Executive Summary

The National Highway Traffic Safety Administration (NHTSA) and the American College of Emergency Physicians (ACEP) co-sponsored a national conference on Crossing Barriers in Emergency Care of Alcohol-Impaired Patients. This one-day conference was held June 5, 2003, at the Fairmont Hotel in Washington, DC.

The goal of the conference was to develop action plans to overcome the barriers to implementation of the best practices recommended in an earlier conference: Developing Best Practices of Emergency Care for the Alcohol-Impaired Patient, held in June, 2000. Specifically, the conference addressed the following question: “What steps need to occur for emergency medical personnel to integrate alcohol screening and brief interventions into the care provided for alcohol-impaired patients?”

The conference also included two panel discussions: One panel addressed research, insurance and reimbursement policies, and behavioral and privacy policy while a second panel discussed health practitioner behavior, culture and care, and emergency medical services (EMS) care of alcohol-impaired patients. Each panel discussion concluded with an open discussion among the conference participants.

Participants represented a variety of organizations including the Agency for Healthcare Research and Quality (AHRQ), American Ambulance Association (AAA), ACEP, American College of Surgeons (ACS), Centers for Disease Control and Prevention (CDC), Emergency Nurses Association (ENA), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), National Association of EMS Physicians (NAEMSP), National Association of State EMS Directors (NASEMSD), National Association of State EMS Training Directors (NASEMSTD), National Association of Emergency Medical Technicians (NAEMT), National Institute of Alcohol Abuse and Alcoholism (NIAAA), and NHTSA.

The outcome of the conference was a compilation of significant barriers to the implementation of alcohol screening and intervention and related steps for overcoming those barriers. These barriers and steps were organized into 4 categories: research, funding, regulation, and training.

Conference Results — Barriers and Action Plans
The main outcome of the conference was a compilation of significant barriers to the implementation of alcohol screening and intervention and related steps for overcoming those barriers. These barriers and steps are grouped into 4 categories — research, funding, regulation, and training — to facilitate organization of the process required to overcome the obstacles that hinder integration of screening and intervention into the emergency care of alcohol-impaired patients.

Research
Lack of research within emergency medicine focused on alcohol-impaired patients, specifically related to screening and intervention.

  • Encourage emergency medicine research forums (e.g., Society for Academic Emergency Medicine [SAEM], ACEP, NAEMSP, ENA, American College of Surgeons-Committee on Trauma [ACS-COT]) to include categories for alcohol abuse research

  • Work with federal and state agencies to set a research agenda to: (1) evaluate and refine alcohol screening tools for the ED, (2) assess barriers to screening, and (3) demonstrate the impact of screening and brief interventions in the ED

  • Increase research on the care of the alcohol-impaired patient by emergency medicine residents through:
    • financial support of research projects in this topic

    • emphasis on research exploring the contribution of environmental factors that increase at-risk alcohol use and abuse

    • a mentoring network of emergency medicine faculty specializing in this area

    • development of “research in a box” or a turnkey model

Inadequate collaboration and exchange of research literature between emergency medicine and other alcohol researchers

  • Continue to develop networks between non-traditional partners (e.g., CDC, NHTSA, Substance Abuse and Mental Health Services Administration [SAMHSA], NIAAA, ACEP, ENA, ACS-COT, American Society of Addiction Medicine [ASAM], NAEMT, NAEMSP, IAFF, International Association of Fire Chiefs [IAFC], National Association of EMS Educators [NAEMSE])

  • Create a research compendium of literature relevant to the care of patients with alcohol problems receiving care in the emergency medicine setting

  • Convene interested organizations (e.g., CDC Research Conference on Identification and Intervention—Alcohol Problems Among Emergency Department Patients) to address issues related to the emergency care of patients with alcohol use problems

Insufficient translation of alcohol-related research into the practice of emergency care

  • Improve dissemination of research (e.g., by developing a research compendium)

  • Collect and disseminate model practices on implementation of alcohol screening and intervention

Funding

Insufficient funding for incorporating alcohol screening and intervention into emergency care practice

  • Increase understanding of appropriate coding by publicizing and disseminating information on current procedural terminology (CPT) coding for alcohol screening and brief intervention

  • Investigate funding sources at local levels by:
    • securing funding through local taxes (e.g., alcohol distribution fees or other innovative programs such as fee-based nickel-per-drink earmark programs like the Romero Bill and use of cigarette tax monies for EMS funding in California)

    • obtaining funds from non-traditional sources (such as foundations) to generate revenue to support
      emergency care for alcohol-impaired patients

    • building local coalitions (agencies and stakeholders, community, experts) to seek legislation

Regulation
Regulatory bodies do not mandate alcohol screening and intervention

  • Explore the pros and cons of establishing screening guidelines for addressing alcohol-related injuries

  • Develop strategies at the national, state, and community levels to collect data on alcohol-related injuries that can be used to inform public policy makers and support public policy changes

Lack of understanding about Heath Insurance Portability and Accountability Act (HIPAA) regulations (and other laws regarding psychiatric records) and how they impact the care of the alcohol-impaired patient

  • Clarify/interpret HIPAA (and other laws regarding psychiatric records) as applied to alcohol screening by appropriate people/agencies

Uniform Individual Accident and Sickness Policy Provision Law (UPPL) hinders the implementation of alcohol screening and intervention in emergency care centers because of concerns related to insurance companies withholding payment for alcohol-related injuries

  • Identify and publicize high profile state test cases of UPPL repeal

  • Identify a coalition of national- and state-level stakeholders to develop specific plans for repeal of UPPL funded by contributions from each group (include those groups/stakeholders who have UPPL repeal position statements, e.g., ACEP, Students Against Destructive Decisions [SADD], Mothers Against Drunk Driving [MADD], National Commission Against Drunk Driving [NCADD], ENA, etc., as well as key stakeholders who could be encouraged to develop a position statement, e.g. American Hospital Association [AHA], American Public Health Association [APHA], American Medical Association [AMA], American Bar Association [ABA], Insurance Institute for Highway Safety [IIHS], International Association of Chiefs of Police [IACP], sheriffs’ groups, state EMS Directors, etc.)

  • Mobilize coalition members to advocate repeal of UPPL

Training
Lack of knowledge among health care practitioners about alcohol-related illness, injury, and the efficacy of intervention

  • Use traditional education approaches (e.g., conference, presentations, newsletter, etc.) to distribute information and train health care practitioners

  • Promote and facilitate the implementation of alcohol screening and intervention through professional organizations, conference presentations, journal articles, and newsletters

  • Offer awareness and skill-based workshops to provide the knowledge and skill base needed to implement alcohol screening and intervention, including how to integrate collection of data/information on sensitive topics and how to address confidentiality concerns (e.g., HIPAA)

  • Explore at hospital level how screening and intervention can be implemented (e.g., providing different delivery options such as kiosks, peer education, or interviews led by a nurse, physician, social worker, or mental health worker, etc.)

Absence of consistent screening for addressing alcohol-related injuries

  • Develop model practices through cross-organizational collaboration

Inadequate training about alcohol-related illness, injury, and the efficacy of intervention among health practitioners

  • Disseminate model practices

  • Disseminate research compendium

Inadequate training about alcohol-related illness, injury, and the efficacy of intervention provided in initial educational and training settings (e.g., EMS training, emergency medicine residency programs, and nursing education programs)

  • Incorporate training about alcohol-related illness, injury, and efficacy of intervention into training curricula (e.g., EMS core curricula, nursing core curricula, emergency medicine core curriculum, etc.)