Screening and Brief Intervention for Alcohol Problems in the Emergency Room: Is There a Role for Nursing?

Trauma is a significant problem in many countries, and is the fifth leading cause of death in the U.S. Trauma accounts for an even higher rate of morbidity, with the rate of serious injury estimated to be over 300 times the mortality rate, and about one in every three individuals treated in the emergency room (ER) is treated for an injury (Vyrostek, et al., 2004). Globally, alcohol is among the most important risk factors for both disability and mortality, with injuries constituting 46% of the deaths attributable to alcohol (and 60% in the Americas) and 42% of the Disability-Adjusted Life Years (DALYs) (Rehm, et al., 2004; Room, et al., 2005). In the U.S. alcohol misuse is estimated to be responsible for more than 100,000 deaths annually, and has been identified as the leading cause of morbidity (Secretary of Health and Human Services, 2000). Much of the data linking alcohol with injuries have come from studies carried out in the ER (reviewed in Cherpitel & Driggers, 2005), and have shown that not only are injured patients, compared to the non-injured, more likely to be both positive for blood alcohol concentration (BAC) and legally intoxicated at the time of ER arrival and to report drinking prior to the event, but non-injured patients are also more likely to report frequent, heavy and problem drinking compared to those in the general population from which they come. ER studies of both injured and non-injured patients have found high rates of prior alcoholrelated injuries, and an alcohol-related ER admission for injury has been found to be predictive of future injury admission. Injury recidivists have also been found significantly more likely to test positive for alcohol and to have a higher BAC at the time of readmission compared with other injury patients (Rivara, et al., 1993). These data underscore the importance of the ER as a point of screening and brief intervention for at-risk and dependent drinking to reduce subsequent alcohol-related ER visits and associated costs and to improve quality of life. While the prevalence of heavy and problem drinking is high in the ER, national surveys in the U.S. have repeatedly found that almost half of the trauma centers do not routinely obtain admitting blood alcohol on patients (Soderstrom, et al., 1994), and concerns with legal issues and reimbursement from health insurance have been cited as major constraints, among others (Gentilello et al., 2005). A, heretofore, relatively little-known law in the U.S., the Uniform Accident and Sickness Policy Provision Law (UPPL), permits third-party payers to deny reimbursement for medical services for patients who are alcohol positive at the time of injury. This law has been in effect since 1947, and while it has been repealed by the National Association of Insurance Commissioners, it is, unfortunately, still on the books in the majority of states (Chezem, 2004/2005). Additionally, estimated BAC at the time of ER admission often fails to detect the majority of heavy drinkers or those with alcohol use disorders. One study found that while two-thirds of BAC positive trauma patients met standard diagnostic criteria for alcohol dependence, almost half of the BAC negative patients also met diagnostic criteria (Soderstrom, et al., 1994) while another study found that a positive BAC identified only 20% of those with current alcohol use disorder (Cherpitel, 1995a). Despite the poor performance of BAC status as a clinically useful predictor of the presence of current harmful drinking or alcohol dependence in the ER setting, until recently little research has been conducted evaluating the performance of screening