Conference Proceedings

Robert W. Schafermeyer, MD, FACEP, Clinical Professor, Emergency Medicine, Pediatrics,
University of North Carolina School of Medicine, Chapel Hill, NC, Associate Chairman,
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC

The focus of this meeting is on the development of an action plan to overcome the barriers to implementation of the best practices identified in the earlier conference, Developing Best Practices of Emergency Care for the Alcohol-Impaired Patient.

Alcohol-impaired patients are seen in the ED every day. But in these times of decreasing resources and ED crowding, the challenge is to find the time to screen and provide brief interventions in the emergency care for patient with AUPs.

What steps need to occur to integrate the identified model practices into the care provided in our emergency departments?

Our objective today is to discuss the known barriers and develop action plans to overcome them and facilitate the use of these tools and model practices.

After providing the introduction, Dr. Schafermeyer moderated the meeting, introduced each speaker and the panel moderators. He provided the charge to the group as they focused on development of the specific action plans.

Address Summaries
Opening Remarks

Jeffrey W. Runge, MD, FACEP, Administrator,
National Highway Traffic Safety Administration (NHTSA), Washington, DC

We are so used to dealing with patients one at a time at the bedside, and trying to change one life at a time. Today you have an opportunity to change thousands of lives at one time, because what we’re after here is a larger plan. We believe we know what the answers are; to try to get a grip on the impaired driving problem and the problem with alcohol related medical illness. It seems like an undoable, prodigious task. In fact, if you break it down into its component parts, it’s very doable, but we have to do all of those little component parts if we want to change thousands of people at a time. So, we need a plan, we need to get from point A, where we are right now, which is understanding that these tools work, into the deployment phase, which is sometimes much, much more difficult to achieve. So, I wish you success today and what I’m going to try to do is just to frame the issue a little bit. And let you know a little bit about why NHTSA is interested in your patients in the emergency department.

There’s the difference between today and the old days when I was talking on my own behalf or on behalf of the college. Now I’m speaking on behalf of President Bush and Secretary Mineta. They are unanimous in one thing, and that is that safety and security are their top priorities in this country. We’ve obviously been talking a lot about security. We’ve been dealing with that for the last year and a half with great energy and leadership. Secretary Mineta stood up the TSA with 35 congressional mandates and his 36th mandate - which was to meet the first 35 on time. And the department actually did it; they did it at the expense of a lot of energy that could have otherwise been put into other things.

Secretary Mineta gave a speech, a press conference recently, that kicked off the National “Click It or Ticket” Campaign. He said we’re going to do for highway fatalities and injuries this year, what we did last year for national security. So we’re looking forward to that and things are changing a bit around the DOT. Secretary Mineta was a Congressman for a number of years, he was a Mayor, and he understands politics. He understands huge policy issues, and impaired driving is one of the two big priorities that we have in reducing highway injuries and fatalities. So how do we do that?

Well, it’s complicated. If the human toll doesn’t get to you, and by the way, it doesn’t get a lot of people in the state legislature or on Capitol Hill. The fact is, it does get to you and me, because we all pay for it. In fact, NHTSA did an analysis of motor vehicle crash costs during the year 2000, and the cost to our country in year 2000 dollars is 230.6 billion dollars per year. And if you break that down, impaired driving is 51 billion of that, speed related crashes 40 billion, failure to use safety belts, 20 billion, medical care, direct cost medical care is 33 billion dollars; the same as our entire highway construction fund. It’s an enormous cost.

The CDC’s chart of the leading causes of death in the United States depicts the extent of the problem. The chart breaks out age groups, and ranks the causes of death from 1–10. This chart shows that we are a society that consumes our young with unintentional injuries. If you break car crashes out of unintentional injuries, car crashes would still appear across the top of the chart. In fact, I’m told that if you divide the chart at age 40, motor vehicle crashes are the leading cause of death for every age group from 24 months to age 40 in this country. So when I talk about motor vehicle injuries and deaths, what I’m really talking about is an epidemic across our nation that we simply have got to approach as a public health problem of enormous proportions.

I asked the research staff at NHTSA to analyze the data, and tell me which interventions have the greatest potential to save the largest number of lives. Very clearly, if we get safety belt use to 90 percent, we’ll save a third of the lives that can be saved. If we reduce impaired driving by a third, it’s another third of the lives that can be saved. I’m a pretty simple guy when it comes to public policy and I like to grab for the big pieces of the pie chart. We could accomplish safety belt at 90 percent overnight, if the 32 states that have secondary safety belt laws would just pass a primary belt law. Our police officers would enforce it and we would get to where Washington state and Oregon, California and Hawaii are, with 90 percent safety belt usage. It’s not a fantasy. It can be done.

But back to our issue today, impaired driving. Unfortunately we are not making progress. Somewhere back in the ‘80s, our society began to figure out that it really wasn’t okay to drive down the road with a drink in your hand or see how many you could fire down and then get behind the wheel. It became socially unconscionable to do that. With that shift in social norms, we saw a downward trend in alcohol-related fatalities until about 1992 or 1993, when slope of the curve changed. We believe the profile of impaired drivers changed. By the early ‘90s, the educable had been educated. And people who respect the law, respected the law.

The new profile of impaired drivers is one of a group of people that have a different problem. The problem is that they drink every day, or they binge when they don’t drink everyday. They have high tolerance. They have high alcohol levels and despite how awake they are, their driving performance decreases, and they get in crashes and they kill people.

There are some cultural issues at play. Impaired drivers are a troubled population that we can’t seem to change. The majority are less than 35 years of age. Eighty-two percent of drivers in alcohol-related crashes are male. Sixty-five percent aren’t belted and roadside surveys suggest that beer is their drink of choice. You know these people. You probably took care of them yesterday or the day before yesterday. They are not only resistant to change, they’re resistant to medical care, and they tend not to go to the doctor.

But when these people interact with the health care system, they interact with the emergency department. Of the number of contacts these people have with the health care system, a very, very high percentage are in the emergency department. So if we don’t get to them, they won’t be “gotten.” And if you just think about their risk of future illness and injury at this early stage, unless we do get to them, they’re a set-up for huge problems later on. These are not people committing social indiscretions; with one beer too many. These are people that are drinking to get drunk; that have tolerance in order to get there. This is a sick population and they need to be dealt with, not just by law enforcement, but also by the health care community.

So what are we doing about it? The way things work in Washington, you can’t just go to the appropriators and say, “Listen, here’s a great idea and we need this amount of money,” and they say, “Okay, that’s great and here it is.” What happens is that every six years, one set of Congressional committees, your authorizing committees, set spending levels that you’re allowed to ask for. And then every year, they pass a bill to fund your agency. The reauthorizing bill they’re trying to get passed this year we’re calling SAFETEA, because Secretary Mineta wanted to make sure that safety is at the very top. It’s the Safe, Accountable, Flexible and Efficient Transportation Equity Act of 2004. After you get the acronym down, then the next step is to pass the bill. We’re at the first stage of that reauthorizing process now.

So, for the next 6 years, where do we want to focus our resources? We must get some money into those states with big problems, so they can do a comprehensive assessment of their issues, identify the chinks in their armor, and then provide some funding to shore them up. The states aren’t the same. They’re all very different. You go to a place like New York, and they have a self-sustaining impaired alcohol driving management program. They do it with high visibility, high advertising, high enforcement, and high fines. They have structured sentencing. They have all the pieces and it pays for itself. They don’t have to go back to their legislators every year to ask for more money.

There are states like South Carolina where the alcohol fatality rate is 4 times the rate of New York; with huge resistance to passing any legislation. States are not the same, and we simply must help the people who want to make life better. So, we are proposing 201 billion dollars in funding for highway safety programs. That includes 50 million dollars a year to get into those states where they have significant problems.

We also have a unique problem with specific groups, like motorcyclists. If you have a motorcyclist that had a crash in your emergency department, please screen him for alcohol use disorders. Motorcyclists are at very, very high risk. Thirty seven percent of motorcycle crashes involve a drinking driver. Low levels of alcohol are even worse with motorcycle riders than they are for car and truck drivers, because of the need for balance and coordination and judgment; the three things that get knocked off early on when you start drinking alcohol.

So we have some needs. In addition to needing more screening and brief intervention, we have needs that fall squarely on your shoulders. They can only be met by the emergency medicine community in particular. Needs for things like more complete data. I talked to a group of trauma surgeons last week with a similar theme. They have a very tiny tip of the iceberg. If you think about the injury pyramid, 90 percent of injured patients that go to the doctor, go to the emergency department. Ten percent are injured badly enough to be admitted to the hospital. 0.1 percent die. You make a lot of decisions based on that 0.1 percent because they’re easy to count.

But we have huge data needs to describe the rest of the pyramid. There are huge gaps on blood alcohol data. Somehow we’ve got to get to the point in this country where post-crash alcohol testing is done routinely without fear of losing insurance payments. Without fear of having to go sit in a court all day long. We also need uniformity in state data, within states and across states. We just don’t have the kind of alcohol data that we need.

We also have the need for better public policy. Public policy means legislation in multiple areas. Laws work. They don’t have a huge double-digit effect in most cases, but laws like ALR mean that if you blow a certain breath level of alcohol, or if you refuse a test, you lose your license on the spot. That’s a decent incentive for people who care if they have a driver’s license. We need more .08 laws. We are now up to 39 States with .08 laws. We still have 11 to go. There is a sanction that kicks in next year whereby states lose highway funding unless they pass .08 laws.

We need graduated drivers licensing and I mean real GDL. These are teenagers who go through licensing stages and if they get a seatbelt ticket, or get an alcohol violation, or if they are caught underage drinking, it all links back to that license; and they can’t move through the stages unless they follow the rules.

Beyond laws and data, we have a very specific, important role to play in emergency care. We have to treat alcohol use disorders just like we treat other diseases that pose problems later on, like high blood pressure or diabetes - things that we screen for routinely. No patient gets into the ED without his blood pressure being taken. If you think about the difference in the public health benefits, from screening everybody with high blood pressure versus screening everybody for alcohol use disorders, we could make enormous strides. If we can get triage nurses, any nurses, any physicians to actually do alcohol screening on patients that come into the ED, we will make an enormous impact. Screening for alcohol use problems has enormous potential for large, long-term benefits.

As you know, the detrimental health affects of alcohol are not just confined to injury. It causes liver disease and many other medical problems you’re all too familiar with. So, alcohol misuse is a huge issue in your patients. Many of them are at risk. Unless we determine who they are, we can’t do anything about it.

Next, I’m going to talk about the study that we did before I became NHTSA Administrator, down in Charlotte and at East Carolina Medical Center. Herb Garrison and I did this, and our staff screened a whole bunch of people. Every driver involved in a motor vehicle crash, between 10am and 10pm, seven days a week was screened. Not surprisingly, 14 percent of our patients were positive for alcohol use disorders. Most of these people were all stone cold sober, by the way. Those who were screened and received a brief intervention actually showed up at the treatment center, 20 times as often as those who didn’t.

We actually had some people who just got asked the questions, had some insight, and asked their doctors about it and then they referred them on. Just receiving advice works for a lot of people, without a big heavy intervention. In our North Carolina study, of those who agreed to further evaluation, 49 percent actually followed up; which is 20 times that of those who said, “not interested.” Even some of those who said, I’m not interested, were in fact interested.

I hope that you will open your ears that you’ll tune into the idea of screening and brief intervention, and develop an action plan about how it can be more widely deployed. There are people who are at-risk drinkers, and there are people who are truly dependent. All of these people have an alcohol use disorder that should be addressed. Some people will respond to just advice. Some people need a structured intervention to reduce consumption or seek treatment. Some need the evidence of the blood alcohol concentration or the ascension of family members, but you have all those things in the ED. It’s actually a great spot to get this done.

So, we need a plan. We need some policy changes. But what we really need is an attitude change. We need an attitude change among ourselves. We’re not talking about the frequent-flyer street drunk. We’re not talking about the people that some people loathe to see.

I’ll tell you a story. Many of you know John Marks, our department chair in Charlotte. When John first came to town, one of his interests was alcohol problems and alcohol and trauma, so he spent his first few lectures talking about this. Then he decided he was going to come down and work some shifts with each of the faculty, each of his new colleagues. I was down there one day and he showed up and started seeing patients, somewhere. I kind of lost him for a while. I didn’t see him, so I looked at the board and one of our regulars was in. I signed my initials on the board and I went down to see him. I walked in, and there was John Marks, washing this guy’s feet, with warm soap and water. And there was a change in this patient from his usual hostile smelly self, cussing at the nurses and spitting on everybody. And there was John Marks the devote agnostic, washing this guy’s feet – right out of the bible. There was a change in that patient, and there was a change in that patient the next time he came in, and the next time he came in. And I learned something about attitudes, and about people that day. I learned a lot from John.

I learned even more when I began doing screening and brief intervention myself. When I asked people, “do you mind if I ask you some questions about drinking alcohol?” almost everyone said, “no, go ahead.” Especially after a car crash, they sort of look for a change. The questions are simple. “How many drinks does it takes before you first feel the affects of the alcohol?” It’s just not that hard to do. The change I noticed is that people, if they have issues, they want to talk about them. It is not hard and it makes you feel good when they say thank you after that interaction.

It’s something that we don’t typically do but you can do it while you’re doing other things. You can do it while you’re sewing him up, you can do it while you picking glass out of his forehead. This is not a hard concept, but it requires change. It requires a change in the way we do business. And that is so hard, because life is busy and we have a set way of doing our jobs. It requires change in us as well. If we’re going to change society, it really starts with us. I hope we can accomplish that. With your help, I believe we can. Thank you very much for your time. Thank you for coming and I hope you have a very productive day.

Crafting Health Policy to Reduce Injuries
Georges C. Benjamin, MD, FACP, Executive Director,
American Public Health Association, Washington, DC

A public health approach focuses on finding the causes. We need more connection between acute care specialists and public health professionals. It may help us to use the word “protection” instead of “prevention.” People understand “protection;” it resonates with the public.

Many public policy issues are going to be discussed in the next few years. Covering the uninsured, including children, is a major issue. Today, there are 41 million people who are uninsured. During any two-year period, 75 million people are uninsured and these people want insurance. The main reasons many people do not have insurance is that it is not available and if it is available it is not affordable. Nearly half of the bankruptcy problems in the United States are health related. This has a negative impact on health care. We must deal with health care disparities – ethnic, economic, etc. Equity means providing health care insurance to everyone.

We need to think globally about health care policy. We are facing extremely complex issues.

We also must work to develop an effective infrastructure for public health. Our challenges include the need to rebuild the infrastructure and attracting qualified personnel. More people are leaving the field of public health care than we are bringing in. For example, government lab workers must compete with biotech labs. If we do not build a public health structure, the medical community will have nothing to link to.

There are challenges to identifying and providing care for those involved in substance abuse. The problem is not recognizing the people who need help, but having the time, tools, and resources to deal with patient needs. We must look at patients in a holistic manor; we must find out their real problems.

Importantly, we must make linkages between acute care and research. This is public health.