Screening, Brief Intervention and Referral to Treatment Implementation in the Emergency Department

At-risk behavior due to drug and alcohol use represents a significant burden to patients, the health care system and society as a whole. The Centers for Disease Control and Prevention report that 80,000 individuals die each year in the United States due to excess alcohol use (Centers for Disease Control and Prevention, 2013). Globally, the World Health Organization estimates that there are 185 million users of illicit drugs and 2 billion users of alcohol, a significant portion of the latter with evidence of abuse and dependency (World Health Organization, 2015). From 2004 to 2010, there was a near-doubling of the number of emergency department (ED) visits due to substance abuse (Substance Abuse and Mental Health Services Administration, 2012).The ED, as the gateway to the acute health care system, inevitably sees the consequences of the burden of at-risk substance use behavior. To address this challenging patient population, protocols in Screening, Brief Intervention and Referral to Treatment (SBIRT) have been developed to allow assessment and the application of motivational interviewing techniques to individuals who present to the ED related to alcohol or drug abuse or dependency. (Academic ED SBIRT Collaborative, 2007; Bernstein et al., 2009; Estee et al., 2010; D'Onofrio et al., 2012) The evidence supporting such SBIRT programs suggests they can make a positive impact upon patients and lead in some cases to long-term rehabilitation. However, the sustainability of such programs is often dependent upon outside grant funding or additional personnel. To translate into widespread practice, EDs need to find a way to incorporate SBIRT into existing operational patterns without additional personnel (Cunningham et al., 2009). How to pragmatically accomplish this is therefore of considerable relevance to EDs, hospitals and the health care system as a whole.Previous publications have highlighted emergency nurses' role in implementing SBIRT protocols (Slain et al., 2014). However, that article did not evaluate how administrative stakeholders, primarily emergency nurse leaders, viewed the process of developing and implementing the SBIRT protocol in ED practice. We sought to use qualitative research strategies to elucidate how administrative stakeholders viewed the incorporation of SBIRT in normal ED nursing workflow at this center. We hypothesized that we would be able to identify attitudinal and structural barriers to implementing SBIRT in the ED by emergency nurses without additional personnel or external resources. The description of these barriers will have relevance to emergency nurses who want to execute innovations in the challenging ED environment.Role of the ResearchersThe two principle researchers in this study were a practicing emergency physician and an experienced qualitative researcher. Neither individual served as a supervisor of the administrative and nursing champions interviewed in this study nor were either involved in the original genesis of the SBIRT project in the ED. As noted below, each participant in the study provided written informed consent under an institutional review board approved protocol prior to interviews. The researchers analyzed data within the context of focus on structural and attitudinal barriers to implementation of SBIRT in normal ED nursing workflow. Given these factors, we do not perceive significant bias or ethical concerns in the methodology described below.MethodsProtocol Background and ImplementationAs previously published, beginning in 2010, administrative and emergency nursing champions at this center trained emergency nurses on SBIRT and integrated its use into the normal workflow of a single, tertiary care center with an annual ED census of approximately 50,000 visits per year (Slain et al., 2014). In the first year of implementation (2012), 47,693 visits by 31,525 patients met protocol inclusion criteria. 83.4% of visits received the initial assessment step of the SBIRT plan at triage. …