Do We Need More Research? Where Are We Now and Where Are We Going?
Phillip A. Brewer, MD, FACEP, Assistant Professor, Yale University School of Medicine, Director, Connecticut Impaired Driver Reporting Project, Medical Safety Fellow, NHTSA, New Haven, CT

Don’t we already know enough? Can’t we take what we have and apply it to both practice and policy in a way that effectively eliminates impaired driving? We know plenty about the roots of impaired driving and how effective various interventions are and are not. Unfortunately, this knowledge is not being applied consistently in practice or in policy, and the ultimate research question is the one that asks why that is the case. We need a new way of integrating the research that we have.

One of the barriers to be crossed in improving the care of injured alcohol-impaired drivers is the mindset of practitioners who think in too narrow terms as to what they can do to help solve this problem. The research is related to practice or advocacy or both and can be organized into several categories, including the following areas:

• Alcohol physiology and driving (tiredness is a common risk factor among young male impaired drivers in nighttime traffic; breath alcohol concentrations within current legal standard can alter a driver’s decision making)
  
  
• Attitudes and beliefs about drinking and injury (general consensus on the role of alcohol as a factor in risky driving; drinkers feel “safe” and “sober” at levels which are subjectively impairing)
  
  
• Attitudes and beliefs about public policies intended to curb impaired driving (studies show clear support for alcohol taxes and sobriety laws)
  
  
• Administrative suspension (people fear they will lose their jobs, however studies show that this is not true)
  
  
• “Safe drinking” strategies (survey of 427 people – predetermined number of drinks is effective; male drivers do not make good designated drivers, designated drivers is not a good solution; warnings on containers do not work)
  
  
• Public information and education (public service announcements [PSAs] do not really work; media coverage does work)
  
  
• Medical restrictions (drivers who were referred to medical evaluation have a higher incidence of crashes and moving violations, however three-fourths of them were determined to be fit to drive without intervention; drivers with license restrictions because of medical problems have slightly higher crash rate than the general population, but lower than male drivers and lower than drivers with impairment but no restrictions)
  
  
• Medical intervention/counseling (not effective with hard-core groups unless combined with punitive measures; forcing offenders to view autopsies does not work; treat this as a medical disease and not let them drive)
  
  
• Criminal sanctions (two-day jail sentence for first-time driving under the influence (DUI) offenders is not effective; combination of license suspension and mandatory treatment has greater impact than simple suspension, jail, or treatment without suspension)
  
  
• Descriptive studies of drinking populations – college age, adolescents, others (earlier age of start of binge drinking correlated with higher incidence of drunk driving and need for more intensive injury prevention measures; college students more likely to drink and drive than same age non-college students, but also more likely to wear seatbelts; 21-year-old drinking limit has reduced but not eliminated adolescent drunk driving; proximity to easy alcohol access, such as Mexico, results in significant border crossing to obtain alcohol; adolescents at high risk for DUI can be identified by testing of attitudes and personality and can become focus of effort to reduce DUI risk; drinking in bars and cars carries a much higher risk of DUI, show that questions about pace of drinking should be part of risk assessment; if first drunk driving incident involves a crash, higher likelihood of recurrent DUI behavior)
  
  
• Community/environmental intervention (anti-drug coalitions have little impact on reduction of DUI; targeted community intervention of a specific venue can reduce alcohol abuse; interventions consistently successful in reducing drunk driving include: .08 blood alcohol concentration (BAC) laws, minimum legal drinking age laws, sobriety checkpoints, lower BAC laws for young and inexperienced drivers and intervention training programs for servers of alcoholic beverages)
  

Effectiveness and Influence of Insurance Statutes and Policies on Reimbursement for Emergency Care
Larry M. Gentilello, MD, FACS, Professor of Surgery, Chairman, Division of Burns, Trauma,
Critical Care, Parkland Medical Center, University of Texas
Southwestern Medical Center, Dallas, Texas

The development of trauma centers in the United States has been extraordinarily successful. The preventable death rate from injuries has been reduced from 40 percent to 2-4 percent. This means that further significant reductions in mortality are not likely to occur as a result of improvements in trauma care. Also, over one-half of all trauma deaths occur at the scene of the injury, before anyone has a chance to respond. These deaths are also not responsive to improvements in care. Further reductions in mortality are therefore more likely to occur as a result of improvements in injury prevention programs. A public health approach to injuries is centered on addressing the underlying causes of injuries. Trauma centers have always known that alcohol use is by far the leading risk factor for injury in the United States, and is a factor in nearly half of all trauma center admission. This makes addressing alcohol problems the most obvious potential target for injury prevention programs.

Each year over 20.5 million adults in the United States sustain injuries requiring ED care. Published studies indicate that approximately 7.4 percent of these patients are intoxicated by alcohol. An additional 19.6 percent of patients who present to the ED for trauma care screen positive on an alcohol screening questionnaire, even though they are not intoxicated at the time. Overall, 25 percent of injured adult patients treated in the ED, or over five million patients, are potential candidates for an alcohol screening and intervention program designed to reduce the risk of injury recurrence, and other alcohol-related morbidity and mortality.

The potential benefits of addressing alcohol problems in this setting are profound. Including alcohol screening and interventions into treatment protocols for injured patients results in a physician patient interaction occurring at a time when the consequences of excessive drinking are most salient to the patient, resulting in a “teachable moment.” Furthermore, patients with an alcohol problem are more likely to require a visit to a doctor for treatment of an injury than for any other medical problem, making EDs the most logical place to initiate contact between patients and needed counseling services. Finally, the type of doctor most frequently seen by a problem-drinking patient is an ED physician.

In recent years a variety of federal, expert, and consensus panels have recommended routine screening and intervention in injured patients. From almost no interest a decade ago, according to a recent survey, 83 percent of trauma surgeons believe that trauma centers are an appropriate place to initiate alcohol treatment. However, despite the interest and opportunity, many physicians are reluctant to screen patients for an alcohol problem because of the potential impact of measuring a BAC on patients, hospitals, and health care providers.

Currently in 36 states, if a doctor documents in the medical record that an injured patient was intoxicated, the insurance company is allowed to deny payment for all charges. A recent survey of ED BAC screening practices for injured patients was conducted to evaluate specific barriers to implementation of intervention programs. Most centers did not provide this service at their center. Of those who did not, 41 percent cited the threatened impact of screening on reimbursement as a key factor. The threat of insurance denials was a greater concern than cost, time, confidentiality, or the potential for offending patients.

The UPPL statute that provides insurers with the right to deny coverage for treatment of alcohol related. The UPPL was drafted in 1947 and adopted as policy by 38 states and provisionally by four others (e.g., narcotics only). The states with insurance laws that allow this provision are shown in Figure 1.

States with Laws that Give Insurers the Option to Deny Medical Reimbursements
to Patients Under the Influence of Alcohol and Narcotics

[d]

(National Conference of State Legislators/Health Policy Tracking Service)

These statutes were passed decades ago, prior to the development of trauma and emergency medicine programs and at a time when there were few treatment opportunities available to patients with alcohol and drug problems. If the purpose of the statute was to reduce insurance costs, it has not had that effect because physicians simply avoid measuring and documenting alcohol use in jurisdictions where the UPPL is in effect and enforced. Therefore, insurers pay for the costs of alcohol-related injuries anyway, and the only effect of the law is to sweep the problem under the rug.

There are multiple stakeholders in favor of repealing the UPPL, including trauma and emergency medicine clinicians, alcohol and drug treatment providers, public safety officials, law enforcement groups, and anti-drunk driving advocacy groups. The National Association of Insurance Commissioners (NAIC), the originators of model legislation upon which the UPPL is based, have revised the model, and now recommends excluding medical coverage from exclusionary provisions. Whether the revision of the model is adopted by states will depend on the interest and activities of these multiple stakeholders.

(See Dr. Gentilello’s paper, Effectiveness and Influence of Insurance Statues and Policies on Reimbursement for Emergency Care, in the Appendix.)

Behavioral and Privacy Policy Issues: Constructive or Obstructive
Stephen W. Hargarten, MD, MPH, FACEP, Chairman, Department of Emergency Medicine
Director, Injury Research Center, Medical College of Wisconsin, Milwaukee, WI

Our culture has a schizoid view of alcohol consumption; it is good and bad, enjoyable and destructive. There are elements/businesses/interests of the environment that struggle with this dichotomy. For example, taverns (alcohol distribution sources) are faced with competing interests; they want people to consume alcohol, but they want patrons to drink safely and responsibly. Happy hours that offer free or low cost drinks encourage customers to drink more at the risk of over consumption. Yet most people arrive at taverns driving their cars, motorcycles, and snowmobiles.

The advertising industry is also caught in this schizoid view. They promote alcohol products and their success is measured by consumption of alcohol products. However, the advertising industries, in their attempts to enhance their success, link the alcohol product to driving and sexual conduct. Both of these activities have bad effects with at-risk alcohol use.

Hospital EDs also have competing interests related to alcohol consumption effecting their patients. Emergency physicians and nurses are focused on addressing their patients’ immediate problems but do not effectively address their patients’ basic issues related to at-risk alcohol use and abuse. One reason for this is due to the vagaries of insurance payments for alcohol-related car crashes. Some insurance companies will not pay for hospital/physician services if the patient was intoxicated at the time of the car crash.

In addition to these behavioral issues of businesses, such as taverns, advertisers, and hospitals, that result in imbalanced interests that perpetuate alcohol-related problems, privacy issues for patients contribute to the complexity of addressing alcohol-related injuries. For example, in hospitals, should doctors and nurses disclose alcohol consumption information to law enforcement agencies? What is the distinction and balance between the patient’s privacy and the need to “protect” the public’s safety? HIPAA has changed the landscape with regard to privacy policy. Health care professionals struggle with interpretation and application of HIPAA, creating myths and potentially paralyzing progress in addressing alcohol-related injuries.

It is very challenging to solve these behavioral and privacy issues and effectively address these competing interests of businesses that comprise parts of the environment of alcohol-related injuries and devise constructive measures to balance them for the public’s health. It is imperative that physicians and nurses remain patient-centered AND reframe the problem of alcohol-related injury as a public health issue. By broadening the discussion to the public’s health, everyone’s interests can be balanced to better manage these behavioral and privacy challenges.

In order to effectively address and balance these competing interests, a public health paradigm is needed. We should recognize a spectrum of alcohol consumption: moderate use, at-risk use, abuse, and alcoholism. Since the environment (home, roadway, tavern, hospital) is a key component of public health strategies, definitions of alcohol-related problems should be clear so that strategies can be aligned with the person’s health, as well as with the public’s health.

Health care professionals need to have a thorough understanding of HIPAA and the rights of patients to privacy. Health care professionals are agents of the patient and screening for alcohol-related problems does not violate that contract as long as it is in the best interest of the patient. However, disclosure of a patient’s behavior and alcohol over consumption to law enforcement is a challenging issue that must balance the needs of the patient’s health and the health and safety of the public.

Recommendations that merit further exploration are:

• targeting the elimination of happy hours
  
  
• including alcohol screening and intervention for alcohol-related problems in the JCAHO standards
  
  
• creating environmental policies to discourage at-risk use or abuse of alcohol
  
  
• implementing a “nickel a drink” tax to fund EMS and assist the systematic approach to address
  alcohol-related injuries
  

Changing Health Practitioner Behavior
Gail D’Onofrio, MD, MS, FACEP, Section of Emergency Medicine
Associate Professor, Yale University School of Medicine, New Haven, CT

Brief intervention works for patients who present to the ED with alcohol problems. However, ED practitioners fail to incorporate screening and intervention for alcohol problems into their daily practice. There are multiple and complex barriers that contribute to this failure to act, including factors related to the individual practitioner as well as the system as a whole.

To begin the process of changing health practitioner behavior, we need to utilize the principles of motivational intervention, which include creating cognitive dissonance, decreasing ambivalence by reflection on conflicting motivations, and negotiating strategies for change. The components of any brief intervention can be used to change practitioner behavior. These steps include: (1) raise the subject, (2) provide feedback, (3) enhance motivation, and (4) negotiate and advise. We should remember, as in the National Institute on Drug Abuse (NIDA) principles, treatment does not need to be voluntary. Incentives, which are negative or positive, may be helpful in bringing about change. Most importantly, system changes will need to occur so that the change is feasible and sustainable.

Changing practitioner behavior can be approached in a variety of ways. The following describes different approaches along with their associated assumptions. (From Grol, R. Improving the quality of medical care: Building bridges among professional pride, payer profit and patient satisfaction. JAMA. 2001:28:2578-86.)

Approaches to Quality Improvement and Their Assumption on Improving
Medical Care Approach Assumption

Effects of Different Strategies to Improve Patient Care

Clinical inertia should be recognized as an issue. This is defined as recognition of a problem but failure to act. Lack of knowledge is not the problem. It is not related to patient adherence to treatment regimens. Clinical inertia is a problem of the provider and the system and is a result of: (1) overestimation of care (providers think they do specific things), (2) use of “soft” reasons to avoid changes, and (3) lack of training (especially skill-based) and practice structure needed to attain goals. (Phillips LS, et al. Clinical Inertia. Ann Intern Med. 2001;135:825-834)

Strategies that can be used to approach practitioner behavioral change include the following:

• provide skills-based educational sessions
  
  
• elicit opinion leaders
  
  
• institute systems changes (forced computer entry, reminders, multiple screeners, etc.)
  
  
• provide ongoing feedback to practitioners
  
  
• provide incentives (positive or negative)
  
  
• be creative

How Culture Affects Care of the Alcohol-Impaired Patient in the ED
Mary Jagim, RN, BSN, CEN, Manager, Emergency Center, MeritCare Health System
ENA Past President, 2001, Fargo, ND

The dictionary defines culture as: a: “the integrated pattern of human knowledge, belief, and behavior that depends upon man’s capacity for learning and transmitting knowledge to succeeding generations, b: the customary beliefs, social forms, and material traits of a racial, religious, or social group, c: the set of shared attitudes, values, goals, and practices that characterizes a company or corporation.” The first definition relates mostly to patients, while the last one describes health care staff in an ED.

As we look at how culture affects care, understanding factors that influence behavior change in both patients and ED staff may be helpful. Keller’s Learning Paradigm describes four areas that affect behavior change.

• Attention – use examples that contradict past experience
  
  
• Relevance – relate health needs to experience
  
  
• Confidence – encourage perceptions of self-efficacy
  
  
• Satisfaction – offers suggestions for reducing drinking

To explore cultural factors that can help us understand at-risk patients, we can look at six major groups or sub-cultures based on age (youth, college, and geriatrics), gender (women at-risk) and ethnicity (Native Americans). Gaining an understanding of each sub-culture’s environment and what affects them helps to understand their risks.

Youth (11-14 years of age)

• The earlier the age of alcohol use, the greater the risk of abusive consumption
  
  
• Demographic and socioeconomic status, childhood conduct problems (over-night stays in jail), negative childhood life events (parent died, divorce), childhood family strain (abuse, absence of love, psychiatric issues)

College students

• Influencing factors include: impulsivity, non-conformity, depression, distance from parents, close peers, living conditions: dorm, fraternity, sorority (the social norm where they live), and social events (making new friends, social rituals)

Women at high risk

• Influencing factors include: heavy drinking father, depression, poor social skills, separated (not divorced, but separated from spouse which creates a period of discontent)

Trauma patients

• 45 percent are positive BAC, many are associated with high risk and aggressive behaviors (will be a trauma patient again), alcohol use risk factor for recidivism

Native Americans

• Influencing factors include: historical influence, learned behavior – societies without cultural guidelines or social norms for drinking, alcohol as a tool of trade and diplomacy, emergence of harmful drinking patterns transmitted through the generations, never developed right and wrong uses of alcohol

Geriatric patients

• Influencing factors include: decreased independence (lost driver’s license, can’t get around without assistance), increased isolation (can’t live like they used to), depression (feeling of not being valuable), stigma, low levels of alcohol can cause adverse health effects due to age-related physiological changes

ED staff

• A variety of cultural factors affect ED staff members. These include: personal experiences (what we have lived through), ethnic background (how acceptable is alcohol use), professional experiences (situations dealt with, types of patients), discomfort, perceptions, personal baggage, and resources (referral services, time, education, and knowing what is available).

To help ameliorate these factors, several approaches could be considered. Providing education on brief intervention and the cultural factors that influence patients’ behaviors is one approach that can help. Mentoring ED colleagues on how to “let go” is also an effective approach. To help staff, referral information should be provided.

Integrating Care for the Alcohol-Impaired Patient in EMS
W. Dan Manz, Director, Vermont State EMS, Burlington, VT

Emergency medical services are faced with several issues when providing care for alcohol-impaired patients.

1. Alcohol-impaired patients can be difficult to assess in a pre-hospital environment. These patients do not show up as alcohol confounding problems; they are linked with certain types of responses, specifically motor vehicle crashes, domestic violence, and various chronic health problems.
   
   
2. EMS personnel are trained to focus on the immediate health problem, but they have limited involvement with injury prevention/wellness. An example of this change of focus is the fire service who now focus on fire prevention not just “wet stuff on hot stuff.”
   
   
3. Legal issues regarding documenting and communicating alcohol impairment need to be addressed. Alcohol can be involved in all kinds of problems not just vehicle related injuries.
   
   
4. EMS provider training on management of alcohol-impaired patients is minimal. (First responders get no training. Emergency Medical Technician (EMT)-Basics get less than two hours of training. EMT-Paramedics get less that seven hours of training.) Overall, the curriculum is assessment based. Alcohol-impaired patients should be a subject of continuing education and professional development.

Specific barriers in caring for alcohol-impaired patients as they relate to EMS include the following:

• EMS providers need more training. Training of initial providers is minimal and street experience may reinforce impressions that the only role for EMS in managing alcohol-impaired patients is the acute care of injuries or medical problems. Thus, EMS providers may not perceive themselves as an important part of the team working on this problem.
  
  
• EMS may be distracted by other priorities. Since 9/11, terrorism preparedness has become the number one job for EMS. As well, evolving threats such as severe acute respiratory syndrome (SARS) require immediate actions. This means that alcohol-impaired patients are at risk of becoming part of the background fabric of EMS responses.
  
  
• EMS works at the intersection of public health and public safety. Some EMS providers may view the problems of alcohol-impaired patients as primarily a law enforcement issue rather than a health care problem. The law enforcement community is increasingly aggressive in enforcing laws.

To impact the care of alcohol-impaired patients, the attitudes of EMS providers need to change. To accomplish this, EMS providers need access to the data (and need to help gather data) regarding alcohol involvement with injuries and illnesses. They need to know which health care interventions are effective. And, importantly, they need to be a part of solving the alcohol problem one patient at a time.

EMS can make a contribution because they are on the scene of the injury, but they need to make sure information is documented and communicated. Strategies that can lead to change for EMS providers focus on:

1. planning the health care team’s response
   Specifically, it is necessary to determine the EMS role in support of physician/nurse/social service practices. Additionally, EMS needs to provide their observations to other hospital providers, and they need to know that the ED staff are committed to addressing the problem of the alcohol-impaired patient.
   
   
2. understanding that it is acceptable to talk
   HIPAA should not become a barrier. Concerns related to HIPAA should be clarified.
   
   
3. realizing that everyone has a role in addressing the emergency care of the alcohol-impaired patient
   This includes bystander recognition and reporting, EMS and public safety response, ED interventions, and in-patient, rehabilitation, and primary care follow-up.