two-step process of asking folks how many drinks they have per week and how many drinks they have on any one occasion. … And we believe in universal screening, because who you think might be drinking may not be the only ones. There are lots of other folks who may be at risk. We know from previous research that in emergency departments, probably between 20 and 30 percent of patients use alcohol at risky levels and would benefit from this type of intervention.
For the brief interventions, we use a technique called motivational interviewing, which is non-confrontational and basically reviews with the patient the amount that they drink, maybe points out some of the negative consequences of their drinking, and leaves the responsibility for change with the patient, but giving them a sense that they really have the power to do that.
There’s been lots of research demonstrating the effectiveness of screenings and brief interventions in emergency departments, and also in primary care environments.
PBN: So far, the research has focused on academic medical centers. Why is that, and how might that affect the usefulness of the model?
MELLO: The research has happened at academic centers where there’s more of an infrastructure and more people, so [there’s a question of], is that going to be able to be translated to a community hospital, which is about 40 percent of hospitals in this country.
When we went and talked to the key people at Kent, we realized that we didn’t really understand where they were at, and that we had to modify our model. … We were asking people that have a lot of clinical duties to do extra things, and they were resistant to it, and probably rightfully so. As well-intentioned as it was, and as important as it is – they recognized the importance of it – their time is very limited.
PBN: How did you adapt the model to be more usable in that setting?
MELLO: We adapted it by having them just do the screening, and we said, here are the screening criteria, let’s give [the questionnaire] out to all the patients and have them fill it out themselves, and you interpret it like you would do with lab results. The physicians were very good about looking at the data that the patient completed and appropriately deciding who was at risk and who was not at risk. And if they did find somebody at risk, instead of delivering the brief intervention themselves, they referred it to a research staff member who was there. … One surprise outcome, though, was that the nurses, who were resistant to do this, when they observed the interventions, they got very interested, and we had 15 nurses who signed up at the end of the study to get trained in how to do brief interventions.
PBN: What happens next? Did the study give you a good sense of how to proceed to make this a nationally usable model?
MELLO: I think there were some positives, things to build on. But one of the biggest things was the negative. A lot of folks – like the [Centers for Disease Control & Prevention] – think that we should be screening all our injured patients, all our ED patients. And realizing that that’s hard to do in the current environment, that emergency departments are busy places, and there’s a lot of pressure to complete all the current clinical activities quickly … so this is a real challenge. And although there’s been a lot of research showing that this can decrease future injuries and negative consequences from alcohol, and it should be done, just saying, doctors and nurses, go do it, is probably not going to work. There has to be other infrastructure there. For us it was the research staff, but it may be a social worker, or other ancillary personnel. Someone with more flexibility has to be able to take on some of these tasks.
PBN: You’ve also looked at doing the interventions as a follow-up?
MELLO: We’ve been looking at can we screen people in the emergency department, identify the ones at risk, and call them up after they’ve left to do the intervention a couple of days later? We’ve been doing research to see if that works as well. Because it’s hard. Emergency departments are very busy places. The staff is busy with lots of patients, and it’s hard to put one more thing on their plate to do.
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