Discussion of


Draft Recommendations


Daniel Hungerford opened the final session of the conference by 

outlining the group’s ultimate task—to create research recommendations from conference deliberations. Before the conference, he and 

Daniel Pollock drafted recommendations for the steering committee 

to consider. During the conference, the steering committee modified 

those recommendations, and they were distributed to attendees for 

general discussion. 

Hungerford stated that the goal of the conference was not to achieve 

unanimity regarding the recommendations, but to have significant and 

general agreement. He indicated the process would be to discuss the 

recommendations one by one, identifying any gaps or omissions and 

offering general comments. He emphasized that the sequence of the 

recommendations did not imply a priority order. Because the published 

recommendations will include supporting text, he encouraged the group 

to consider any points of clarification that would be instructive. 

Hungerford then opened the floor for discussion. 

Recommendation #1 

Research on screening and intervention should address 

the full spectrum of alcohol problems among ED patients. 

Richard Brown remarked that in many circles, “intervention” does not 

necessarily include referral, so he suggested that the first recommendation include “referral.” Also, he said the phrase “alcohol problems” does 

not always include risky drinking and problem drinking, so he suggested 

adding “risky and problem drinking” to the recommendation. 

Daniel Hungerford noted that the supporting text could provide detail 

on the spectrum of alcohol problems. He suggested the main point of 

the first recommendation was that research efforts should include the 

whole continuum of alcohol problems, not just a portion of the continuum such as alcohol-dependent drinkers. 

Draft Recommendations 171 
Jean Shope advocated that the definition of “the full spectrum of alcohol 

problems” include primary prevention. She recommended this understanding be made explicit in the final document. 

Gordon Smith suggested that the recommendations should address the 

problems of poly-substance abuse. 

Carl Soderstrom wondered whether “alcohol problems” referred to the 

spectrum of drinking problems or the medical problems associated with 

drinking. 

Herman Diesenhaus pointed out that hazardous drinking causes a 

complex set of problems that include personal, social, and legal problems in addition to medical problems. The phrase “alcohol problems” 

includes all those problems as well as the hazardous drinking. He noted 

that different pieces of the solution will lie in the medical realm and in 

the social welfare realm. He expressed concern about how to reflect this 

complexity in the recommendations. 

Guohua Li suggested changing the phrase “among ED patients” to 

“in the emergency setting” because alcohol problems are not limited 

to patients. Perhaps the recommendations should address alcohol 

problems among providers and physicians. 

Stephen Hargarten thought that the term “alcohol-related problems” 

would appeal to clinicians more than “alcohol problems” because they 

see those problems in their practices. He said that including “related” in 

terms gives the sense of broadening them. 

Richard Ries said he did not believe that screening for alcohol neuropathy was intended to be part of the recommendation. He suggested that 

the recommendation be clear that it is addressing alcohol use disorders 

or problems, not for medical care consequences. 

Hungerford replied that screening for specific medical care consequences was not part of the recommendation, but that consequence 

items may be used in the screening. He added that broad screening 

would identify people with medical conditions as well. He found that 

172 Alcohol Problems Among Emergency Department Patients 
screening with a low cut point on the AUDIT identified more people 

with severe alcohol problems and alcohol dependence than did not 

using a uniform screening method. He agreed that this issue needs 

clarification in this recommendation. 

Richard Longabaugh said that the term “alcohol problems” implies 

that the patient’s problem is consumption. He favored “alcohol-related 

problems” because consumption is not the problem. The problem is the 

consequences resulting from excessive drinking. 

Elinor Walker endorsed the notion of using “the emergency care setting” 

rather than “the ED” particularly to include focus on the pre-hospital 

care setting. 

Hungerford added that the trauma care setting should be included as 

well. 

Li added his support to “alcohol-related problems,” but suggested 

another alternative, “problem drinking,” which is commonly used. 

Edward Bernstein pointed out that the recommendations would likely 

stand alone for readings and come without context. With that in mind, 

he suggested listing the full spectrum of alcohol problems, from risky 

drinking to alcohol abuse to alcohol dependency. He felt that it would 

be a mistake to open this set of research recommendations with a 

recommendation that included screening for withdrawal or other 

conditions. Another possibility would be to say, “the full spectrum of 

alcohol misuse.” 

Recommendation #2 

Screening instruments under consideration for use in 

EDs should be evaluated as a component of protocols 

that provide interventions for patients. 

Robert Woolard supported the recommendation and noted that 

most research on screening has involved an evaluation of screening, 

but not an intervention. Trying to apply those findings to a clinical 

Draft Recommendations 173 
setting, where there is the question of training and the link between the 

screening instruments and the intervention, becomes problematic. 

Enough research has been conducted on instruments alone, he said, and 

new research should link screens with interventions. 

Linda Degutis recommended amending the recommendation to read, 

“screening, interventions, and methods under consideration.” Then in 

the supporting text, she suggested addressing the different people who 

might be doing the screening and the need to tie it to intervention. 

Longabaugh wondered whether the intended consumers of the document would include government officials, researchers, practitioners, 

and academicians. 

Hungerford answered that the summary of the conference would be 

published in an emergency medicine journal and that readers would 

include these groups. 

Daniel Pollock added that the message of the recommendations could 

also be conveyed at professional meetings. The goal was to influence 

people who are in a position to make changes in the field. 

Brown believed the recommendation was worded too strongly. To him, 

it was saying that work should not include screening research in isolation. He noted that little is known about effective screening for certain 

sub-populations, so screening research still has its place. Although he 

agreed that a total research portfolio should have a strong emphasis on 

intervention and not just screening. 

Diesenhaus described his use of a slogan and abbreviation for a treatment strategy, “Screening, Brief Intervention, and Referral—SBIR.” 

Research on the individual components is important, but the strategy 

for the emergency room setting is as follows: screen, decide if a brief 

intervention is called for, and if not, give a referral. Emergency setting 

personnel need to understand all three components and how they are 

linked. He was not sure if “referral” could be included every time, but 

acknowledged that it is a vital part of the work. 

174 Alcohol Problems Among Emergency Department Patients 
Hungerford emphasized that research on screening is needed. However, 

he believed research on screening instruments that is not linked with an 

intervention leads to the easy assumption that results will be generalizable to using that screening instrument in a full protocol. The second 

recommendation, therefore, is intended to point out that results from 

the screening literature are not necessarily generalizable to real-world 

settings in which screening would be paired with interventions. 

Ries suggested that defining “SBIR” upfront might help clinicians 

understand the recommendations better. If we do not, a clinician who 

is interested in seizures or pancreatitis could easily misread the wording 

of this recommendation. To avoid that, for this recommendation we 

would have to say something like, “Problematic alcohol-use screening 

instruments under consideration for use in the ED should be evaluated 

as a component of protocols that provide alcohol-use interventions for 

patients to decrease problems or use.” 

Hungerford said he understood. If we do not pre-define “SBIR,” we 

have to define what we are talking about with each recommendation. If 

we do define “SBIR” upfront, we make the reading more understandable 

and more efficient. 

Gail D’Onofrio noted that in this context, we use “referral” to mean 

sending a patient to a specialized treatment facility. However, in emergency medicine, everyone gets a referral—to primary care, a clinic 

follow-up, or another health or social service. The “referral” in SBIR 

could include both meanings. 

Hargarten’s initial understanding of this recommendation was that 

screening activities for alcohol problems should be integrated with the 

screening and interventions the ED does for a whole range of problems. 

He suggested that the recommendation be worded in such a manner that 

this effort does not seem to be a parallel activity. 

Hungerford proposed that just as screening research should be carried 

out in the context of protocols that include interventions, those protocols should be integrated with the whole system of ED operations. 

Draft Recommendations 175 
Christopher Dunn thought the word “evaluate” made this recommendation vague. What would be evaluated—the usefulness of a screen or 

the psychometric properties of a screen? He believed that the screen can 

have an interventive effect, so he wanted research on whether patients 

fare as well with a screen as they do with brief advice or more sophisticated techniques. 

David Fiellin advocated eliminating the second recommendation. To 

him the statement implied that screening instruments should be evaluated only as a component of protocols that provide interventions. He 

believed that the statement was dangerous because there are research 

methodologies that are related to evaluating screening and separate ones 

related to evaluating interventions, and we may not want to obligate 

tying the two together. 

Thomas Babor supported technical research on screening and the 

wording of this recommendation. However, he raised a larger issue—the 

moral imperative of screening. He said that screening sets up the expectation that something has to follow. Without screening, there cannot be 

much intervention. He noted that the recommendation could be seen as 

a way of driving widespread applications of interventions. If that is the 

goal, he thought we should be examining how to accomplish screening. 

There are large obstacles to screening, and practical research on screening implementation, incentives, efficiency, and its ability to reach large 

numbers of people at low cost is necessary. He believed in a public 

health approach to screening which means we would not do it if the 

yield is low. He suggested that the technical aspects of screening were 

not as fruitful topics for research as how to screen the greatest number 

of patients at the lowest cost. 

Bernstein suggested that the recommendation not be eliminated, but 

rewritten to reflect the discussion. 

Pollock and Hungerford concurred. Hungerford added that the intent 

of the recommendation was not so much that integrating the screen 

with the intervention gave better estimates of the performance characteristics of the screen, but that it would redress the imbalance between 

176 Alcohol Problems Among Emergency Department Patients 
research emphasizing the performance characteristics and research on 

operational and practical characteristics. 

Recommendation #3 

Interventions that have shown promise in other clinical 

settings should be adapted to and evaluated in emergency 

departments. 

Charles Bombardier wondered whether the recommendation should 

limit evaluation only to interventions shown to be effective in other 

settings. There might be interventions developed specifically for the 

ED that would be worthwhile to test. 

Walker thought the goal of this recommendation was to de-emphasize 

fine-grained, developmental work and to emphasize pursuing work 

using available interventions. 

Woolard noted that the effectiveness of screening, brief interventions, 

and referrals has been proven outside the emergency department, but 

not yet in the ED. Therefore, he hoped that the supporting text for this 

recommendation would include statements about the need for a large, 

multi-center trial in EDs. 

Longabaugh noted that new and creative interventions may be developed in the ED that the rest of the field will want to adapt and explore. 

Walker made a plea not to adopt the abbreviation “SBIR” because it is 

already used to designate small business innovation research grants by 

federal agencies. It could be very confusing. She suggested “SIR” instead. 

Smith returned to the idea of linking alcohol interventions with the 

other interventions in the ED. If there were a package of interventions 

that providers could document and be reimbursed for, that would ease 

acceptance by practitioners and help institutionalize these new practices. 

Documentation would also help ensure interventions would not be 

repeated unnecessarily. 

Draft Recommendations 177 
Pollock pointed out that proving the cost-effectiveness of a specified, 

well-described service in a clinical setting is a critical consideration in 

moving a new practice from a research endeavor to a reimbursable 

service. Whether the service emerges as an adaptation from primary care 

or as an innovation from the ED is less important than whether it can be 

evaluated to the satisfaction of those who make key decisions about 

whether it becomes part of standard practice. 

Larry Gentilello asserted that effective treatments already exist, not just 

treatments that “hold promise.” The “promise” has to do with the 

intervention’s likelihood of success in the ED, not with its success in 

other settings. He suggested that the wording be made less tentative: for 

example, “treatments that work should be made to work in the ED.” 

Catherine Gordon proposed that the recommendations address the 

issue of financing and suggested the following phrase, “Research should 

also identify the most effective and cost-effective interventions and 

delivery mechanisms (e.g., provider types or technologies).” She said 

this type of information is absolutely critical for insurers. 

Pollock asked Gordon whether research on alcohol interventions had to 

be done in a specific clinical setting in order for interventions provided 

in that setting to qualify for reimbursement. He also asked how Medicare distinguishes between prevention and treatment for the purposes 

of authorizing reimbursement. 

Gordon explained that because Medicare is prohibited by statute from 

covering preventive services, it must draw a distinction between treatment and prevention. The kind of information insurers require to cover 

these services includes necessary frequency of treatment, types of 

providers best suited to provide treatment, an ironclad case that the 

intervention is effective, a consensus in the professional community 

around the intervention, and an ability to guard against the potential 

for fraud and abuse. 

178 Alcohol Problems Among Emergency Department Patients 
Pollock added the notion that demonstrations of effectiveness in 

primary care settings, in the eyes of policymakers and payers, are not 

tantamount to demonstrating cost-effectiveness in emergency departments, underscoring the importance of research in that setting. 

Gordon agreed. 

Recommendation #4 

Research is needed to evaluate the effects of legal, 

privacy, confidentiality, regulatory, and human subjects 

issues on screening and interventions for alcohol 

problems among ED patients. 

Brown praised the recommendation for addressing a very important 

issue. However, he thought the human subjects aspect might not belong, 

because human subjects issues will not affect screening and intervention 

on a daily basis in the clinical setting. They only affect research studies. 

Bombardier suggested that in addition to evaluation, this research 

should develop ways to mitigate legal, privacy, and confidentiality 

problems associated with screening and treatment. 

Ann Mahoney said the recommendation should be worded to focus 

on systems as well as individuals. For example, she indicated that the 

concerns institutional and professional systems have about reimbursement or legal, privacy, and confidentiality issues influence whether 

ED patients receive screening and interventions. 

Hargarten commented that this area has the potential to cause consternation and divisiveness, so it will require a great deal of textual commentary to tease out the important issues that it addresses. He noted 

that alcohol screening in the ED is currently being discussed on the 

“ethics circuit.” He suggested that perhaps ethics should be added to 

the recommendation. 

Draft Recommendations 179 
Recommendation #5 

Research is needed on how demographic and cultural 

attributes of ED patients, practitioners, and interventionists influence the success of screening and interventions for alcohol problems. 

Hargarten said there should be some reference in the recommendations 

to the high-risk environment in which these people live and work and 

visit the ED. He wondered if this recommendation was the appropriate 

place. 

Marilyn Sommers noted that different clinical settings can profoundly 

influence how screening and intervention is delivered. She cited differences between Level I trauma centers and community hospitals. She 

suggested that the influence of setting be made explicit somewhere in 

the recommendations. 

Alison Moore indicated that these differences can also influence how 

researchers and clinicians tailor interventions to apply to people with 

different cultural attributes. 

Li suggested that co-morbidity or patients’ medical characteristics could 

also have a large impact on the success of interventions. 

Recommendation #6 

Research is needed to identify the factors that foster 

the organizational and practitioner behavior changes 

needed to institutionalize screening and intervention 

for alcohol problems among ED patients. 

Walker urged that this research not be confined to academic medical 

centers, but be designed and carried out in partnerships with other 

stakeholders, particularly community-level providers. She believed that 

this should be in the recommendation, not just supporting text, because 

reviewers would want to know how screening and intervention can be 

implemented into clinical practice when considering grant applications. 

180 Alcohol Problems Among Emergency Department Patients 
Robert Lowe suggested a range of research topics could come under this 

recommendation. Who should do interventions in the ED? How should 

ED interventions be linked to the primary care and public health 

systems? Which services should be provided in the ED and which should 

be provided elsewhere? How can referrals be effectively accomplished? 

How can interventions be paid for? He suggested wording for the 

supporting text for this recommendation. “Research in this category 

may address a broad range of organizational issues—from the structure 

of alcohol and screening treatment services within the ED to the relationship of the ED to other sources of primary care and the organizational and fiscal factors affecting that relationship. This research is 

crucial as the field progresses from evaluating efficacy in research 

settings to examining effectiveness in the current, complex health care 

delivery system.” 

Babor supported Lowe’s revision and suggested adding the word 

“implementation” to the recommendation. Research is needed on 

how to implement and institutionalize these programs. Factors to be 

explored range from practitioner behavior and practice guidelines to 

policy changes that are needed to facilitate implementation of screening 

and intervention in these settings. If this recommendation is too narrowly defined, we will encourage people to look at small things like 

training programs. However, no matter how strong a training program 

is, if there are no incentives for practitioners to use the training or the 

legal restrictions are insurmountable or the health care system is in total 

chaos and you cannot find who is in charge of the department because 

somebody has bought out the hospital, you will have difficulty implementing an intervention. 

Peter Rostenberg noted that most trauma care is delivered in community hospitals, and practitioners in that setting often do not relate 

to Level I trauma care research. Therefore, he supported including 

community hospitals in research efforts. He thought the biggest 

barrier was how to change the culture in the ED so that staff would 

ask screening questions. 

Draft Recommendations 181 
Ries thought that the recommendations should encourage studying 

outcomes that are important to medical personnel, such as health care 

outcomes and recidivism, rather than alcohol use outcomes. 

Hargarten related that a recent survey found that almost one-third of 

academic EDs have faculty in community settings. He thought that 

encouraging this linkage in research proposals could help increase this 

proportion. He also suggested that involving opinion leaders in the 

field of emergency medicine could help reduce the lag time between 

academic research showing the effectiveness of an intervention and 

broad implementation in non-academic, clinical settings. 

Patricia Perry believed that the recommendation was not yet comprehensive. Hospital administrators merit mention because they are key 

to wide implementation. She thought state and federal policymakers 

should also be included in the statement. She observed that institutionalizing new practices was just the beginning of the task. Once they 

are in place, the program needs to be maintained. She wondered what 

factors influenced maintenance. 

Pat Lenaghan suggested that clinicians need recommendations about 

what could be accomplished now. They need to know that screening 

works and that the sooner screening is implemented the sooner patients 

with alcohol problems can receive help. She noted that collaboration 

with community groups and public health agencies is appropriate for 

alcohol problems because they are not just present in the ED. She said 

that such collaboration has contributed to the success of domestic 

violence screening across the country. 

Bombardier noted that barriers exist among departments within 

institutions as well as among institutions. He advocated developing 

information systems that follow patients so that data collected in the 

ED can be used later. 

Ronald Maio suggested defining the unique role of the emergency 

department in the overall picture of treating alcohol problems. What can 

the emergency department do that cannot be done in other settings? 

182 Alcohol Problems Among Emergency Department Patients 
Soderstrom suggested that the term “practitioner” in this recommendation needs to be clarified because it can mean anyone who takes care of a 

patient, including RNs, MDs, therapists, and others. 

Bernstein noted that alcohol-dependent patients clearly need specialized 

treatment and that some patients with hazardous drinking need outpatient counseling. He said if access to that counseling is not available, 

screening and interventions are less likely to happen in the ED. He called 

for research on barriers emergency physicians face in getting further care 

for ED patients with alcohol problems. 

Hargarten wondered about supporting text that calls for policy-relevant 

research to institutionalize and to promote organizational changes. He 

suggested that research on ways of paying for these services could be an 

important factor in promoting and institutionalizing changes. 

Recommendation #7 

Research is needed to explore and define the role of 

information technology in facilitating screening and 

intervention for alcohol problems among ED patients. 

Brown asked whether other forms of technology should be included, 

such as audio tape headsets. 

Janet Williams suggested the phrase “information and communication 

technology.” She said that these technologies can assist in follow-up 

and continuity of care. 

Ries commented that educational videos in waiting rooms can be 

helpful. 

Hargarten added that tele-medicine has a role in making the booster 

intervention a reality. 

Draft Recommendations 183 
Recommendation #8 

Funding agencies should support research on screening 

and interventions for alcohol problems among ED patients 

and make the mechanisms of research support known to 

potential applicants in emergency medicine. 

Longabaugh wanted the recommendation to include research training 

as an explicit component. He said that it has been difficult to get good, 

physician applicants for Brown’s post-doctoral program in intervention 

and treatment research. However, the program has produced a great deal 

of research. Mechanisms to facilitate the training of good researchers, 

particularly ones from emergency medicine, are needed and should be 

encouraged. 

Hargarten added that training mechanisms should not be limited to 

physicians. He suggested including nurses and PhDs. 

Diesenhaus noted that agencies are required to fund different types of 

research. SAMHSA funds applied research, and their application program is oversubscribed. 

Brown felt that the recommendation placed too much responsibility on 

funding agencies. He suggested the recommendation encourage the 

emergency medicine academic organization to help its members find 

other funding opportunities. He thought there were many opportunities 

through other organizations that should be tapped. 

Gentilello said he has long supported placing a priority on research in 

this area. However, funding agencies cannot be forced to accept this. He 

agreed with Brown that professional societies should be clear about 

funding opportunities. At the same time, the data indicate many missed 

opportunities for treatment in the ED. For some patients, the ED visit is 

the only contact with the medical care system. It can be their only 

opportunity for intervention, and injuries are the most common events 

that bring people into contact with the emergency department. We can 

present a strong case that work in the ED should be a high priority. 

184 Alcohol Problems Among Emergency Department Patients 
Pollock suggested that ED visits are crucial opportunities, and the 

supporting text for this recommendation can make that clear. It is 

possible to emphasize this topic without stating that it should take 

precedence over other issues or have a certain amount of resources 

devoted to it. 

Hungerford thought that work in the ED needed a higher priority and 

more resources if the field is to move forward. 

Pollock asked for a more specific definition of “prioritization.” It is 

unfortunate, but in the eyes of funders, it is perceived as a zero sum 

game. 

Bernstein suggested that the supporting text for this recommendation 

would have to explain the need for political commitment to changing 

the health and social outcomes resulting from alcohol problems. 

Hargarten suggested that we do not have to ask federal agencies to make 

research on alcohol problems in the ED a high priority. Instead, we 

could recommend that, compared with other settings, the prevalence of 

alcohol problems among ED patients makes it worthy of careful consideration. We can also recommend that research efforts should include an 

ED focus and that emergency medicine experts should be included in 

the grant review process. This strategy would attempt to broaden the 

focus of current research activities to include the ED. 

Longabaugh commented that an NIAAA effort to conduct research on 

spirituality and addiction came about by setting aside funds specifically 

for this topic. He said the way to accomplish this is to find and work 

with agency staff interested in the topic. He believed that data on the 

prevalence and severity of alcohol problems in EDs can have a major 

impact. 

Ries agreed and suggested that this recommendation should promote 

ED-based research by emphasizing the large number of ED patients 

affected by alcohol problems and the significant health care impact of 

those problems. 

Draft Recommendations 185 
Fiellin suggested the recommendation should ask for a level of support 

that is commensurate with the burden of illness. 

Gentilello pointed out that the literature includes 40 randomized trials 

on brief interventions in family and general practice settings. Three 

(one in press) are in emergency medicine. The emergency department 

at Harborview probably sees 50 times as many patients with alcohol 

problems as the psychiatry or family medicine departments. If we were 

to choose one place to set up a screening system to find people who 

need interventions, it should be the emergency department. He said 

there needs to be a shift in priorities. 

Mary Dufour described how NIAAA sets research priorities. To secure 

some funding for this conference, she had to “compete” with other 

conferences, which indicates that this issue is high on the NIAAA list 

of priorities. NIAAA has a National Advisory Council with a subcommittee that helps to set research priorities. Interacting with the Council 

is an important way to influence research priorities, she said. Every three 

to five years, NIAAA reviews its whole research portfolio; it identifies 

gaps, which become research priorities. Alcohol and injury, as well as 

brief interventions, are on the list. NIAAA is a small institution with 

more priorities than money. 

Brown suggested that the recommendation remain as is, but that the 

supporting text list ways that priorities could be changed. Because drug 

use is also an important issue among ED patients, he thought combining alcohol and drug research in EDs could lead to more research 

dollars. He noted a growing understanding of the importance of screening for alcohol and other drugs together. To appeal to NIDA, he said, the 

referral aspect of the research should be strong because of their focus on 

treatment. 

Diesenhaus agreed that both support from staff in an agency and the 

“burden of illness” argument could be influential. He said that demand 

for research in EDs from outside an agency would also be important. He 

suggested that conference participants needed to interact with individuals and groups that influence policy. 

186 Alcohol Problems Among Emergency Department Patients 
Gentilello acknowledged that there is a demand problem. The goal is to 

help trauma surgeons and emergency physicians realize that dealing 

with alcohol problems is an integral part of their job. Research on 

alcohol problems is as important as research on sepsis and CPR. At the 

NIH web site, he found no information on alcohol-related research in 

the surgery section. It was all in the alcohol section, which surgeons do 

not explore. If we want surgeons to become interested, it should be 

repeated in the surgery section. 

Longabaugh remarked that NIH is increasingly trying to individualize 

the routing of grant applications so that study section members are a 

matter of public record. If a study section does not include a relevant 

expert, then a cover letter with the grant application can request such 

an expert. 

Li suggested that adding a reference to the Healthy People 2010 objective 

to reduce alcohol-related injury and ED visits by 15% might enhance the 

rationale for more research. 

General comments about the recommendations 

After participants had given extensive feedback on specific proposed 

recommendations, Hungerford asked if they had general comments 

about the recommendations overall. 

Fiellin reflected on increasing information about the biological basis for 

addictive disorders, the increasing effectiveness of pharmacotherapy, and 

the fact that we are trying look at these disorders the same way we look 

at chronic medical conditions like hypertension and diabetes. He asked 

whether we might initiate pharmocotherapy for patients with alcoholrelated problems in the ED, much like we initiate use of oral hypoglycemics and anti-hypertensives with some type of follow-up. 

Draft Recommendations 187