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Screening And Brief InterventionIntroductionNearly one-third of all persons using hospital emergency services use alcohol in hazardous or unhealthy ways. Millions more require hospital emergency services due to their use of illicit drugs or misuse of prescription medications. Emergency services patients with untreated alcohol problems are 81% more likely to be admitted to the hospital and 46% more likely to report at least one prior emergency service visit in the previous year. Research clearly shows that screening patients in emergency, ambulatory and inpatient settings for alcohol use and providing them with immediate brief counseling can cut subsequent hazardous substance use, reduce injury and hospitalization, and cut health care costs. Unfortunately, very few hospitals and other health care settings routinely screen and treat the alcohol and drug problems of their patients. McGlynn and her colleagues at RAND (2006) found that only 15.5% of traumatically injured inpatients had any medical record indication that substance use had been assessed. Within the health care system, however, recent steps have been taken to change this. As of May 1, 2007, the American College of Surgeons' Committee on Trauma, the accrediting body for the nation's trauma centers, requires all Level I trauma centers to screen admitted patients for unhealthy alcohol use and provide a brief intervention to those who screen positive as a requirement for verification of their trauma center status. The US Preventive Services Task Force (2005) reviewed the research evidence of the effectiveness of alcohol screening and brief intervention in emergency, inpatient and ambulatory health care settings, and recommended that all adolescents and adults receiving general medical services be routinely screened for hazardous alcohol use, and if positive, to receive brief counseling. The National Quality Forum (NQF) (2007) recently released national consensus standards for evidence based substance use treatment. Routine, periodic alcohol screening and brief intervention in emergency, inpatient and ambulatory health care settings was strongly affirmed. Thirteen medical profession groups have developed evidence based clinical practice standards for the conditions seen by their specialties in which routine screening and brief intervention are recommended. The Substance Abuse and Mental Health Services Administration (SAMHSA), through its Screening, Brief Intervention and Referral to Treatment (SBIRT) grant program, has supported screening and brief intervention programs in hundreds of hospitals, community health clinics and other organizations. So far, more than 540,000 people have been screened through this program, approximately 18% of whom screened positive for unhealthy alcohol or drug use. The research evidence supporting the effectiveness and the cost-benefit of alcohol screening and brief intervention is substantial. Practical experience of training physicians and other health care providers to deliver SBI effectively and efficiently is extensive. Professional consensus is strong that screening for alcohol and other drugs should be moved toward the status of a vital sign (IOM, 2005). Recent decisions by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) may also offer incentives for health care providers to deliver these services. In 2006, CMS approved new HCPCS level II procedure codes for screening and brief intervention (H0049 and H0050). The AMA adopted new alcohol and drug screening and brief intervention CPT E&M codes that were published in the 2008 CPT manual, and have relative values that are consistent with other counseling procedures. The purpose of this topic is to initiate discussion around what role, if any, The Joint Commission might play in supporting this evidence-based process of care. This forum offers a mechanism through which the SBI issue can be explored and, where appropriate, to assist in the development or refinement of accreditation requirements. Quality improvement topics related to the implementation of SBI can be accessed through the Screening & Brief Intervention Quality Improvement Topic. Note: To describe your organization's experiences with SBIRT implementation, just click on the link below and then select "Post new field experience." (To enter a field experience, you will first need to Login)
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Comments 27 Jun 08 15:32 | ThomasSweeney said...: Although universal screening for alcoholism is a laudable goal, great caution must be urged before laying further mandates onto emergency departments. These mandates should not come without the resources to carry them out. Currently resources are shrinking, the number of patients is growing. Many Emergency Departments in the United States are struggling to provide a basic level of evaluation and treatment within a time frame that might still do a patient some good. Although screening for issues such as domestic violence and alcoholism are good public health initiatives, they should not distract us from our primary objective of providing basic emergency care. If society values these as secondary objectives, then they must be financially supported. The Joint Commission would be wrong to lay unfunded mandates onto hospitals that are struggling to provide basic emergency care in a timely fashion. 13 Jun 08 01:44 | TimNoonan said...: Considering that the problem of access to care is limited by the overcrowding of the emergency departments, how will this help to improve care? Emergency department personnel are already spending far too much time on tasks that are not directly related to patient care. Some would say that the only relation to patient care is that they are performed by people who should be performing patient care, instead. I understand the desire to improve the lot of those who are not able to care adequately for themselves, but this is the wrong way to do it. Emergency care requires experts in patient care, not screeners for chronic conditions. Emergency departments are for acute care. Screening the chronically ill, because they have acute exacerbations is something that would be better performed by those trained to provide care to the chronically ill. If you arrive in the emergency department with a life threatening condition, you do not want someone cross-trained in half a dozen different screening techniques to be the one making treatment decisions. You want someone who is specialized in emergency care. Cross-training leads to a dilution of skill. Some people do well when cross-trained, but that is not the way to improve skill. If you have a problem of nurses and physicians being too skilled, if they need to be distracted from patient care, then this is the right approach. That is not the case. This will not improve patient care. This will help to drive out those who do provide excellent patient care. This makes me wonder where the teachable moment is for those who are not regular providers of acute care? Why would you implement such a plan? 12 Jun 08 12:08 | ErNursey said...: .....................JCAHO is the biggest detriment to patient care that ever came down the pike. Thanks to their endless mandates I know spend 45 minutes doing paperwork for every 15minutes of patient care - please tell me how that has improved patient care? JCAHO is a bloated, self-procreating entity whose entire focus is to justify their continual existence. The only think that the have done is ensured the destruction of half the forests in the world by creating endless, pointless, redundant paperwork. 02 Jun 08 22:50 | StevenBernstein said...: I have developed SBIRT interventions for cigarette smokers in the emergency department. These interventions are effective, particularly with smokers presenting with tobacco-related conditions such as exacerbations of asthma. This lends credence to the teachable moment concept. Insofar as tobacco remains the most commonly used harmful substance, I would urge that tobacco be considered, along with alcohol and illicit drugs, in SBIRT policies. At the same time, as a practicing emergency physician I am well aware of how another 'unfunded mandate' would be perceived by my colleagues. It is important that any SBIRT standard of care be sensitive to the very real constraints of time and resources that EDs have. I am pleased that The Joint Commission is considering this vital matter. 27 May 08 18:01 | DianeRiibe said...: Our organization is supportive of the Joint Commission adopting quality standards for Screening and Brief Intervention (SBI) in medical settings. We feel strongly that all adolescents should be screened for underage drinking in emergency departments, as well as inpatient and primary care settings. In Nebraska, patients aged 18 to 24 are the most likely age group to have alcohol in their system at the time of trauma center hospitalizations. Young people have the highest binge drinking rates, and often seek treatment in the emergency department. Brief interventions have been shown to reduce drinking and its negative consequences among adolescents. We understand that time constraints and limited resources are often a concern in medical settings; however, this is an initiative that is both cost-effective and has the potential to prevent further injuries and save lives. Diane Riibe, Executive Director Project Extra Mile 23 May 08 13:55 | HollyDelaney said...: I have been involved with the SBIRT study in Washington state for four years both as a Screener providing brief intervention and a brief therapist offering follow-up services. The logic of implementing screening and brief interventions in medical settings seems obvious – It is strange to think that it has taken so long to provide any mainstream attention and avenues for people with substance issues. It is somewhat like not screening blood pressure until someone has a stroke or a heart attack. By not asking about substance use in medical settings, the covert message is, “Don’t tell.” This only increases the significant stigma and marginalization surrounding substance abusers, and results in postponing treatment and increasing social costs on every level. Even non-users benefit in becoming more aware of substance abuse as a health issue. The opportunity to open a dialogue with those who have family members or friends with substance issues is another side benefit from this type of intervention. Further, the knowledge gained by the medical community and providers as they uncover and become more familiar with the links and overlaps contained in this multi-faceted problem also offers substantial benefits and opportunities in setting and implementing health care policies and approaches. Medical education and intervention for substance abusers is long overdue. It is also important to maintain and expand alternative treatment options, brief therapy being key among them. I strongly support any actions that mandate AND fund these important services.... 22 May 08 16:38 | DianeShannon said...: As a Wasbirt counselor for three years in an emergency department setting, I strongly support this initiative. I have had the opportunity to approach patients at a teachable moment regarding prevention, brief intervention, harm reduction and early detection/referrals for at-risk patients. Through motivational interviewing one is able to raise awareness which initiates change. 22 May 08 12:00 | DulceRodriguez said...: I agree, SBI services should be a requirement at all hospitals. This past year I have had the opportunity to work with CASBIRT in San Diego. I am a Health Educator Supervisor and I am screening patients in the Trauma, Burn unit department and ED at two different hospitals and one clinic. I can say from first hand experience that these services are very beneficial and needed everywhere. Doctors, nurses, other health care workers and patients are very appreciative of these services, especially when I am able to make referrals. Many patients I have spoke to who had substance abuse problems in the past have expressed to me that they wished that the program was there in their time of need. The information I provide to the patients provides awareness and also help for the patient or their families. SBI services are not only cost-effective, but very helpful in the community. 21 May 08 20:21 | GailFernandes said...: I have a dual role as I am involved with SBI at our local Community College (Bristol Community College)from a data point of view but I am so a Substance Abuse Counselor at a Outpatient Mental Health Clinic that works with a College on this grant using the SBI. The screening was used along with the AUDIT and DAST. It was amazing the response we received from students and those that welcome the help from staff and counselors. We also used Motivational Interviewing which we feel also helps to engage people. I saw it as such an asset to the counseling center and health clinic at the campus. Helping to educating anyone to how drugs can affect their lives is always a good thing! For me I see it as such a valuable tool because it opens the door to discussion then to possible treatment if so needed. I can only hope that this can be used more often in ER rooms along with MI(motivational interviewing) for as we all know, not everyones approach to patients with substance abuse, addiction, or the potential for either is always empathic, non blaming, non judging. 21 May 08 17:39 | LeighFischer said...: Over the past year, SBIRT Colorado has assisted a variety of clinics and hospitals across our state in implementing screening and brief intervention procedures. Overall we have encountered minimal barriers in trying to implement change in large healthcare settings, in part due to expectations from the American College of Surgeons and the recent release SBI billing codes. Data has demonstrated that screening and brief intervention reduces morbidity and mortality related to the misuse of alcohol, and points to the tremendous costs that are saved due to prevention and early intervention. Similarly, anecdotes shared by providers, health educators, administrators, and patients in Colorado indicate that screening and brief intervention is changing lives and saving costs. It seems that for too many years, providers have grappled with how to identify and assist their patients who are using alcohol and other substances at risky levels. Routine screening and brief intervention offers a time-efficient and cost-effective solution. If we hope to continue to prevent and reduce injury and illness caused by alcohol, tobacco, and other drugs, healthcare facilities need to implement policies and standardized procedures for screening patients and for providing brief interventions when needed. SBI protocols are more likely to be integrated and sustained through support and accreditation standards established by the Joint Commission. | |
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