Nurse Advocacy for SBIRT Policy in the ED

Abstract

Alcohol related injuries and deaths are preventable.  Given the unique opportunity emergency department (ED) nurses have to interact with many of those injured in alcohol related traumas, as well as the large number of patients one interacts with in a single shift, ED nurses can greatly influence patient’s future choices regarding alcohol intake and consequentially, the adverse events caused by hazardous alcohol consumption.  Endorsed by the Center for Disease Control and Prevention (CDC), National Institute for Alcohol Abuse and Alcoholism (NIAAA), and the Substance Abuse and Mental Health Services Administration (SAMHSA), screening, brief intervention and referral to treatment (SBIRT) has been shown to be effective when used by ED nurses.  Several studies will be discussed, which show great promise for ED implementation of SBIRT as well as the most common opposing viewpoint, which is, that while promising, SBIRT needs to be studied more.  Indeed, SBIRT could be studied more but the evidence for its effectiveness shows enough promise and the intervention is so simple, implementation should not be delayed for future studies, rather each new implementation could be used as a new study.  The interventions proposed by SBIRT implementation will be discussed, and finally how nurses can advocate for the policy enactment of SBIRT screening in one’s ED, and every area of nursing.

Key Words: SBIRT, screening brief intervention and referral to treatment in the emergency department, nurse led SBIRT, SBIRT health policy advocacy, alcohol abuse prevention

Nurse Advocacy for Screening, Brief Intervention and Referral to Treatment (SBIRT) Policy in the Emergency Department

Introduction to Health Policy

According to the Department of Health and Human Service’s January 2015 publication, an average of six people die of alcohol poisoning in the United States every day.  Excessive alcohol use contributes to 88,000 deaths per year in the United States and in 2010 cost the U.S. $249 billion dollars. Much of the general population is ignorant of what constitutes binge drinking and a 90% percent of binge drinkers are not alcohol dependent.  Thirty-eight million adults binge drink in the U.S. about four times per month consuming an average of eight drinks per binge (National Center for Chronic Disease Prevention and Health Promotion: Division of Population Health [CDC], 2015).

There are life-saving measures that must be realized in every community to reduce these truly sobering statistics. Nurses are the largest group of healthcare providers in the United States (American Nurses Association [ANA], 2011) and it is a moral obligation to advocate for health policy enactment to prevent alcohol related illnesses and deaths.  The damaging effects of excessive alcohol consumption carries grave personal meaning, having been a vessel of its many detriments.   Without personal intervention and referral to treatment much more serious and irreversible harms would have ensued at incalculable personal expense.

Thankfully, there are sufficient evidence-based interventions being practiced that demonstrate a significant decrease the incidence of binge drinking when effectively employed.  SBIRT (screening, brief intervention, and referral to treatment) is one such strategy, endorsed as an effective countrywide health promotion and illness prevention policy by the National Institute for Alcohol Abuse and Alcoholism (NIAAA).  SBIRT is recommended for implementation at every intersection of patient care across the lifespan.  Unique occasions exist for ED nurses due to the high incidence of alcohol related visits and alcohol associated traumas, injuries and deaths.  Even if alcohol was not the reason for the ED visit, all patients should be screened.  The sheer number of patients seen in an ED provides an incredibly broad base for prevention of alcohol related injuries.  Ideally, SBIRT is integrated as a public health priority within the community as an early intervention to prevent the many adverse effects of binge drinking and alcohol abuse.   The nursing profession sees first-hand the effects of alcohol misuse, which provides the unique ability to impact thousands of patients if SBIRT is implemented in emergency departments nationwide.  Not only is this system simple and straight forward, it can be used by nurses within the inpatient, outpatient and community setting as well.

Policy Overview

In this section, we will discuss how the implementation of SBIRT in the ED would greatly decrease the incidences of harmful alcohol consumption.  Several studies citing the efficacy of SBIRT will be discussed as well as studies in disagreement with SBIRT’s effectiveness.  The interventions proposed by SBIRT implementation will be explored in greater detail and finally, steps that nurses can take to advocate for SBIRT policy enactment in their own workplaces and areas of influence within the healthcare system.

Several studies show significant decreases in alcohol consumption with patients that received a brief intervention and referral to treatment after screening positive for risky alcohol behavior in the ED.   A study conducted by The American Surgeon demonstrated a quality improvement program’s success for implementing SBIRT for trauma patients, resulting in nine out of 10 patients screened and receiving appropriate treatment one year post discharge (Thomas et al., 2016) Consequentially, all level I and level II trauma centers require SBIRT to maintain accreditation (Thomas et al., 2016).

Yale University School of Medicine professors Gail D’Onofrio and Steven L. Bernstein reviewed the literature on SBIRT implementation in the ED and strongly recommend its adoption, urging healthcare providers to see ED visits as an invaluable opportunity to positively influence patients who may otherwise receive no other care (2013). In an additional study by D’Onofrio and coauthors, 740 patients who visited the ED as result of harmful drinking received an intervention, which decreased their incidence of hazardous drinking at one year by four drinks per week, reduced the episodes of monthly binge drinking, as well as occurrences of driving while intoxicated (D’Onofrio et al., 2012).

The Journal of Emergency Nursing’s 2010 quasi-experimental study on SBIRT efficacy showed a 70% decrease in alcohol consumption in the patients who received interventions versus only a 20% decrease in the non-intervention group (Desy, Howard, Perhats, Li, &, 2010).   The Journal of Substance Abuse Treatment compared cost and effectiveness of SBIRT in the ED setting versus the outpatient setting (Barbosa, Cowell, Bray, & Aldridge, 2015).   The study found ED patients decreased their drinking to below threshold or abstinence by %13.8 more than those in the outpatient setting, with mean net cost savings of $531.74 per SBIRT patient in the ED and $271.95 savings for outpatients (Barbosa et al., 2015).  This supports Bernstein and D’Onofrio’s position that the emergency department is an invaluable place to conduct SBIRT (Bernstein & D’Onofrio, 2013).

In addressing opposing viewpoints, it is relevant to mention that no literature outright opposes SBIRT implementation in the ED or otherwise, only states that further studies should be conducted to absolutely confirm its efficacy.  As stated by Glass and coauthors in the Society for the Study of Addiction, brief interventions show great promise as a method for linking high risk individuals to alcohol treatment, yet their conclusion articulates a need for more convincing data and suggests exploring possible adjustments to the brief intervention methods presently used (Glass et al., 2016).  All articles discussed in this paper agree with Glass and coauthors and also encourage additional studies to prove SBIRT efficacy. Although alcohol related injuries and deaths may never be fully eradicated due to the nature of free will, SBIRT ED policy execution will drastically lower the percentage of alcohol misuse.

The interventions proposed by SBIRT in the emergency department are as follows: provide a standardized screening method, provide a brief intervention (empathetic listening and motivational interviewing), and if necessary refer the patient to treatment. The interventions provided in a Journal of Emergency Nursing study were as follows; nurses were trained to conduct SBIRT, patients with a positive screening were given a brief intervention consisting of five to ten minutes of motivational counseling, provided with educational brochures and a community resources list where further treatment could be found (Desy et al., 2010). The educational piece of SBIRT should include the NIAAA standard drink size as well as what constitutes binge drinking (National Institutes on Alcohol Abuse and Alcoholism, 2005).  The Joint Commission (TJC) as well as the Substance Abuse and Mental Health Services Administration (SAMSHA) are in agreement with SBIRT implementation and jointly agree on the importance of a final step, following up with patients after discharge (The Joint Commission, 2012).

The ENA has joined with TJC, NIAAA, the CDC and SAMSHA in their SBIRT Joint Position Statement imploring nurses of all specialties to advocate for this worthy cause (2013).  As a professional nurse in the ED, advocacy for SBIRT is available on the ENA website.  For example, the ENA has a Joint Statement with the International Nurses Society on Addictions calling for nurses to be prepared to deliver SBIRT effectively, hospital investment in training, RN involvement in research and effectiveness of these interventions and to expand current curricula of bachelor, graduate and continuing education on delivering high-quality care to patients with substance abuse (Emergency Nurses Association [ENA], 2013).  The ENA website has toolkits for SBIRT implementation and free online training for staff nurses and managers for this policy (ENA, 2013). Training fellow nurses and physicians and being aware of the community resources available to one’s institution is a personal responsibility of every nurse.  Advocating for such a simple, brief intervention with such life-saving results is an absolute must for all registered nurses.  SBIRT is an easily translatable framework to any area of nursing and should becoming a standard part of every nursing assessment.

Conclusion

In conclusion, screening for alcohol misuse, providing brief interventions and referral to treatment is an efficient health promotion and illness prevention policy that is cost effective and takes little time and effort in comparison with its positive results.  Although many providers may believe that this kind of policy would be ineffective due to a jaded mentality, personal experience and the available data prove otherwise.    More research should continue to be conducted regarding SBIRT efficacy in the ED and elsewhere but should not delay its implementation. One should never underestimate the teachable moments in the emergency department and never take for granted the short window one has to positively influence a life.  Taking responsibility to implement an SBIRT policy in the ED should be a top priority for emergency department nurses and nurses of all specialties should consider translating this research to their area of expertise.

 

References

American Nurses Association. (2011). Fact sheet. Retrieved from http://nursingworld.org/NursingbytheNumberFactSheet.aspx

Barbosa, C., Cowell, A., Bray, J., & Aldridge, A. (2015, January 6). The cost-effectiveness of alcohol screening, brief intervention and referral to treatment (SBIRT) in emergency and outpatient medical settings. Journal of Substance Abuse Treatment, 53(1), 1-8. Retrieved from http://dx.doi.org/10.1016/j.sat.2015.01.003

Bernstein, S. L., & D’Onofrio, G. (2013, December). A promising approach for emergency departments to care for patients with substance use and behavioral disorders. Health Affairs, 32(12), 2122-2128. Retrieved from http://search.proquest.com.ezproxy2.library.drexel.edu/nahs/docview/1467750007/20E99E3EC26348EFPQ/8?accountid=10559

Desy, P. M., Howard, P. K., Perhats, C., & Li, S. (2010, November). Alcohol screening, brief intervention, and referral to treatment conducted by emergency nurses: An impact evaluation. Journal of Emergency Nursing, 36(6), 538-545. Retrieved from http://dx.doi.org/10.1016/j.jen.2009.09.011

D’Onofrio, G., Fiellin, D. A., Pantalon, M. V., Chawarski, M. C., Owens, P. H., Degutis, L. C., … O’Connor, P. G. (2012, August 8). A brief intervention reduces hazardous and harmful drinking in emergency department patients. Annals of Emergency Medicine, 60(2), 181-192. Retrieved from https://www-clinicalkey-com.ezproxy2.library.drexel.edu/ – !/content/playContent/1-s2.0-S0196064412001515

Emergency Nurses Association. (2013). SBIRT joint position statement. Retrieved from https://www.ena.org/SiteCollectionDocuments/Position Statements/Joint/ExpandedRolesResponsibilities.pdf

Glass, J. E., Hamilton, A. M., Powell, B. J., Perron, B. E., Brown, R. T., & Ilgen, M. A. (2016, January). Revisiting our review of screening, brief intervention and referral to treatment (SBIRT): Meta-analytical results still point to no efficacy in increasing the use of substance use disorder services. Society for the Study of Addiction, 111(1), 179-183. Retrieved from http://onlinelibrary.wiley.com.ezproxy2.library.drexel.edu/doi/10.1111/add.13146/abstract

National Center for Chronic Disease Prevention and Health Promotion: Division of Population Health. (2015). CDC Vital signs: Alcohol poisoning deaths: A deadly consequence of binge drinking. Retrieved from http://cdc.gov/vitalsigns

National Institutes on Alcohol Abuse and Alcoholism. (2005). Helping patients who drink too much: A clinician’s guide. Retrieved from https://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

The Joint Commission. (2012). Substance abuse. Retrieved from http://www.jointcommission.org/substance_abuse

Thomas, P., Seale, P. J., Johnson, A. J., Dhabliwala, J., Kitchens, D., Okosun, I. S., … Ashley, D. (2016, May). Impact of a quality improvement intervention to increase brief alcohol and drug interventions on a level I trauma service. The American Surgeon, 82(5), 468-473. Retrieved from http://www.library.drexel.edu/cgi-bin/r.cgi/login?url=http://search.proquest.com/docview/1792166058?accountid=105

 

 

 

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