Do you screen patients for alcohol abuse?

When a 53-year-old janitor was brought to an ED after a motor vehicle accident, his examination revealed acute alcohol intoxication. The man was reported as an impaired driver and was referred to a program where he successfully obtained treatment.

This success story illustrates the dramatic impact that a simple screening and intervention for alcohol abuse can have in the ED, says Laurie Flaherty, RN, MS, an ED nurse at Suburban Hospital in Bethesda, MD, and traffic safety consultant with the Washington, DC-based National Highway Traffic Safety Administration (NHTSA).

However, Flaherty acknowledges that many ED nurses remain skeptical. "That’s because the only patients we see are those who "flunk." If they solve their problem, we never see them again," she says. She notes that ED nurses tend to "believe what they see. If injury prevention works, the direct result is the complete opposite — the absence of the injuries we are working to prevent," she says.

Flaherty says that awareness of current research is the best way to overcome skepticism, and she points to one study showing that 24% of patients who presented to an urban ED by ambulance were alcoholic,1 and another study’s findings which showed that patients with mild to moderate alcohol problems can be helped through brief screening and intervention in the ED.2

"Research shows that for most people with alcohol use problems who aren’t truly dependent yet, brief intervention works and they never progress to dependence," she says. "They never need treatment if we can get to them before they are truly alcoholics."

Here are effective ways to assess for alcohol abuse:

• Screen patients at risk for developing a problem.

Flaherty recommends screening of patients who are likely to develop an alcohol use problem, in addition to patients who already have an obvious problem. "The earlier we interrupt the continuum in the development of alcohol use problems, the greater the chance that we’ll be able to positively change behavior," she explains. (To see an ED screening tool for problem drinkers, click here).

Flaherty notes that patients who already have developed alcohol dependence are easily identified. These are the "frequent fliers" who come in with extremely high blood alcohol levels, in delirium tremens, and various health complications related to alcohol dependency, she says. However, it’s not as easy to recognize patients who are developing an alcohol use problem, says Flaherty. These include younger patients who come in after a binge, and patients who are making their first ED visit subsequent to alcohol abuse, she says. "I think we tend to equate the first ED visit with the first time these patients drink too much. In reality, by the time they show up on our doorstep, it’s already a problem," says Flaherty.

Many times the ED visit is a sentinel event, signaling that the problem has moved to another level, says Flaherty. "As emergency nurses, we should take advantage of the opportunity to screen and refer these folks for treatment," she urges.

• Don’t assume screening will take too much time.

Both screening and referral can be routinely accomplished in fewer than 10 minutes, according to Flaherty. She adds that you routinely screen patients for other health risks, such as heart disease. "We would never think of discharging a newly diagnosed patient with hypertension without some kind of patient teaching," Flaherty says. "Yet we do it all the time with patients who have alcohol use problems."

She says that alcohol has a huge impact on the ED, as a contributing factor to motor vehicle injury, domestic abuse, violence, self-injury, and numerous health problems. "Yet, we do very little when the opportunity presents to do something," Flaherty says.

Flaherty recommends using a screening and referral tool for use in the ED, such as the one developed by the Dallas-based American College of Emergency Physicians (ACEP). The ACEP kit contains a small laminated card with the screening questions, she says. (See "Sources and resources" at the end of this article for ordering information.)

• Ask social workers to watch for red flags.

Social workers at Harborview Medical Center continuously monitor the tracking board, which lists a patient’s chief complaint, along with results of blood-alcohol tests and urine toxicology, says Bonnie Conley, MSW, social work supervisor for the ED at Harborview Medical Center in Seattle.

She points to chief complaints that may indicate alcohol abuse: seizure, found unconscious, out of control, decreased level of consciousness, and altered mental status. If Conley suspects alcohol abuse, she consults with the ED nurse to determine the need for involvement. She cites the following red flags for alcohol abuse: irritability, anxiety, limited memory, and lifestyle disruption such as job loss or poor relationships. "Patients often minimize the impact on their life, despite evidence that things are messed up," she notes.

References

1. Whiteman PJ, Hoffman RS, Goldfrank LR. Alcoholism in the emergency department: An epidemiologic study. Acad Emerg Med 2000; 7:14-20.

2. Hungerford DW, Pollock DA, Knox TH. Acceptance of emergency department-based screening and brief intervention for alcohol problems. Acad Emerg Med 2000; 7:1,383-1,392.

Sources and resources

For more information about alcohol screening in the ED, contact:

Bonnie Conley, MSW, Emergency Department Social Work Supervisor, Harborview Medical Center, 325 Ninth Ave., Box 359760, Seattle, WA 98104. Telephone: (206) 731-1539. Fax: (206) 731-8652. E-mail: conley@u.washington.edu.

Laurie Flaherty, RN, MS, Office of Communications and Outreach, US DOT/NHTSA, 400 Seventh St., S.W., NTS-22, Room 5119, Washington, DC 20590. Telephone: (202) 366-2705. Fax: (202) 366-6916. E-mail: Laurie.Flaherty@nhtsa.dot.gov.

An Alcohol Screening and Brief Intervention Resource Kit is available with information about screening and brief intervention for patients presenting to the ED with alcohol problems. Screening tools and a template for locating community resources are included. The kit can be accessed on the American College of Emergency Physicians (ACEP) web site (www.acep.org) at no charge (Click on "Practice Resources," then "Alcohol Screening and Brief Intervention in the ED." Or to obtain a paper copy, contact ACEP Customer Service Department (ask for product 409036). Telephone: (800) 798-1822, ext. 6. E-mail: customerservice@acep.org.

A report, Developing Best Practice Standards of Emergency Medical Care for the Alcohol Impaired Patient, addresses screening and brief intervention for alcohol problems in the ED, measuring alcohol levels, and reporting impaired drivers. To order the report (Report No. DOT HS 809 281) contact: Print and Graphics Team, NTS-21 National Highway Traffic Safety Administration, 400 Seventh St., S.W., Washington, DC 20590. Telephone: (202) 366-2590. Or the report can be accessed at no charge from the NHTSA web site (www.nhtsa.dot.gov). Click on "Traffic Safety Occupant Issues," then "Injury Prevention," then "Impaired Driving (Alcohol and Drugs)," and scroll down to the report title.