Study urges trauma centers to screen for alcoholism
October 1, 1999 4 minutes read
Study urges trauma centers to screen for alcoholism
Intervention reduced reinjury rate by 48%
Nearly half of the patients that come into your trauma center are there due to an alcohol-related injury. Yet, screening for alcohol addiction has been sorely lacking in most trauma centers. A new study by a group of University of Washington physicians has found that such screening can lead to a significant reduction in the trauma patients’ alcohol consumption, and a reduction of 48% in the reinjury rate up to three years.
Larry Gentilello, MD, associate director of the trauma/intensive care unit at the university’s Harborview Medical Center in Seattle, and one of the authors of the study, hopes that screening for alcohol addiction will change the practice of trauma care.
"Trauma care is relatively standardized throughout the nation," he says. State departments of public health designate particular hospitals as trauma centers, requiring a rigorous evaluation and mandating that certain services be available, including physical therapy, occupational therapy, speech therapy, nutritional/dietary therapy, and spinal cord therapy.
"But therapy for alcoholism is conspicuously absent from trauma care, given that 45% of patients admitted to trauma centers are admitted due to an alcohol-related injury," says Gentilello. "Of those 45% with elevated alcohol levels, 85% test positive for a diagnosable alcohol problem if a formal assessment is undertaken."
Alcohol problems are so prevalent in trauma centers that a quarter of patients admitted without any alcohol in their blood still test positive for an alcohol problem when screened with standardized assessment questionnaires, Gentilello points out. And one-eighth of all U.S. hospital beds are occupied by a patient injured as a result of alcohol, he added. The statistics are stunning. But, despite that, few trauma centers look for alcohol problems among their patients.
Gentilello says his study is the first on the effects of incorporating alcohol interventions as a routine component of trauma care. He says the screening, assessment, and intervention process was deliberately made to be consistent with the time, financial, and staffing constraints of busy trauma centers.
Little work, great results
An admission blood alcohol level was incorporated into routine admission blood tests obtained for all trauma patients, says Gentilello. The study also added to the admission a simple laboratory test to detect liver dysfunction. Then — once any traumatic brain injury to the patient had been treated, any intoxication had worn off, and any need for excessive narcotics had passed — a brief standardized screening instrument for alcoholism, the Short Michigan Alcoholism Screening Test (SMAST), was administered.
A key to success is that a life-threatening injury and a visit to a trauma center presents the patient with a "teachable moment," says Gentilello. A half-hour interview with a psychologist or someone else in the facility who has undergone appropriate training might get the patient to reconsider his or her drinking.
Gentilello says there were three ways a screen for alcoholism could be considered positive: if the patient was legally intoxicated; if the patient had an SMAST score of 3 or more; or if there was any blood alcohol level accompanied by signs of liver disease.
Widely available diagnostic criteria used
The study verified the presence of disease by using the Diagnostic Interview Schedule of the DSM-3R, a book listing diagnostic criteria for all mental health diagnoses that lists the criteria necessary to establish or disprove an alcohol problem. It is widely available, and Gentilello says most physicians and nurses are familiar with it.
Of the 2,524 patients studied, 46% screened positive for alcohol problems. Of these, 366 were assigned to the intervention group, and the remainder received standard trauma care. After a year, the intervention group had decreased its average weekly alcohol consumption by about half. With up to three years of follow-up, the benefit appeared to be sustained, Gentilello says, with the intervention group 48% less likely to be readmitted to a hospital for treatment of a new injury.
Gentilello says there are a variety of simple screening tests that detect alcohol problems that a hospital can incorporate into its trauma routines with minimal disruption. Along with the SMAST, which has been around for more than 20 years, there is the CAGE questionnaire, a 1974 test that was printed in the American Journal of Psychiatry.1
A third is the Alcohol Use Disorders Identifica-tion Test, recently developed by the World Health Organization. Gentilello says that this test was designed to detect not only patients with severe alcohol problems, but those with any alcohol use, including hazardous drinking without any signs of dependence. It also provides a point score that provides some information about the severity of the alcohol problem encountered, and takes only five to 10 minutes to administer.
This test is widely available and can be found in most medical libraries. The National Institute of Alcoholism and Alcohol Abuse in Bethesda, MD (www.niaaa.nih.org) can also help hospitals locate copies of those or a variety of other tests.
The complete study on incorporating addiction treatment with trauma care is being published in the October issue of Annals of Surgery.
Reference
1. Mayfield, D, McLeod G, Hall, P. The CAGE questionnaire: Validation of a new alcoholism instrument. Am J Psychiatry 1974; 131:1,121-1,123.
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