Implementation of a computerized alcohol advice concept in routine emergency care

Emergency Department Screening for Unhealthy Alcohol and Drug Use with a Brief Tablet-Based Questionnaire

Background

Screening for unhealthy alcohol and drug use in the emergency department (ED) can be challenging due to crowding, lack of privacy, and overburdened staff. The objectives of this study were to determine the feasibility and utility of a brief tablet-based screening method in the ED and if patients would consider a face-to-face meeting with a certified alcohol and drug counselor (CADC) for more in-depth screening, brief intervention, and referral to treatment (SBIRT) helpful via this interface.

Methods

A tablet-based questionnaire was offered to 500 patients. Inclusion criteria were age ≥18, Emergency Severity Index 2–5, and English comprehension. Subjects were excluded if they had evidence of acute intoxication and/or received sedating medication.

Results

A total of 283 (57%) subjects were enrolled over a 4-week period, which represented an increase of 183% over the monthly average of patients referred for SBIRT by the CADC prior to the study. There were 131 (46%) who screened positive for unhealthy alcohol and drug use, with 51 (39%) and 37 (28%) who screened positive for solely unhealthy alcohol use and drug use/drug use disorders, respectively. There were 43 (33%) who screened positive for combined unhealthy alcohol and drug use. Despite willingness to participate in the tablet-based questionnaire, only 20 (15%) with a positive screen indicated via the tablet that a face-to-face meeting with the CADC for further SBIRT would be helpful.

Conclusion

Brief tablet-based screening for unhealthy alcohol and drug use in the ED was an effective method to increase the number of adult patients identified than solely by their treating clinicians. However, only a minority of subjects screening positive using this interface believed a face-to-face meeting with the CADC for further SBIRT would be helpful.

Development of an electronic alcohol screening and brief intervention program for hospital outpatients with unhealthy alcohol use

Background

Alcohol screening and brief intervention is recommended for widespread implementation in health care systems, but it is not used routinely in most countries for a variety of reasons. Electronic screening and brief intervention (e-SBI), in which patients complete a Web-based questionnaire and are provided with personalized feedback on their drinking, is a promising alternative to practitioner delivered intervention, but its efficacy in the hospital outpatient setting has not been established.

Objective

The objective of our study was to establish the feasibility of conducting a full-scale randomized controlled trial to determine whether e-SBI reduces alcohol consumption in hospital outpatients with hazardous or harmful drinking.

Methods

The study was conducted in the outpatient department of a large public hospital in Newcastle (population 540,000), Australia. Adults with appointments at a broad range of medical and surgical outpatient clinics were invited to complete an e-SBI program on a laptop, and to report their impressions via a short questionnaire. Follow-up assessments were conducted 2-8 weeks later by email and post.

Results

We approached 172 outpatients and 108/172 (62.8%) agreed to participate. Of the 106 patients capable of self-administering the e-SBI, 7/106 (6.6%) did not complete it (3 due to technical problems and 4 because they were called for their appointment), 15/106 (14.2%) indicated that they had not consumed any alcohol in the past 12 months, 43/106 (40.6%) screened negative for unhealthy alcohol use (scored less than 5 on the Alcohol Use Disorders Identification Test Consumption [AUDIT-C] questions), 33/106 (31.1%) screened positive for hazardous or harmful drinking (AUDIT-C score 5-9), and 8/106 (7.5%) screened positive for possible alcohol dependence (AUDIT-C score 10-12). Among the subgroup with hazardous or harmful drinking, 27/33 (82%) found the feedback on their drinking very, quite, or somewhat useful, 33/33 (100%) thought the intervention would appeal to most or some of the people who attend the service, and 22/30 (73%) completed the follow-up. We also found that some well established procedures used in trials of e-SBI in the primary care setting did not translate to the hospital outpatient setting (1) we experienced delays because the e-SBI program had to be developed and maintained by the health service’s information technology staff for security reasons, (2) recruiting patients as they left the reception desk was impractical because patients tended to arrive at the beginning of the clinics with few arrivals thereafter, and (3) use of a laptop in a fixed location resulted in some patients rushing through the e-SBI so they could return to their seat in the area they had been advised to wait in.

Conclusions

e-SBI is acceptable to outpatients and with some adaptation to organizational and physical conditions, it is feasible to recruit and screen patients and to deliver the intervention without disrupting normal service provision. This suggests that e-SBI could be provided routinely in this important setting if shown to be efficacious.

Feasibility of a computer-assisted alcohol SBIRT program in an urban emergency department: patient and research staff perspectives

Objectives

The study objective was to assess the feasibility of a computerized alcohol-screening interview (CASI) program to identify at-risk alcohol users among adult emergency department (ED) patients. The study aimed to evaluate the feasibility of implementing a computerized screening, brief intervention, and referral to treatment (SBIRT) program within a busy urban ED setting, to report on accurate deployment of alcohol screening results, and to assess comprehension and satisfaction with CASI from both patient and research staff perspectives.

Methods

Research assistants (RAs) screened a convenience sample of medically stable ED patients. The RAs brought CASI to patients’ bedsides, and patients entered their own alcohol consumption data. The CASI intervention consisted of an alcohol use screening identification test, a personalized normative feedback profile, NIAAA low-risk drinking educational materials, and treatment referrals (when indicated).

Results

Five hundred seventeen patients were enrolled. The median age of participants was 37 years (range, 21-85 years); 37% were men, 62% were Hispanic, 7% were Caucasian, 30% were African American, and 2% were multiracial. Eighty percent reported regular use of computers at home. Eighty percent of patients approached consented to participate, and 99% of those who started CASI were able to complete it. Two percent of interviews were interrupted for medical tests and procedures, however, no patients required breaks from using CASI for not feeling well. The CASI program accurately provided alcohol risk education to patients 100% of the time. Thirty-two percent of patients in the sample screened positive for at-risk drinking. Sixty percent of patients reported that CASI increased their knowledge of safe drinking limits, 39% reported some likeliness to change their alcohol use, and 28% reported some intention to consult a health care professional about their alcohol use as a result of their screening results. Ninety-three percent reported CASI was easy to use, 93% felt comfortable receiving alcohol education via computer, and 89% liked using CASI. Ninety percent of patients correctly identified their alcohol risk level after participating in CASI. With regard to research staff experience, RAs needed to provide standby assistance to patients during <1% of CASI administrations and needed to troubleshoot computer issues in 4% of interviews. The RAs distributed the correct alcohol risk normative profiles to patients 97% of the time and provided patients with treatment referrals when indicated 81% of the time. The RAs rated patients as “not bothered at all” by using CASI 94% of the time.

Conclusions

This study demonstrates that an ED-based computerized alcohol screening program is both acceptable to patients and effective in educating patients about their alcohol risk level. Additionally, this study demonstrates that few logistical problems related to using computers for these interventions were experienced by research staff: in most cases, staff accurately deployed alcohol risk education to patients, and in all cases, the computer provided accurate education to patients. Computer-assisted SBIRT may represent a significant time-saving measure, allowing EDs to reach larger numbers of patients for alcohol intervention without causing undue clinical burden or interruptions to clinical care. Future studies with follow-up are needed to replicate these results and assess drinking reductions post-intervention.

Increased detection of alcohol consumption and at-risk drinking with computerized alcohol screening

BACKGROUND

The impact of alcohol use has been widely studied and is considered a public health issue. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends Screening and Brief Intervention and Referral Treatment (SBIRT), but the actual practice in the Emergency Department (ED) is constrained due to limited provider time and financial resources.

OBJECTIVES

To assess the effectiveness of alcohol screening using Computerized Alcohol Screening and brief Intervention (CASI) compared to alcohol screening by triage nurse during Medical Screening Examination (MSE) in the ED.

METHODS

Retrospective review of CASI/MSE database from January 2008 through December 2009, collected in the tertiary, Level I Trauma ED was performed. Inclusion criteria included age ≥18 years, and completion of both the MSE and CASI. We analyzed the database by comparing age, gender, primary language (English, Spanish), and Alcohol Use Disorders Identification Test scores using McNemar's test.

RESULTS

Data were available for 5835 patients. CASI showed a significant increase in detection of at-risk drinking over MSE across all ages, gender, and primary language (p < 0.05). MSE found 2.5% at-risk drinkers and CASI found 11.5% at-risk drinkers (odds ratio [OR] 8.88, 95% confidence interval [CI] 6.89-11.61). Similar results were found in 18- to 20-year-old patients. MSE identified 1.8% at-risk drinkers and CASI reported 15.94% (OR 19.33, 95% CI 6.30-96.47).

CONCLUSION

CASI increased detection of at-risk alcohol drinkers compared with MSE across all ages, gender, and primary language. CASI is a promising innovative method for alcohol screening in the ED for the adult population, including under-aged drinkers.

What makes emergency department patients reduce their alcohol consumption?--a computer-based intervention study in Sweden

OBJECTIVES

This study investigates the effectiveness of a computerized emergency department intervention for alcohol consumption and identifies explanation factors associated with reduced alcohol consumption from risk to non-risk drinking.

METHODS

Patients aged 18-69 years registered at the ED triage answered alcohol-related questions on a touch-screen computer. Follow-up data were collected by means of a postal questionnaire that was mailed to the patients 6 months after their ED visit.

RESULTS

There were four independent explanations for reduced alcohol consumption: being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider. 339 patients could be followed up and of these were 97 categorized as risk drinkers at baseline and 45 became non-risk drinker 6 month later.

CONCLUSIONS

Being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider were predictors for change from risk to non-risk drinking 6 months later.

Improvement of Physical Activity by a Kiosk-based Electronic Screening and Brief Intervention in Routine Primary Health Care: Patient-Initiated Versus Staff-Referred

Background

Interactive behavior change technology (eg, computer programs, Internet websites, and mobile phones) may facilitate the implementation of lifestyle behavior interventions in routine primary health care. Effective, fully automated solutions not involving primary health care staff may offer low-cost support for behavior change.

Objectives

We explored the effectiveness of an electronic screening and brief intervention (e-SBI) deployed through a stand-alone information kiosk for promoting physical activity among sedentary patients in routine primary health care. We further tested whether its effectiveness differed between patients performing the e-SBI on their own initiative and those referred to it by primary health care staff.

Methods

The e-SBI screens for the physical activity level, motivation to change, attitudes toward performing the test, and physical characteristics and provides tailored feedback supporting behavior change. A total of 7863 patients performed the e-SBI from 2007 through 2009 in routine primary health care in Östergötland County, Sweden. Of these, 2509 were considered not sufficiently physically active, and 311 of these 2509 patients agreed to participate in an optional 3-month follow-up. These 311 patients were included in the analysis and were further divided into two groups based on whether the e-SBI was performed on the patient´s own initiative (informed by posters in the waiting room) or if the patient was referred to it by staff. A physical activity score representing the number of days being physically active was compared between baseline e-SBI and the 3-month follow-up. Based on physical activity recommendations, a score of 5 was considered the cutoff for being sufficiently physically active.

Results

In all, 137 of 311 patients (44%) were sufficiently physically active at the 3-month follow-up. The proportion becoming sufficiently physically active was 16/55 (29%), 40/101 (40%), and 81/155 (52%) for patients with a physical activity score at baseline of 0, 1 to 2, and 3 to 4, respectively. The patient-initiated group and staff-referred group had similar mean physical activity scores at baseline (2.1, 95% confidence interval [CI] 1.8-2.3, versus 2.3, 95% CI 2.1-2.5) and at follow-up, (4.1, 95% CI 3.4-4.7, vs 4.2, 95% CI 3.7-4.8).

Conclusions

Among the sedentary patients in primary health care who participated in the follow-up, the e-SBI appeared effective at promoting short-term improvement of physical activity for about half of them. The results were similar when the e-SBI was patient-initiated or staff-referred. The e-SBI may be a low-cost complement to lifestyle behavior interventions in routine primary health care and could work as a stand-alone technique not requiring the involvment of primary health care staff.

Randomized controlled trial of mailed personalized feedback for problem drinkers in the emergency department: the short-term impact

BACKGROUND

Evidence exists for the efficacy of emergency department (ED)-based brief alcohol interventions, but attempts to incorporate face-to-face interventions into routine ED practice have been hampered by time, financial, and attitudinal constraints. Mailed personalized feedback, which is likely to be more feasible, has been associated with reduced alcohol consumption in other settings, but its cost-effectiveness in the ED has not been examined.

METHODS

The intervention was evaluated with a randomized controlled trial of patients presenting to 5 rural EDs in New South Wales, Australia. Patients aged 14 years and older were screened using the Alcohol Use Disorders Identification Test, and those scoring 8 or more were randomly allocated to the intervention or control group. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback.

RESULTS

Two hundred and forty-four (80%) participants were successfully followed up at 6 weeks. A significant effect of the mailed feedback was observed only in patients with an alcohol-involved ED presentation. Among this subgroup of participants, those in the intervention group consumed 12.2 fewer drinks per week than the control group after controlling for baseline consumption and other covariates (effect size d = 0.59). The intervention was associated with an average cost of Australian $5.83 per patient, and among participants with an alcohol-involved ED presentation, an incremental cost-effectiveness ratio of 0.48.

CONCLUSIONS

Mailed personalized feedback is efficacious in reducing quantity/frequency of alcohol consumption among patients with alcohol-involved ED presentations. Mailed feedback has high cost-efficacy and a low absolute cost, making it a promising candidate for integration into ED care.

The evidence for implementing alcohol screening and intervention in the emergency department - time to act

The harmful effects of alcohol and its contribution to Emergency Department (ED) presentations are evident on a daily basis and undoubtedly add a significant burden on the health care system. Despite alcohol's prevalence in ED presentations, formal screening for alcohol use is not routinely applied in EDs. This paper reviews the evidence supporting the use of screening and the use of brief interventions in the ED. It aims to provide some insights into what may constitute best practice for health workers in relation to identifying and treating patients with problematic alcohol use. Although the burden of alcohol-related presentations is evident and the prevalence of problem acknowledged by health care professionals, the implementation of formal screening and brief interventions is at best inconsistent and sparse. Contemporary screening tools and interventions are critiqued within the ED setting and their advantages and disadvantages discussed. In conclusion, while there is a lack of homogeneity regarding the efficacy of screening tools and brief interventions in the ED setting, there are some promising indications that effectiveness may be enhanced by targeting the interventions at specific patient populations. It may also be possible to start considering innovative information technology applications to screen and intervene.

Referral to an electronic screening and brief alcohol intervention in primary health care in sweden: impact of staff referral to the computer

The aim of this paper was to evaluate whether primary health care staff's referral of patients to perform an electronic screening and brief intervention (e-SBI) for alcohol use had a greater impact on change in alcohol consumption after 3 month, compared to patients who performed the test on their own initiative. Staff-referred responders reported reduced weekly alcohol consumption with an average decrease of 8.4 grams. In contrast, self-referred responders reported an average increase in weekly alcohol consumption of 2.4 grams. Staff-referred responders reported a 49% reduction of average number of heavy episodic drinking (HED) occasions per month. The corresponding reduction for self-referred responders was 62%. The differences between staff- and self-referred patient groups in the number who moved from risky drinking to nonrisky drinking at the followup were not statistically significant. Our results indicate that standalone computers with touchscreens that provide e-SBIs for risky drinking have the same effect on drinking behaviour in both staff-referred patients and self-referred patients.

Alcohol consumption and motivation to reduce drinking among emergency care patients in Sweden

This study compares the alcohol consumption and motivation to reduce drinking among injured and non injured patients in a Swedish emergency department (ED). Patients aged 18-69 registered at the ED triage room were requested to answer alcohol-related questions on a touch-screen computer. Injury patients drank alcohol significantly more often than patients without injuries and in a significantly higher typical quantity than non-injury patients, yielding a significantly larger average weekly consumption. However, there were no significant differences between injury and non-injury patients with regard to heavy episodic drinking. As a consequence of injury patients being younger and more often male in comparison with non-injury patients nearly all differences between the two patient groups disappeared when controlling for age and sex. There were no significant differences in motivation to reduce drinking between injury and non-injury patients. There were small differences in the drinking variables and motivation to reduce drinking between injury patients and non-injury patients.