Implementation of Screening and Brief Intervention with Fidelity in Trauma Centers: Challenging but Not Impossible

Since 2005, level I trauma centers have been mandated to have the capacity to identify and intervene in patients with unhealthy alcohol use. This study randomized 20 trauma centers either to receive enhanced training in motivational interviewing (MI) for nursing and social work screening and brief intervention (SBI) providers (1 day of training and 4 30-minute follow-up coaching sessions), or to no additional training for SBI staff (control). To assess MI skills, providers from both groups participated in 7 20-minute standardized telephone MI sessions with patient-actors, and the sessions were scored using a coding system. The study then enrolled 878 in-patient trauma patients with positive blood alcohol levels who were assessed for alcohol consumption and consequences (using the AUDIT) at the initial trauma visit and at 6- and 12-month follow-up.

• Providers who received the training demonstrated greater MI skills and spent twice as much time at the bedside delivering alcohol SBI than those who did not.
• The rates of hazardous alcohol use declined in both groups, but the MI group experienced an 8% greater reduction and had a greater increase in days abstinent over the follow-up year.
• The MI had a greater effect (15%) on hazardous alcohol use in patients without traumatic brain injury (TBI).

Comments:

Implementation of SBI with fidelity in health care settings is complex and challenging, but this study shows that even brief training of providers can have a positive clinical effect. If these findings generalize to the 30 million patients who present with traumatic injury annually in the US, the reductions in alcohol use—particularly among patients without TBI—would have an important population impact. That said, replication and dissemination of the intensive training, practice, and coaching required might also prove challenging but not impossible.

Peter D. Friedmann, MD, MPH

Reference:

Zatzick D, Donovan DM, Jurkovich G, et al. Disseminating alcohol screening and brief intervention at trauma centers: a policy-relevant cluster randomized effectiveness trial. Addiction. 2014;109:754–765.