David B. Hoyt, MD, Chairman,
American College of Surgeons Committee on Trauma,
Professor of Surgery, UCSD Medical Center
The focus of organized trauma care has been to try to define "best care" in the acute care situation, develop trauma centers, develop trauma systems, and focus on our core abilities as physicians. A recent consensus conference has demonstrated that trauma systems are responsible for approximately a 10% mortality reduction overall. There have been many improvements in care of the trauma patient during this time and yet the challenge of immediate mortality has been largely unaffected by trauma system development. Because trauma system development has had a profound effect on mortality reduction, many have shifted their attention to prevention. This shift in focus is based on the potential efficacy of prevention and that it is the only way to affect early mortality. Itís also the right thing to do.
Shifting to prevention has been a challenge. It often creates conflicts between fundamental values of personal freedom versus social responsibility, and the overall perception is a fatalistic mentality and transference of responsibility to the offender. Perhaps of greater importance, prevention strategies historically have not been a core priority and most healthcare providers (doctors and nurses) are not trained in prevention, have not been taught that it works, and have not seen evidence to justify allocation of scarce resources for prevention programs.
One area that can be dramatically impacted through prevention efforts is alcohol abuse. The evidence that alcohol is a problem in traumatic injury is overwhelming. Despite this, less than one-third of trauma providers routinely screen patients for alcohol use. This is primarily due to lack of familiarity with existing tests, lack of training, and the perception that there is inadequate time to do so.
There are now multiple studies demonstrating that simple assessments can identify alcohol dependence and that, if trained, doctors and nurses are willing to provide this assessment. There are also multiple studies demonstrating that a short intervention can be effective treatment in adolescents, college students, trauma patients, and even the elderly. There is evidence that physicians are willing to do short interventions if appropriately trained.
What, then, are the barriers to implementation? First and foremost is agreement on a core prototype for screening and intervention. Once identification of the minimum standard for intervention is made, the resources needed to provide this to an at-risk population can be calculated. Following this, appropriate sources of funding need to be identified if it is to sustain itself as an essential program. Additional barriers include the potential conflict of interest that a physician or nurse may have in providing this screening and intervention when insurance payers may then use this information to relieve them of financial responsibility for so-called self-destructive behavior. This issue must be resolved or widespread implementation of such programs is unlikely to be successful.
The certification of trauma centers and the definition of optimal resources for the care of the injured patient are active, ongoing processes. The evidence that screening and brief interventions are effective in reducing the current alcohol-related trauma should mandate the instatement of this type of intervention as part of optimal care. It is essential that these data be widely shared, that the resources necessary to implement such programs be defined and secured, and that payers join in the responsibility for realizing the value of early detection through screening and active intervention to prevent recurrent excessive alcohol use and the related injury that accompanies it. A true public health approach to this problem on behalf of the government, the payers, and the providers is in the patientís best interest. It is indeed the right thing to do. Our values are changing.