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Center for Substance Abuse Treatment. Alcohol and Other Drug Screening of Hospitalized Trauma Patients. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1995. (Treatment Improvement Protocol (TIP) Series, No. 16.)

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Alcohol and Other Drug Screening of Hospitalized Trauma Patients.

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Chapter 1—Introduction

This Treatment Improvement Protocol (TIP) takes a detailed look at the hospitalized, injured patient and discusses screening urine and blood for alcohol and other drugs (AODs) when the patient arrives at the hospital or trauma center. Such screening is an essential first step in understanding a patient's medical needs and determining if there is an underlying substance use disorder. This TIP describes some of the ways in which use of alcohol and other drugs can complicate immediate assessment and longer term rehabilitation of patients with traumatic injuries. Several screening instruments are examined, and the screening and assessment process is described, as well as a number of brief interventions that could be used in the hospital setting. Ethical and legal issues are also discussed in detail to dispel myths, to acknowledge realities, and to give healthcare planners a menu of suggested strategies to ensure compliance with Federal confidentiality regulations.

AOD screening of trauma patients is an essential first step in understanding patients' medical needs and determining if there is an underlying substance use disorder.

This TIP does not address those patients who visit emergency departments and are discharged without being hospitalized. Although it is very likely that substance abuse interventions with many of these patients would prevent them from sustaining more serious injuries in the future, most healthcare institutions do not have the resources to implement routine screening of this large patient group. This TIP focuses on injured patients who require hospitalization because these patients are sicker and because hospitalization allows clinicians time to perform screens and appropriately address the results.

The Goals of This TIP

Implementing Screening Programs

The overall goal of this TIP is to provide State AOD agencies, hospitals, clinicians, treatment facilities, and healthcare policymakers with practical guidelines for starting screening and assessment programs for hospitalized injured patients. Such programs can be initiated at the State level or by hospitals that treat severe injuries. The assumption of the consensus panel that developed this TIP is that when these guidelines are used, trauma patients will receive appropriate medical treatment that includes substance abuse assessment, if needed, and referral for substance abuse treatment or education, when that is appropriate.

Policymakers, regulators, specialty medical societies, and hospital administrators should be responsible for assuming leadership to see that the guidelines recommended in this TIP are implemented and that positive and negative incentives are in place to ensure that hospitalized patients with traumatic injuries receive appropriate medical care and assessment of underlying substance use disorders.

Preventing Injury

As this TIP points out, the role that physicians and other healthcare providers can play in preventing further injury in this group of patients, many of whom are at high risk for reinjury, should not be underestimated. When screening programs identify injured patients who may have alcohol or other drug problems, the concern shown by healthcare providers, even during brief encounters or interventions, can provide patients with significant motivation for engaging in the assessment and treatment process. Many trauma centers and hospitals employ full-time AOD counselors. The costs of AOD counseling for severely injured patients in relation to the costs for injury hospitalization are small, but the value in terms of prevention may be great.

The costs of AOD counseling for severely injured patients in relation to the costs for injury hospitalization are small, but the value in terms of prevention may be great.

Taking time to talk with patients about injury prevention measures must be seen as a legitimate "value-added" component of any clinician-patient encounter. Hospitals, health maintenance organizations, and other facilities should study institution value-added fees. State AOD agencies should encourage State legislatures to pass laws that require insurance companies and other third-party payers to reimburse for this value-added component. Reducing the demand for costly healthcare services for injury is an important goal. Currently, only 3 percent of total healthcare dollars is spent on prevention, and a much smaller fraction is spent on reinjury prevention, although, as described below, costs related to injuries are higher than for cancer or heart disease.

Injury as Disease and the Role of Alcohol and Other Drugs

Many medical authorities define injury as a primary disease, such as heart disease or cancer. In all forms of disease, tissue damage occurs. What differentiates acute injury from chronic disease such as arteriosclerosis (hardening of the arteries) is that tissue damage occurs quickly, in a matter of seconds or minutes, whereas in chronic disease or overuse injuries, the damage takes place over a longer time. The critical similarity between acute injury and other diseases is that both occur as a result of actions of specific agents in the environment. To reduce the incidence of heart disease, clinicians and public health policymakers look for underlying causes of the disease and focus on risk factors such as smoking and poor diet.

When injury is viewed as a disease, the underlying causes are examined. When people are admitted to a hospital, they have the right to expect that the underlying causes of their conditions will be sought and addressed. Hospitals and physicians are responsible for doing so. For example, when a heart attack patient is hospitalized, patient education about diet and exercise begins as soon as the patient is stabilized, and education becomes a major focus of the discharge treatment plan. However, in the treatment of trauma patients, the underlying cause of AOD abuse is seldom sought and addressed.

The Need for Screening

Although injury is strongly related to substance use, studies have shown that clinicians and hospitals that treat trauma patients do not routinely determine blood alcohol concentrations (BACs) or perform urine drug screens. A national survey of trauma centers was conducted to assess clinical practices involving alcohol during 1984 (Soderstrom and Cowley, 1987). Responses from 154 centers in 43 States and the District of Columbia indicated that BACs were routinely obtained in only 55 percent of the centers. Fewer than a third of the centers employed an alcoholism counselor/clinician. An updated survey for 1989, which involved 316 respondents, showed little improvement, with a slight increase in BAC determinations (62 percent) (Soderstrom et al., 1994). Testing for drugs other than alcohol was routinely performed at only 39 percent of the centers. However, there was a significant increase in the number of centers employing a full-time counselor/clinician with specific training in substance abuse—59 percent of the centers employed such counselors.

Patients with diseases have the right to expect hospitals to seek the underlying causes of their illnesses, and hospitals and physicians are responsible for doing so.

Addressing Positive Results of Screening

Even when facilities screen patients with traumatic injuries for alcohol and other drugs, positive screening results are often used to address patients' immediate medical needs but not to confirm and address underlying substance use problems. This situation is comparable to that of a physician treating a patient's pneumonia expertly but ignoring his or her tobacco dependency.

Fielding and Colquitt(1987) studied a community hospital equipped with an inpatient detoxification unit with specially trained AOD clinicians. During the study period, 84 injured motor vehicle crash patients were admitted to the hospital; their BACs averaged 215 mg/dl, which is more than twice the legal limit for intoxication -- 100 mg/dl -- in most States. None of the 84 patients were referred to the hospital's detoxification unit or for consultation with an AOD clinician. In another study, Lowenstein and associates(1990) followed 153 patients treated in an emergency department who had BACs above 100 mg/dl; 46 of these were trauma patients. Among the 153 patients, the injured intoxicated patients were three times less likely than the intoxicated patients with no injuries to receive AOD counseling or referral.

Finally, in a large study in California, MacKenzie and associates (1989) reviewed 27,000 discharge summaries from hospitalized trauma patients and found that alcohol was mentioned in only 3 percent, even though it is generally accepted that between 20 and 50 percent of trauma admissions have alcohol use as a contributing factor.

The Risk of Reinjury

As is discussed later in this TIP, people who have sustained one traumatic injury are at greatly increased risk of reinjury. Many clinicians, researchers, and epidemiologists believe that rates of readmission for second and third traumatic injuries are strongly related to untreated substance use problems in this subgroup of trauma patients. In one recent study, more than 2,500 trauma patients (most of whom were victims of unintentional injury) were followed for 18 months after their injury; patients who were intoxicated at the time of the initial injury were 2.5 times more likely than other patients in this group to sustain a second injury during the 18-month period; those who were found to have chronic alcohol use were 3.5 times more likely (Rivara et al., 1993b).

People who have sustained one traumatic injury are at greatly increased risk of reinjury.

In a 5-year followup study of 263 trauma patients admitted to a Detroit Level 1 trauma center, Sims and colleagues (1989) found that 44 percent sustained two or more subsequent injuries that required hospitalization. Alcohol abuse was identified in 67 percent of those sustaining recurrent injury and 60 percent of those sustaining a single injury during the study period. A large proportion of persons in the study were victims of interpersonal violence.

Substance abuse treatment interventions with patients who have multiple episodes of injury hold great promise for the prevention of a significant portion of traumatic injuries. This TIP will help the State agencies and others to inform the healthcare system of the benefits of addressing AOD use in individuals who engage in high-risk behaviors likely to result in injuries—whether the patient is dependent on alcohol or other drugs, is a substance abuser, or is someone who has used poor judgment in regard to substance use.

Substance abuse treatment interventions with patients who have multiple episodes of injury hold great promise for the prevention of a significant portion of traumatic injuries.

Scope of the Problem

In the United States, injuries are the leading cause of death among persons younger than 44 years and the leading cause of life years lost because of premature death (National Center for Injury Prevention and Control, 1991). Each year injuries affect one in four Americans. For each death resulting from injury, 19 other injured persons are hospitalized and 354 receive medical care (Adams and Benson, 1992). Each year, more than 2 million persons are injured seriously enough to be hospitalized. During 1987, one of 10 hospital discharges and 1 of 6 days of care were injury related (Rice et al., 1989).

A number of population-based studies have shown that falls are the leading cause of injury, accounting for about one-third of hospitalized injured persons. Motor vehicle crashes result in the most costly injuries and account for 22 percent of hospitalized trauma patients (Rice et al., 1989). Every year, more than 80,000 Americans receive permanently disabling injuries to the brain or spinal cord.

Costs

Costs due to injury are calculated in several ways. Direct costs include the amount spent for personal care for injured persons, including hospitalization, rehabilitation, nursing home care, and related professional services. Indirect costs (also called morbidity costs) are generally calculated as the value of the goods and services not produced because of injury-related illness and disability; these costs are borne by society. The direct and indirect costs of all traumatic injuries are about $110 billion per year, making injury more costly than any other disease (Rice et al., 1989).

Both types of costs are combined to calculate lifetime costs, which take into account the costs incurred the year in which the injury occurred plus the costs incurred in each successive year. The lifetime cost of injuries in 1990 was estimated at $215 billion (Blancoe and Faigin, 1991). Such economic costs, of course, do not take into account the pain and emotional anguish suffered by injured people and their families.

The direct and indirect costs of all traumatic injuries are about $110 billion per year, making injury more costly than any other disease.

The Role of AODs

Use of alcohol and other drugs is a well-known contributing factor to all injuries. For example, more than half of all people who incur traumatic brain injuries (TBIs) have been drinking; the percentage can range up to 72 percent in some groups of patients (Sparadeo and Gill, 1989). Patients with TBIs are often dependent on their families or are wards of the State. Even patients with mild head injuries sometimes experience permanent changes in cognition and behavior. The costs of caring for patients with TBIs exceed $25 billion annually.

As awareness of traumatic injury as a major public health problem has grown, injury prevention has become a primary goal of legislators, policymakers, and planners at all levels. Many preventive measures have been implemented, such as passing mandatory seat belt and helmet laws, increasing the legal drinking age, redesigning roads, and adding fire retardants to building materials and furniture. Communities all over America now have specially trained personnel to provide advanced life support to trauma victims at the scene of the injury. In many systems of trauma care, helicopters are used to provide rapid transportation to trauma centers. However, as Gentilello and associates noted (1988), there is "an obvious flaw in the delivery of trauma care today." A major cause of traumatic injury—substance abuse and dependence -- is virtually ignored in the care of these patients.

The accumulated evidence makes two things clear. First, it is urgent to improve AOD screening and assessment among hospitalized trauma patients. Second, "doing it right the first time" will result in large savings -- in both human and economic terms.

Barriers and Opportunities

Many factors contribute to the present situation in which the hospitalized injured patient may not be screened for substance use, and in which positive results of screens are not addressed by referral for AOD assessment and treatment when indicated. These include

  • Physicians' negative attitudes toward substance abusers and physicians' pessimism about the efficacy of treatment
  • Institutional avoidance of the responsibility for treating all aspects of injury
  • Lack of awareness of some healthcare providers about the benefits to the injured person of addressing substance abuse problems
  • The failure of some insurance companies to reimburse for treatment related to alcohol and other drug use.

Bringing about a change is not easy in many hospitals. However, the attitudes of staff and administration evolve in positive ways in hospitals where testing and assessment become routine and even mandated. Improved nursing morale, greater patient and family satisfaction, and better patient management and followup contribute to the experiential change witnessed in these hospitals. The desire to foster such changes underlies the current movement to institute the guidelines included in this TIP.

When AOD testing and assessment become routine, hospitals can expect

  • Improved nursing morale
  • Greater patient and family satisfaction
  • Better patient management and followup.

Although epidemiologically the relationship between AOD use and injury is striking, at the clinical level this relationship is all too frequently ignored. For example, a recent issue of the Journal of the American Medical Association devoted a series of articles to injury prevention. The first article reported the results of a study that examined all motorcycle injuries in California for a 2-year period to show the effectiveness of the State's 1992 helmet use law (Kraus et al., 1994). The second article summarized other research on the effectiveness of using helmets (American Medical Association [AMA], Council on Scientific Affairs, 1994). It included six recommendations, one of which was to encourage physicians to prevent injury by counseling patients to use approved helmets and wear protective clothing. An editorial accompanying these articles called for a "new perspective" on injury (viewing it as a disease) and described the role physicians could play in injury prevention (Martinez, 1994).

However, although the first article noted that in 1991 nearly half of the injured motorcyclists in the study were intoxicated, neither the AMA Council on Scientific Affairs nor the accompanying editorial encouraged physicians to prevent injury by counseling patients about use of alcohol and other drugs while using motorcycles or bicycles.

Ethical and Legal Issues

Good medical care depends on careful attention to ethical and legal concerns. In some hospitals, unanswered legal and ethical questions—real and perceived -- have impeded the development of alcohol and other drug screening and assessment programs for trauma patients. Until hospital administrators and staff in general hospitals have practical guidelines to deal with such issues as patient privacy and the confidentiality of some patient records containing AOD-related information, the reluctance to screen for substance use and dependence will continue.

Therefore, one of the consensus panel workgroups dealt almost entirely with ethical and legal issues. Panelists included a medical ethicist, an attorney specializing in confidentiality law, a coordinator of New York State's Health Care Intervention Service, which provides intervention programs to 18 general hospitals, and a representative of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

Background of This TIP

In 1991, the American Society of Addiction Medicine (ASAM) adopted a Public Policy Statement on Trauma and Chemical Misuse/Dependency. The policy calls for obtaining BACs and performing urine drug screens for all hospitalized trauma patients at the time of admission. The statement further calls on the attending physician responsible for the care of the trauma patient to promptly address any positive results of these screening procedures. Such measures lead to obtaining a consultation or referral for evaluation of underlying AOD problems and treatment for these problems, if indicated.

To gain further support, ASAM brought its Public Policy Statement on Trauma and Chemical Misuse/ Dependency before the American Medical Association. The result was AMA Resolution A91 Screening for Alcohol and Other Drug Use In Trauma Patients, passed by the AMA House of Delegates in December 1991. For the first time, the AMA took a position on hospitalized trauma patients and alcohol and other drugs. In the resolution, the AMA encourages hospitals to promote alcohol and drug testing of injured patients and urges those caring for the patients to implement appropriate substance abuse evaluation and treatment.

In 1991, the American Society of Addiction Medicine adopted a policy that called for obtaining BACs and performing urine drug screens for all hospitalized trauma patients at the time of admission.

After the ASAM public policy and the AMA resolution were passed, ASAM's president, executive vice president, and trauma committee cochair sought funding to study how to provide the healthcare system -- at the Federal, State, and local levels -- with compelling reasons and guidelines for instituting appropriate early intervention and treatment for this population. The Center for Substance Abuse Treatment subsequently decided to devote a Treatment Improvement Protocol to the subject of screening for AOD use and dependence in hospitalized trauma patients.

Some Final Notes

A number of experts in the medical and substance use treatment systems who reviewed a draft version of this TIP pointed out that the TIP focuses on alcohol more than on other drugs. Several factors have contributed to this imbalance in focus. First, alcohol is legal, available, and affordable, and its use is widespread. Although research is beginning to confirm that other drugs play a more significant role in injuries than has been previously thought, especially in motor vehicle crashes, most injuries related to substance use are due to alcohol.

In addition, most clinical research about abused substances has looked at alcohol. This focus is related to alcohol's wide use and to the fact that many aspects of its metabolism and cognitive and physiological effects are much more clearly understood than those of other drugs. For example, alcohol's dose-response pattern is clear; that is, a specific amount of alcohol produces in most people a specific degree of impairment or intoxication. The relation between a specific dose of cocaine or marijuana and the effect on cognitive and physiological processes cannot be measured in a clinical setting.

Thus, although the consensus panel that developed this TIP clearly recognizes the role played in traumatic injury by all abused substances, the more heavy focus on alcohol and its role has been unavoidable in some sections of the TIP.

Some of the field reviewers also mentioned that much of the literature cited in the TIP refers to research conducted in Level 1 trauma centers rather than in community hospitals. (The difference in facilities is explained further in Chapter 2.) Since the most severely injured patients are generally transported to trauma centers, results of research done in these settings may not reflect issues and concerns related to the entire spectrum of hospitalized trauma patients, most of whom are treated outside of Level 1 centers.

Further, in Chapter 4, the consensus panel describes several screening questionnaires for hospitals and trauma centers to consider using in their screening programs or as examples for developing their own questionnaires. As several reviewers pointed out, research continues on validating and improving the efficacy of these instruments, both in general and with various patient groups. The consensus panel felt that it was beyond the scope of this document to provide a comprehensive review of validation research or to compare the sensitivities or specificities of various instruments. Rather, the panel's objective was to describe a variety of screening instruments for readers' consideration.

Readers may be confused about the use of the terms intoxication and impairment in the TIP. Most States have established a legal definition of intoxication. As is explained in more detail in Chapter 3, blood alcohol concentration is measured in milligrams of alcohol per deciliter of blood. In most States the legal definition of intoxication is 100 mg/dl (sometimes expressed as a percentage—.1 mg percent). Impairment from alcohol has been demonstrated at 40 and 50 mg/dl, and some States have set the legal definition of intoxication at 80 mg/dl. With chronic use, many individuals develop a high tolerance for alcohol and show few signs of intoxication even after ingesting significant amounts. Thus, because of the differences in definitions, unless otherwise indicated, no attempt has been made in this TIP to standardize usage of the terms intoxication or impairment to reflect legal or clinical definitions.

Finally, it is beyond the scope of this TIP -- whose focus is on screening -- to describe the many levels and modes of treatment for alcohol and other drug problems. Readers are referred to other TIPs in this series, which provide AOD abuse treatment guidelines for a variety of patient populations, including adolescents, pregnant women, persons with mental illness, HIV-infected patients, and opiate-addicted persons, and describe various treatment modalities, including detoxification and intensive outpatient treatment. Hospital staff who do discharge planning and make aftercare referrals to AOD treatment should have a thorough knowledge of treatment and of options available in their communities.

Readers are referred to other TIPs in this series, which provide AOD abuse treatment guidelines for a variety of patient populations and which describe various treatment modalities.

Overview of This TIP

Chapter 2 Trauma Patients familiarizes persons in the AOD treatment field with hospitalized trauma patients, including the types of injury they sustain, the physical and psychological effects of these injuries, and the typical course of treatment for trauma patients. Five types of risk factors that contribute to the likelihood of sustaining a traumatic injury -- including alcohol and other drug use -- are presented. Major types of traumatic injury, such as traumatic brain injury and spinal cord injuries, are described in detail, while others are highlighted.

Chapter 3 Effects of Alcohol and Other Drugs on Trauma Patients describes the effects of acute and chronic use of alcohol and other drugs on the management of trauma patients. These effects can occur immediately, in the emergency phase of treatment, and later, in the subacute and rehabilitation phases. The chapter introduces the idea that injury creates a "teachable moment" or a unique opportunity to intervene and affect a person's behavior and choices about the use of alcohol and other drugs.

In Chapter 4 Screening and Assessment the processes of screening and assessment are described. Various chemical tests for detecting alcohol and other drugs in blood and urine are described. Several screening questionnaires are presented, and guidelines are provided for conducting a biopsychosocial AOD assessment of the trauma patient. The effectiveness of brief AOD interventions is reviewed, and suggestions for designing simple interventions in the hospital setting are offered.

Chapter 5 Cost-Benefit Issues Affecting Implementation of Screening discusses the benefits of screening of hospitalized trauma patients and the financial costs associated with implementing a screening program targeted to this population.

Chapter 6 Legal and Ethical Concerns explores ethical issues concerning protection of patients' confidentiality, and the use of screening. A case example illustrates ethical and legal concerns and is intended to aid healthcare workers in making clinical decisions while protecting patients' rights to privacy and confidentiality.

Chapter 7 Recordkeeping and Quality Improvement presents four possible models for handling records to comply with the Federal regulations governing confidentiality of AOD-related information. The chapter explores ways in which outcomes can be defined and measured in order to ensure continued quality improvement.

Appendix A lists references cited in this TIP and provides other sources of information. Appendix B is a glossary of medical terms. Appendix C lists the names of those who attended the Federal resource panel in the early stages of developing this TIP and who made valuable suggestions about the TIP's contents. The names of experts from a variety of disciplines who reviewed an early draft of this document are listed in Appendix D.

Conclusion

Knowledge of a patient's AOD use will help the treating physician and other appropriate persons involved in the patient's medical care to improve diagnosis and patient management. One goal of AOD screening and assessment of hospitalized trauma patients is to identify a target population of injured patients who have AOD abuse and dependence problems. AOD intervention and treatment appropriate to the patient's needs should be included in the treatment plan and implemented early in the course of treatment.

The National Research Council report Injury in America: A Continuing Public Health Problem (1985) concluded that, "Injury is not an insoluble problem. Exciting opportunities to understand and prevent injuries and reduce their effects are available. By taking advantage of such opportunities, we can save or improve the lives of countless Americans who otherwise will die or become disabled because of injuries."

The consensus panel that has developed this TIP believes that screening for AOD use in hospitalized trauma patients is one of the "exciting opportunities" available in this important effort to prevent injury and disability. It is hoped that the TIP will be used to facilitate broad implementation of AOD screening in this patient group. In addition, the panel hopes that this TIP will provoke further research, especially in the AOD abuse treatment field, in developing successful strategies for conducting prevention, intervention, and treatment with trauma patients.

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