Attitude changes among emergency department triage staff after conducting routine alcohol screening

Combining Physician Expertise and Women's Lived Experience to Educate Health Professionals about Preventing Fetal Alcohol Spectrum Disorders

INTRODUCTION

Physician Champions from the American College of Obstetricians and Gynecologists (ACOG) and trained women Speakers from FASD United, who have given birth to a child with a fetal alcohol spectrum disorder (FASD), co-present to healthcare providers (HCPs) in medical residency programs as part of an educational intervention. They present FASDs as a biological and social problem surrounded by stigma that prevent pregnant women from talking openly to their HCPs about their alcohol use or alcohol use disorder (AUD) and getting the medical help they need.

METHODS

Semi-structured interviews were conducted with 10 ACOG Champions and nine FASD United Speakers and a thematic analysis assessed how the co-presentations can enhance HCPs' understanding about FASDs and address stigma associated with alcohol use during pregnancy.

RESULTS

Interview findings indicated that both Champions and Speakers emphasized the need for HCPs to be nonjudgmental and create a safe space for open dialogue. They reported that residents were moved by mothers' personal stories, wanted to understand AUD better, and asked about the type of help HCPs can offer women.

DISCUSSION

Combining physicians' expertise with mothers' personal stories of lived experiences of FASDs directed at residents, who are more reflective and open at this phase of their careers, moved them from a fact-based to an empathy-based approach to learning that is critical to address the stigma surrounding women who may be using alcohol or struggling with an AUD during pregnancy. Collaboration between national organizations allowed this intervention to be widely implemented across the country.

Acceptability Among Frontline Staff Toward Distributing an Anonymous Alcohol Survey in Emergency Departments: A Mixed Methods Study

ABSTRACT

Emergency departments (EDs) serve as the front line when patients encounter the hospital system. Limited data are available of patients' alcohol habits collected during Danish ED visits, and no studies have, to our knowledge, examined frontline staffs' (registered nurses and medical secretaries) acceptability to deliver anonymous alcohol surveys to patients. We aimed at examining the proportion of survey respondents and the prevalence of patients' alcohol habits and also exploring frontline staff acceptability of the distribution of an anonymous survey regarding patients' alcohol habits in EDs. Intendedly, all eligible patients ≥18 years old entering two EDs in March 2019 should receive a survey based on the Alcohol Use Disorder Identification Test. The study was an explanatory, sequential, mixed methods design, and results were analyzed with descriptive statistics and a deductive content analysis based on the theoretical framework of acceptability. In total, 15% (n = 1,305) of the total 8,679 patients in the EDs returned the survey. Qualitative analysis of interviews (n = 31) with staff showed that they had been reluctant to distribute the survey primarily because of ethical concerns of anonymity, freedom of choice, and being nonjudgmental toward patients. Hence, patients with no obvious alcohol problems were more likely to receive the survey. Still, we found that 23% of the respondents had an Alcohol Use Disorder Identification Test score ≥ 8. Results indicate that frontline staffs' recognition of patients' alcohol use is inadequate, and findings show a low degree of acceptability among staff to deliver an anonymous survey, which is in line with earlier described barriers toward screening activities in EDs.

Alcoholism and American healthcare: The case for a patient safety approach

Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioral health condition. The aims of this paper are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population. The authors performed a narrative review of the literature on the current state of AUD treatment and patient safety, finding extensive evidence that patients with AUD usually go undiagnosed, unreferred and untreated. When they do receive AUD treatment, little evidence was found to indicate that a patient safety approach is incorporated into their care. Behavioral medicine is virgin territory for the patient safety movement. Medical care and behavioral medicine in the United States currently constitute two separate and unequal systems generally lacking in pathways of communication or care coordination for AUD patients. Significant barriers include institutional culture, individual and systemic bias against those with AUD, and health care infrastructure, especially the separation of medical and behavioral treatment. It is the authors’ conclusion that care of patients with AUD is unsafe. We advocate for the patient safety approach common in American hospitals to be extended to AUD treatment. Experienced patient safety leaders are in the strongest position to initiate collaboration between the mainstream medical and substance abuse treatment communities to reduce harm for this patient population.

Emergency and Mental Health Nurses' Perceptions and Attitudes towards Alcoholics

Knowing professionals' attitudes is the basis for the development of skills for dealing with drug dependence. These attitudes may affect patients' clinical safety and the cost-benefit ratio of the interventions. The goal of this study was to assess emergency and mental health nurses' attitudes and perceptions towards alcoholics. A multicenter prospective descriptive study was conducted in six hospitals with 167 emergency and mental health nurses. Nurses classified alcoholics as sick individuals, although there was a tendency to feel uncomfortable working with them. Results indicated that these professionals had a rejecting attitude towards moderate alcohol consumption. It found that there was a significant association between the attitude of the nurse and gender, with the degree of rejection towards the alcoholic being higher in men than in women, and with less punitive attitudes in professionals with 0 to 11 years of professional experience.

Commentary on Blow et al. (2017): Leveraging technology may boost the effectiveness and adoption of interventions for drug use in emergency departments

The effect of brief interventions for drug use can depend upon the type and severity of substance use, as well as psychosocial stability and other variables. Innovative technology, such as the computer delivered or assisted approaches tested by Blow et al., should be used to support implementation of brief interventions by maintaining simplicity and enhancing efficiency.

Would brief alcohol intervention be helpful in facial trauma patients?A Narrative Review

Facial trauma is commonly associated with excessive consumption of alcohol and is often associated with interpersonal violence or motor vehicle accidents. Alcohol-related trauma presentation to hospitals causes a major service burden, and there have been efforts to reduce such trauma load with educational programs and social support. Brief alcohol intervention (BAI) in an acute setting (emergency department or trauma centre) has been shown as an effective means to reduce future alcohol intake and the incidence of future alcohol-related injuries, especially in the period immediately following injuries. Less is known about the potential benefit of BAI when provided by the surgical team in the same clinical context. This article explores the individual component of brief alcohol intervention and its provision by an acute surgical service by way of a narrative review. The progress of research into brief alcohol intervention for facial trauma patients is also reviewed. The methods and rationale behind screening patients for targeted BAI are discussed in a separate article.

Alcohol screening and brief interventions for adults and young people in health and community-based settings: a qualitative systematic literature review

BACKGROUND

Systematic reviews of alcohol screening and brief interventions (ASBI) highlight the challenges of implementation in healthcare and community-based settings. Fewer reviews have explored this through examination of qualitative literature and fewer still focus on interventions with younger people.

METHODS

This review aims to examine qualitative literature on the facilitators and barriers to implementation of ASBI both for adults and young people in healthcare and community-based settings. Searches using electronic data bases (Medline on Ovid SP, PsychInfo, CINAHL, Web of Science, and EMBASE), Google Scholar and citation searching were conducted, before analysis.

RESULTS

From a total of 239 papers searched and screened, 15 were included in the final review; these were selected based on richness of content and relevance to the review question. Implementation of ASBI is facilitated by increasing knowledge and skills with ongoing follow-up support, and clarity of the intervention. Barriers to implementation include attitudes towards alcohol use, lack of structural and organisational support, unclear role definition as to responsibility in addressing alcohol use, fears of damaging professional/ patient relationships, and competition with other pressing healthcare needs.

CONCLUSIONS

There remain significant barriers to implementation of ASBI among health and community-based professionals. Improving the way health service institutions respond to and co-ordinate alcohol services, including who is most appropriate to address alcohol use, would assist in better implementation of ASBI. Finally, a dearth of qualitative studies looking at alcohol intervention and implementation among young people was noted and suggests a need for further qualitative research.

Multidimensional attitudes of emergency medicine residents toward older adults

INTRODUCTION

The demands of our rapidly expanding older population strain many emergency departments (EDs), and older patients experience disproportionately high adverse health outcomes. Trainee attitude is key in improving care for older adults. There is negligible knowledge of baseline emergency medicine (EM) resident attitudes regarding elder patients. Awareness of baseline attitudes can serve to better structure training for improved care of older adults. The objective of the study is to identify baseline EM resident attitudes toward older adults using a validated attitude scale and multidimensional analysis.

METHODS

Six EM residencies participated in a voluntary anonymous survey delivered in summer and fall 2009. We used factor analysis using the principal components method and Varimax rotation, to analyze attitude interdependence, translating the 21 survey questions into 6 independent dimensions. We adapted this survey from a validated instrument by the addition of 7 EM-specific questions to measures attitudes relevant to emergency care of elders and the training of EM residents in the geriatric competencies. Scoring was performed on a 5-point Likert scale. We compared factor scores using student t and ANOVA.

RESULTS

173 EM residents participated showing an overall positive attitude toward older adults, with a factor score of 3.79 (3.0 being a neutral score). Attitudes trended to more negative in successive post-graduate year (PGY) levels.

CONCLUSION

EM residents demonstrate an overall positive attitude towards the care of older adults. We noted a longitudinal hardening of attitude in social values, which are more negative in successive PGY-year levels.

Brief interventions for hazardous and harmful alcohol consumption in accident and emergency departments

The prevalence of alcohol abuse among patients treated in accident and emergency departments (A&E) is considered as substantial. This paper is a narrative review of studies investigating the effectiveness of brief interventions (BI) for hazardous and harmful alcohol consumption in A&E. A&E departments in hospitals (and other health care infrastructures) are commonly the place where serious consequences of alcohol drinking are seen and need to be tackled, supporting the suggested theoretical usefulness of delivering BI in this environment. Available research shows that BI may be considered a valuable technique for dealing with alcohol-related problems. However, it is suggested that the usefulness of BI may depend significantly on the target population to be dealt with. BI have proved to be beneficial for male individuals and those patients who do not abuse other psychoactive substances. In contrast, evidence indicates that BI in A&E settings are not effective at all when dealing with men admitted as a consequence of a violence-related event. In addition, some studies were unable to confirm the effectiveness of BI in female population, in emergency setting. Studies investigating the association between drinking patterns and the effectiveness of BI also present inconsistent results. Most studies assessing the effectiveness of BI in A&E settings only adopted a short perspective (looking at the impact up to a maximum of 12 months after the BI was delivered). When assessing the effects of BI, both the amount of alcohol consumed and expected reductions in alcohol consequences, such as injuries, can be taken into account. Evidence on the implementation of brief intervention in emergency departments remains inconclusive as to whether there are clear benefits. A variety of outcome measures and assessing procedures were used in the different studies, which have investigated this topic.

Will emergency and surgical patients participate in and complete alcohol interventions? A systematic review

BACKGROUND

In the everyday surgical life, staff may experience that patients with Alcohol Use Disorders (AUDs) seem reluctant to participate in alcohol intervention programs. The objective was therefore to assess acceptance of screening and intervention as well as adherence to the intervention program among emergency department (ED) and surgical patients with AUDs.

METHODS

A systematic literature search was followed by extraction of acceptance and adherence rates in ED and surgical patients. Numbers needed to screen (NNS) were calculated. Subgroup analyses were carried out based on different study characteristics.

RESULTS

The literature search revealed 33 relevant studies. Of these, 31 were randomized trials, 28 were conducted in EDs and 31 evaluated the effect of brief alcohol intervention. Follow-up was mainly conducted after six and/or twelve months.Four in five ED patients accepted alcohol screening and two in three accepted participation in intervention. In surgical patients, two in three accepted screening and the intervention acceptance rate was almost 100%. The adherence rate was above 60% for up to twelve months in both ED and surgical patients. The NNS to identify one eligible AUD patient and to get one eligible patient to accept participation in alcohol intervention varied from a few up to 70 patients.The rates did not differ between randomized and non-randomized trials, brief and intensive interventions or validated and self-reported alcohol consumption. Adherence rates were not affected by patients' group allocation and type of follow-up.

CONCLUSIONS

Most emergency and surgical patients with AUD accept participation in alcohol screening and interventions and complete the intervention program.

Will emergency and surgical patients participate in and complete alcohol interventions? A systematic review

Background

In the everyday surgical life, staff may experience that patients with Alcohol Use Disorders (AUDs) seem reluctant to participate in alcohol intervention programs. The objective was therefore to assess acceptance of screening and intervention as well as adherence to the intervention program among emergency department (ED) and surgical patients with AUDs.

Methods

A systematic literature search was followed by extraction of acceptance and adherence rates in ED and surgical patients. Numbers needed to screen (NNS) were calculated. Subgroup analyses were carried out based on different study characteristics.

Results

The literature search revealed 33 relevant studies. Of these, 31 were randomized trials, 28 were conducted in EDs and 31 evaluated the effect of brief alcohol intervention. Follow-up was mainly conducted after six and/or twelve months.

Four in five ED patients accepted alcohol screening and two in three accepted participation in intervention. In surgical patients, two in three accepted screening and the intervention acceptance rate was almost 100%. The adherence rate was above 60% for up to twelve months in both ED and surgical patients. The NNS to identify one eligible AUD patient and to get one eligible patient to accept participation in alcohol intervention varied from a few up to 70 patients.

The rates did not differ between randomized and non-randomized trials, brief and intensive interventions or validated and self-reported alcohol consumption. Adherence rates were not affected by patients' group allocation and type of follow-up.

Conclusions

Most emergency and surgical patients with AUD accept participation in alcohol screening and interventions and complete the intervention program.

Beliefs and practices of pediatric emergency physicians and nurses regarding counseling alcohol-using adolescents: can counseling practice be predicted?

OBJECTIVES

The objectives of the study were to investigate the attitudes and practices of pediatric emergency department (PED) physicians (MDs), MD extenders (MD's assistants [PAs], nurse practitioners [NPs]), and nurses (RNs) regarding their counseling of alcohol-using adolescent PED patients and to determine which, if any, PED clinician characteristics predict current counseling practice.

METHODS

An Internet-based survey of PED clinicians (MDs, PAs, NPs, and RNs) from 11 academic US PEDs was conducted. Respondents were asked about their counseling training, current counseling practices, confidence in their counseling skills, importance of counseling, attitudes and beliefs about counseling, and demographic information. Univariate and multivariate analyses were performed to determine the relationship between clinician characteristics and counseling practice.

RESULTS

Counseling practice was strongly associated with one's profession; PED MDs/PAs/NPs reported significantly higher rates of counseling alcohol-using adolescents than PED RNs. These 2 groups differed significantly in terms of counseling training and experience. Counseling training and experience remained significant predictors of counseling practice, even after controlling for profession and other covariates. Both groups had similar views on the importance of counseling, confidence in their ability to counsel, and counseling substance-using adolescent PED patients.

CONCLUSIONS

Pediatric ED MDs/PAs/NPs differ significantly from PED RNs in their counseling training, experience, and practice. These findings have important implications for the training and support necessary to successfully implement PED counseling. Specifically, formal training in counseling during professional schooling and garnering counseling experience after completing training may be critical factors in promoting PED counseling.

Counselor- versus provider-based HIV screening in the emergency department: results from the universal screening for HIV infection in the emergency room (USHER) randomized controlled trial

OBJECTIVE

We compare rates of rapid HIV testing, test offer, and acceptance in an urban emergency department (ED) when conducted by dedicated HIV counselors versus current members of the ED staff.

METHODS

The Universal Screening for HIV Infection in the Emergency Room [USHER] trial is a prospective randomized controlled trial that implemented an HIV screening program in the ED of an urban tertiary medical center. ED patients were screened and consented for trial enrollment by an USHER research assistant. Eligible subjects were randomized to rapid HIV testing (oral OraQuick) offered by a dedicated counselor (counselor arm) or by an ED provider (provider arm). In the counselor arm, counselors-without other clinical responsibilities-assumed nearly all testing-related activities (consent, counseling, delivery of test results). In the provider arm, trained ED emergency service assistants (nursing assistants) consented and tested the participant in the context of other ED-related responsibilities. In this arm, ED house officers, physician assistants, or attending physicians provided HIV test results to trial participants. Outcome measures were rates of HIV testing and test offer among individuals consenting for study participation. Among individuals offered the test, test acceptance was also measured.

RESULTS

From February 2007 through July 2008, 8,187 eligible patients were approached in the ED, and 4,855 (59%) consented and were randomized to trial participation. The mean age was 37 years, 65% were women, and 42% were white. The overall testing rate favored the counselor arm (57% versus 27%; P<.001); 80% (1,959/2,446) of subjects in the counselor arm were offered an HIV test compared with 36% (861/2,409) in the provider arm (P<.001). HIV test acceptance was slightly higher in the provider arm (counselor arm 71% versus provider arm 75%; P = .025).

CONCLUSION

Routine rapid HIV testing in the ED was accomplished more frequently by dedicated HIV counselors than by ED staff in the course of routine clinical work. Without dedicated staff, HIV testing in this setting may not be truly routine.

Emergency provider attitudes and barriers to universal HIV testing in the emergency department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED).

STUDY OBJECTIVE

The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines.

METHODS

Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions.

RESULTS

There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]).

CONCLUSIONS

After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.

Nurses' perceived facilitators and barriers to assessing for alcohol use in Taiwan

AIMS

To explore nurses' perceived facilitators and barriers to assessing for alcohol use in Taiwan.

BACKGROUND

Excessive alcohol use has been associated with health, social and legal problems. Helping health care providers to detect and treat hazardous or harmful drinkers is an important worldwide issue.

DESIGN

A cross-sectional design was used.

METHODS

Nurse participants (n = 741) were recruited from 10 randomly selected hospitals in Taiwan. In these hospitals, nurses were selected from the Emergency Department, psychiatric and gastrointestinal medical-surgical units where most patients with alcohol problems are seen. Data were collected by facilitator and barrier scales as well as a background information form.

RESULTS

Nurses identified the top facilitator and barriers to assessing for alcohol use as 'want to know if patients' drinking problems are related to their illness' and 'patients' purposefully conceal information', respectively. Older nurses and those with longer general clinical experience had more perceived facilitators to assessing for alcohol use. Nurses' perceived facilitator scores were significantly and positively related to their intention scores, whereas their perceived barrier scores were significantly and negatively related to their intention scores. In addition, scores for perceived facilitators and barriers differed significantly by nurses' education level, work unit, experiences with assessing for alcohol use and previous attendance at training courses for assessing alcohol use.

CONCLUSIONS

Our results suggest a need to strengthen nurses' education and training on the assessment of alcohol use in Taiwan.

RELEVANCE TO CLINICAL PRACTICE

Education and training programmes should aim to enhance Taiwanese nurses' alcohol knowledge, to emphasise the impact of alcohol use on illness and treatment and to enhance nurses' perceived facilitators and decrease their perceived barriers to assessing for alcohol use.

Usual drinking patterns and non-fatal injury among patients seeking emergency care

OBJECTIVES

To explore the association between drinking patterns, irrespective of whether alcohol was consumed in the event of the injury or not, and different injury variables; and to identify settings and situations in which risky drinkers have an increased likelihood of injury.

STUDY DESIGN

The study population consisted of all patients aged 18-70 years registered for an injury according to ICD-10 at a Swedish emergency department during an 18-month period. After informed consent, the injury patients were screened for drinking habits by the AUDIT-C questionnaire. The gender, age and drinking pattern of injury patients were compared with the general population.

METHODS

A total of 2782 patients aged 18-70 years were registered for an injury during the study period. The number of drop-outs was 631. Drop-outs include those who did not consent to participate, were severely injured, too intoxicated or did not fill out the questionnaire satisfactory. Thus, 77.3% of the target group were included for further analysis (1944 drinkers and 207 abstainers). The patients were categorized into three drinking categories: abstainers, non-risky and risky drinkers. Risky drinkers were defined according to usual weekly consumption of 80g or more of alcohol for women and 110g or more for men and/or heavy episodic drinking (i.e. having six glasses or more one glass=12g alcohol), or both, on one occasion at least once a month, valid for both women and men. To estimate the relationship between drinking patterns and the injury variables (environment, cause of injury, activity and diagnosis), odds ratios (OR) were calculated by logistic regression. Multiple logistic regression was used in order to control for age and sex differences between the various drinking and injury categories.

RESULTS

The proportion of risky drinkers was higher in the study population compared with the general population in the same area. When controlling for age and sex, risky drinkers (OR 6.4(adj) Confidence interval CI 1.9-21.2) and non-risky drinkers (OR .4.5(adj) CI 1.4-14.5) displayed an increased risk for injury compared with abstainers, in amusement locations, parks, by or on lakes or seas, especially while engaged in play, hobby or other leisure activities (risky drinkers: OR 2.8(adj) CI 1.3-5.6; non-risky drinkers: OR 2.4(adj) CI 1.2-4.6). All differences between drinking patterns in external cause of injury disappeared when age and sex were considered. During rest, meals and attending to personal hygiene, the non-risky drinkers had a lower probability of injury compared with abstainers (OR 0.3(adj) CI 0.1-0.8). Non-risky drinkers had a higher probability than abstainers of suffering luxation (dislocation) or distortion (OR 1.6(adj) CI 1.1-2.5). Nine per cent of the study population reported that they believed that their injury was related to intake of alcohol. Half of this group were non-risky drinkers (CI for the 13.7% difference was 9.7-17.6).

CONCLUSIONS

Few significant associations between drinking pattern and injury remained when age and sex were controlled for.