Alcohol and Alcoholism Advance Access originally published online on August 2, 2007
Alcohol and Alcoholism 2007 42(5):430-435; doi:10.1093/alcalc/agm052
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Simple advice for injured hazardous drinkers: an implementation study
1 Agència de Salut Pública de Barcelona, Spain
2 Ciber en Epidemiología y Salud Pública CIBERESP, Spain
3 Fundació Clínic, Barcelona, Spain
4 Hospital de St. Pau, Barcelona, Spain
* Author to whom correspondence should be addressed at: Agència de Salut Pública de Barcelona, Pl Lesseps, 1, 08023-Barcelona, Spain. Tel: 34 93 202 77 05; Fax: 93 292 14 44; E-mail: amartos{at}aspb.es
Received 2 April 2007; in revised form 29 May 2007; accepted 31 May 2007
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ABSTRACT |
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Aim: To evaluate the implementation of a screening and intervention procedure for hazardous drinkers in the routine praxis of an emergency service, without increasing the ED (emergency department) staff. Methods: Four stages of the implementation process were undertaken: exploration and adoption, programme installation, and initial implementation. Two hospitals participated, with a coordinator, four trainers and all the emergency nursing staff. Eligible patients were males over age 15 presenting at the weekend with a traffic injury. Screening was performed with five questions (the three items of alcohol use disorders identification test (AUDIT-C) plus two questions about drinking within 6 h before the crash). Hazardous drinkers and drivers who had driven while intoxicated were offered simple advice. The programme implementation was evaluated by reviewing the patients' forms and by interviews and surveys of the nursing staff. Results: The study lasted for 27 weeks. Knowledge and compliance with the programme were good. However, only 25% of the eligible patients were identified. Simple advice was accomplished by 94.7% of those in need of it. Although the majority of nurses felt at ease performing the intervention, 75% considered the programme as a work overload and only 21% reckoned that it was feasible for the emergency service. Conclusion: The emergency setting poses important barriers to the implementation of brief interventions.
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Introduction |
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Alcohol is an important risk factor for all types of injuries, among them those derived from motor vehicle crashes (MVC). Patients attending emergency services because of injuries are more likely to have a positive blood alcohol concentration than the non-injured ones. Drinking and driving constitutes the main indicator of hazardous drinking.
In Spain, 37.4% of fatalities among drivers and 35.2% among pedestrians, had a positive blood alcohol concentration (BAC) in 2003 (Delegación del Gobierno para el Plan Nacional sobre Drogas, 2005
). To curb MVCs and related injuries and deaths, has become a governmental priority. The latest traffic safety measure is a penalty points system (Law 17/2005 of 19 July 2005, enforced from 1 July 2006).
Emergency departments and trauma centres are in a privileged position to screen and intervene on alcohol-related casualties. Screening and brief intervention (SBI) has proven to be cost-effective, even in the form of a simple advice. Brief motivational interviewing was found to be effective in a recent meta-analytic review (Vasilaki et al., 2006).
Screening is especially effective at care settings where patients are likely to present with injuries (National Institute on Alcohol Abuse and Alcoholism, 2006) and young adults seem to benefit the most from motivational interviewing (Vasilaki et al., 2006). The post-traumatic period may present a teachable moment (Waller, 1990), suitable for an intervention, and the injury becomes a motivational factor for change (Longabaugh et al., 1995).
In the largest study of brief intervention in the emergency department, counselled patients had accrued fewer alcohol related injuries and fewer negative consequences at 1 year. In this study, patients injured in MVC had even better outcomes after an intervention than other injured patients (Mello et al., 2005). MVC casualties might benefit both from brief motivational intervention as well as from simple advice, as shown in some randomized controlled trails (Rodríguez-Martos et al., 2006; Sommers et al., 2006). Moreover, patients' attitudes towards alcohol screening and advice by their physicians are mostly positive (Hungerford et al., 2003; Sise et al., 2005; Miller et al., 2006), even at the emergency room (Rodríguez-Martos et al., 2006). Nevertheless, most trauma and emergency services around the world do not use the opportunity that the injury represents to tackle the alcohol issue with the patient.
The European Commission recommends promoting brief intervention also at emergency settings, but the routine implementation of SBI is difficult, especially in emergency departments (EDs). Implementation rates are low and will probably remain so because of several hindrances, such as lack of time, inadequate space, lack of training, and negative attitudes towards alcohol problems.
The lack of interest in addressing alcohol problems is quite common among ED staff and trauma surgeons (Cryer, 2005; Cherpitel, 2006) and even among trauma surgeons (Schermer et al., 2003), who are not under the same time pressure as the emergency setting. Some of the explanations can be: the invalid assumption that the target population comprises hardcore alcoholics (Cryer, 2005); being unaware of what a hazardous drinker means; not feeling capable or adequate to intervene in alcohol problems; scepticism about the effectiveness of SBI; and believing that the intervention intrudes upon the patient's privacy and will be refused; fear of legal problems; or lack of reimbursement. On the contrary, the most potent predictors for the physicians to support SBI are: thinking that patients with alcohol problems should be referred; that trauma centres are appropriate for SBI; understanding the concept of SBI; and the belief that the procedure would not be too costly (Schermer et al., 2003). However, positive attitudes towards SBI do not seem to be sufficient. Ordinary staff participating in routine screening and intervention procedures and having improved their competence and role legitimacy, were still doubtful of the adequacy of ED for implementing this preventive strategy (Nordqvist et al., 2006). This was also the opinion of nurses participating in a previous study on SBI effectiveness performed in Barcelona (Rodríguez-Martos et al., 2005).
Although more studies are needed so as to have better evidence of the efficacy of SBI at the ED (Cherpitel, 2006), comprehensive implementation studies are warranted in order to gain an insight into the real possibilities and best strategies for implementing such an intervention tool in daily practice before spreading it. Up to now, acceptability and feasibility studies have mostly (Hungerford et al., 2000; 2003) used hired, full dedicated staff to perform SBI. Sise et al. (2005) also added hired and trained health educators for their successful implementation study. No ‘pure implementation study’, using the regular and trained staff has been performed at the ED, as far as we know, although the feasibility of SBI in a trauma centre, was positively evaluated, provided that it was committed to its implementation (Schermer, 2005).
The implementation perspective is crucial for any strategy, because the most effective programme would not help if it is not properly used. Furthermore, we have to know what the main factors involved in the success or failure of the implementation are at each setting in order to overcome hindrances or maximize benefits.
The aim of this study was to evaluate the implementation of a screening and intervention procedure for hazardous drinkers in the routine practice of an emergency service.
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Methods |
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The methodology of this study was inspired by Fixsen et al. (2005
) literature on implementation research. The first three stages of the implementation process (exploration and adoption, programme installation and initial implementation) were undertaken.
- Exploration: The draft project was in line with the Municipal Action Plan on Drugs of Barcelona, and a grant was obtained to fund implementation. Four hospitals were contacted and support was found at two hospitals, which agreed to participate and implement the protocol. Support material was drafted.
- Installation of the programme: Staff selection and staff training are core implementation components (Fixsen et al., 2005). Each hospital selected as project coordinator the chief nurse of the emergency service. Eight nurses (four at each hospital) were then selected as trainers because they were supervisors or interested in prevention work. These eight nurses were trained as trainers in an eight-hour course on SBI, emphasizing practice and including role playing by a researcher trained in motivational interviewing. Afterwards, they filled in a post-training questionnaire made up of ten items, scored by a Likert scale (0–3), to evaluate their satisfaction with the course. Those trainers subsequently trained the ED nursing staff (2–4 h) under the supervision of a researcher, who scored the quality of the content, the pedagogic skills and the adequacy of responses to the trainees' questions, by five items also scored by a Likert scale (0–3).
- Initial implementation: Under the clinical protocol of the study (Fig. 1), the ED nursing staff delivered the SBI to eligible patients (over 15-year-old males injured in an MVC at the weekend). This target was selected for fitting the profile with the most probability of being BAC positive, as shown in a previous study (Rodríguez-Martos et al., 2006). Under the protocol, hazardous drinkers or those who had driven while intoxicated were given simple advice. Screening was performed with five questions (the three alcohol use disorders identification test (AUDIT-C) items plus two questions about alcohol consumption in the 6 h prior to the crash). Exclusion criteria were severe physical, psychiatric or social problems, as well as acute intoxication. Criteria for intervention were being AUDIT-C positive:
5, in men, in the Spanish version (Gual et al., 2002) or having driven while intoxicated. In both cases, the patient received advice on risk levels of drinking and about drinking and driving, plus an information leaflet. A data collection form was filled in by the nurse for each patient, with demographic data, information on the screening and on the intervention delivered.
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Staff coaching, evaluation and fidelity are core implementation components The staff was coached by a researcher (supervision of the procedure, assessment and continuing teaching and emotional support, carried out in regular interviews). A contact with the coordinators was maintained throughout the project. Initial implementation was finally evaluated: The number of eligible patients who had attended the hospital at the weekend were reported weekly by the hospital, and compared with the number of the patients included in the corresponding period (implementation degree). The context of the programme was explored through five questions, which could be answered with sufficient, partially sufficient or insufficient. The fidelity to the model (knowledge and compliance with the protocol) was explored by two supervision questionnaires of five questions each, scored from 0 to 2, depending on how correct the answer was.
The information about patients was collected on a specific form including: Age, date and time of crash and of assistance, professional who did the intervention, main injury diagnosis, traffic position and score and answers to AUDIT-C and to the 2 driving while intoxicated (DWI) questions. The completed forms of each patient were also checked by researchers to see if they were properly filled in. A descriptive statistical analysis of these data was performed based on percentages and means. The statistical significance of the differences in the bivariate analysis was evaluated by the Chi-square (qualitative variables) and the Kruskal–Wallis test (quantitative variables). P values under 0.05 were considered significant.
The final opinion of the participating staff was collected by an opinion survey.
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Results |
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Four hospitals were contacted, but finally only two agreed to participate. Refusals were justified because of changes in hospital organization in one case, and for building works at the emergency service and space constraint, in the other.
The eight selected trainers were satisfied with their training and all were self-confident about their capability in performing the intervention (83.3% agreed to a great extent and 16.6%, totally agreed) and their skills for training the staff (50% agreed to a great extent and 50% totally agreed). These trainers trained all the ED nursing staff in both hospitals (79 nurses) with a mean dedication of 2–4 h. Training was uneven between hospitals and depended on the trainer, but it was mostly at a good level: The quality of the content, the pedagogic capabilities and the skills to give adequate responses were satisfactory in 80% of cases. Role playing was not always performed.
Evaluation of the programme Context was evaluated both by the participating staff and by the researcher, who realized that the two hospitals had trouble in delivering the SBI. The project was well designed but not always accomplished. Although all nurses were theoretically participating, the intervention seemed to be repeatedly performed by only some of them. Some forgot to put their names on the form, which made their identification impossible. Those identified (28) could be supervised. The space was considered sufficient by 78% of them; prior training was considered sufficient by 79.5%, whereas the available time was considered as partially sufficient (61%) or insufficient (29%), although SBI only took an average of 10 min. Nurses (96%) felt backed up by their hospital trainer, but the internal support (interest and backup by the emergency staff) was mainly considered insufficient (82.5%).
The implementation degree was lower than expected. A quarter of eligible patients were identified. Ninety percent were screened and 38% received a completed intervention. Simple advice was delivered to 94.7% of those in need of it (Fig. 2). Implementation was quite irregular over the 27 weeks of patients' recruitment (Fig. 3), with an unplanned break in July, justified by the hospitals because of the summer holidays (most trainers were on holiday and the replacement staff were seldom trained).
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The patients' profile They had a mean age of 29.4 years, and 77% were drivers. Nearly a third of them scored positive in AUDIT and 25% had driven while intoxicated. Both risk criteria (positive in AUDIT-C and DWI) appeared in 12% of patients. There was a significant relationship (P < 0.001) between a positive AUDIT-C and consumption before driving (Table 1). Among AUDIT-C positive patients, those who drove under the effects of alcohol scored significantly more than those who did not (Table 2). There were no significant differences hospital-wise.
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Fidelity to the programme The nursing staff had good knowledge of the programme (mean score of 9, within a range of 0–10) and also a good compliance with the protocol (9.35 within a range of 0–10). There were no differences hospital-wise.
The overall final opinion of the participating nurses identified, was collected by a survey and completed by 24 (85.7%) of them (Table 3).
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Discussion |
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This study is the first to explore the implementation process of SBI at a Spanish emergency department. It is also one of the few research projects counting only on regular staff, thus reflecting the feasibility of SBI in real conditions. Intervention was offered to adult males injured in an MVC on weekends.
Although the Spanish health and traffic authorities are interested in promoting SBI, hospitals do not find it so easy to perform. Two of the four contacted hospitals found it impossible to collaborate because of current infrastructure problems. Beyond the practical difficulties, prevention does not seem to be a priority to managers and most ED professionals. This attitude seems to be especially prevalent among emergency physicians. Beyond the barriers mentioned in the literature (Schermer et al., 2003; Cryer, 2005; Cherpitel, 2006), this might be explained because, in Spain, prevention programmes at a hospital level, are almost always led by the nursing staff. This fact, together with the always hectic rhythm of emergency settings, could explain why EDs do not prioritize preventive activities.
The training of staff enables detection and advice (Touquet, 2006). Ordinary staff have been used in a few studies (Nordqvist et al., 2006; Rodríguez-Martos et al., 2006). Other studies have used hired nurses (Sommers et al., 2006), which makes the research easier, but does not help an implementation study. An alternative to training the nursing staff is to employ an ‘alcohol health worker’ (Barret et al., 2006), a professional especially trained and hired for this task, or a trained half-time research assistant, in the case of a trauma centre (Schermer, 2005). Another alternative might be a telephone intervention; Di Giuseppi et al. (2006) have successfully implemented a telephone screening among injured patients seen in acute care clinics. Mello et al. (unpublished) are using telephone intervention for prevention of DWI and MVC. A telephone SBI would be an alternative to consider in the future. Training trainers was not a problem in this study; key information and skills could be taught in 8 h. Longer training can be useful, but difficult for active nurses who sometimes have to devote extra time. The training of the staff by the trainer varied, not only depending on the prior training and personal skills, but also of the hospital circumstances which allowed trainers to devote more or less time as needed.
The implementation started well, but evolved irregularly. Even so, a quarter of eligible patients started the protocol, and advice was given to almost all those in need of it.
Most of the participating nursing staff felt capable of performing the SBI, and 50% thought that the patients welcomed the intervention, although half of the them were sceptical about its usefulness and reckoned that the available time and staff were insufficient for applying the procedure.
The high prevalence of alcohol problems in this study (38% of the sample at risk drinking or DWI) shows the need for implementing an SBI procedure at the ED, and altogether, for intensifying preventive approaches.
The main barrier hindering SBI is the hospital infrastructure (lack of time and professionals). These contextual factors turn any prevention work into a very demanding task, which cannot be done without considerable personal effort, commitment and rewarding support.
Limitations of this study are mainly the low number of cases and the few participants and supervised nurses. Halving the number of the foreseen participant hospitals meant a reduction in collected data and precluded a finer analysis. Another limitation could be the few hours devoted to the training of the nursing staff by hospital trainers, especially in one hospital, although their knowledge and compliance with the programme did not differ.
Full operation, innovation and sustainability, the last stages of the implementation process (Fixsen et al., 2005), will only be feasible once barriers, such as the lack of funding to allow adequate resources, are overcome, and a clear alcohol- and health-policy is available.
Time constraints always play an important role. Even in trauma centres with adequate beds and no overcrowding, ‘lack of time’ remains the main reason for not screening (Danielsson et al., 1999), despite the few minutes—around ten—needed for screening and intervention (Hungerford et al., 2003; Sise et al., 2005; Rodríguez-Martos et al., 2006).
In the present study, although core components of implementation have been carefully developed, contextual factors have hindered the proper implementation of the procedure.
Lessons to be learned from the experience are:
- the need to allocate enough resources to preventive work at the ED
- the need for widespread education in the effectiveness of SBI
- the need to find the easiest possible way of screening and intervening at the ED
- the need for commitment on the part of ED leaders and staff to enforce routines once screening and intervention is implemented.
Although the SBI expansion is promoted in Spain also at the emergency setting, there is still a long way to go before the achievement of a proper financed infrastructure and of a group of motivated key professionals, aware of the cost benefit of SBI, and ready to enable and promote it at the emergency and trauma setting. Meanwhile, we are only paving the way for it. While current barriers hinder routine implementation of SBI at the ED, external, complementary interventions might make the intervention easier and cheaper. Telephone SBI after the patient's discharge could be a profitable way of linking the injury with advice. A telephone consultant might cover several hospitals. The best way to recruit patients for such an intervention (at the clinic or directly by phone) (Di Giuseppi et al., 2006) and the effectiveness of telephone SBI deserves further investigation.
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ACKNOWLEDGEMENTS |
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The programme had a grant from the Catalan Traffic Service. The whole nursing staff of two main hospitals made the study possible. A special acknowledgment has to be paid to E. Gómez and C. Jover (coordinators), as well as to S. García, MJ Gracia, J Leal, S. Montforte, M. Prieto, Y. Pueyo, R. Salesa and C. Torres (staff trainers).
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References |
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