Stephen Hargarten, MD, MPH, Professor & Chair
Department of Emergency Medicine, Medical College of Wisconsin;
Gail D’Onofrio, MS, MD, Associate Professor, Section of Emergency Medicine,
Yale University School of Medicine;
Laurie Flaherty, RN, MS, Traffic Safety Consultant, NHTSA,
Emergency Nurses Association
Addressing the consequences of alcohol use problems (AUPs) presently requires significant time and effort from every segment of the emergency medical system. The disproportionate incidence of illness and injury among patients with AUP is well documented. These patients consume huge health care resources in time, money, and care, inside and outside the hospital. While the existence of the AUP problem seems to be fairly well accepted within the emergency medical community, there has been little consensus on how to address the problem, and even less agreement on how to act. The development of these "Recommended Best Practices" is proposed as a first step in beginning the process of actively and effectively dealing with the patient with AUP. Future directions include action within the areas of clinical practice, education, research, and policy.
The overriding goal is to improve the care of patients with AUP in the clinical setting within the emergency medical system. This goal is reflected in the Recommendations for Best Practices, articulated for each discipline within this system and in the hospital. Most of the recommendations directly address the care of the patient with AUP in the clinical setting. It is important that the best practices be implemented like they would be for any other medical problem, and evaluated to improve our care. Other recommendations for education, research, and advocacy all have the ultimate goal of improving the care of these patients. It is important that all emergency care professionals continue to strive to apply these best practices and to examining their impact on patient outcomes. The development of a system to more accurately describe the scope and nature of this population of patients will be extremely important.
Before we can hope to educate patients with AUP, EMS, ED, and Trauma professionals must first increase their own knowledge base and skills. Before this process can be accomplished, future directions must include emergency care providers acceptance of AUP as a problem, and agreement to adopt actions to address AUP. We are asking health care professionals to change their practice. This requires a change in mind set on the part of many emergency medical professionals. With the help of tools such as the recommendations for best practices, and the support we can engender from committed professionals, care of patients with AUP can be improved, and ultimately, a reduction in AUP can be realized.
One model for such change can be found in "the change pyramid," as stated by Dr. Ricardo Martinez, former NHTSA Administrator. This model includes 5 stages: Increased awareness, education, perceived need to change, support for change, and change itself. While these steps seem fairly simple, they may require great effort to accomplish. Simply identifying the need for change does not mean change will occur. Not everyone or every situation is ready for change. Proceeding through the steps of the change model may facilitate the process of changing the mind set of caregivers, help to move the AUP agenda forward, and effectively address the problems posed by the patient with AUP.
At the basis of this pyramid of change is an increased awareness of the AUP problem, and awareness of the potential role of emergency and trauma professionals in solving it. These professionals no doubt are aware of AUP, but perhaps not the extent to which it impacts the the emergency medical system. It is important that the this system not only recognize the existence of AUP, but also accept that AUP is a problem in our communities that they can and should address. Emergency care providers have a responsibility to screen patients for "non-presenting" health problems such as AUP. Indeed this has been a standard for other medical problems For example, every patient has vital signs taken and any undiagnosed hypertension is addressed. The same should be true for undiagnosed AUP. Emergency care providers can influence change and improve the health protection behaviors of the public. Smoking and heart disease are two examples of how behavior has been influenced by health care professionals for positive change. AUP is another important health problem to be addressed by the caregivers.
Most emergency care professionals’ understanding of the problem of AUP may not be as accurate as they would like to believe. Myths and misperceptions about AUP are not limited to the public. For example, many emergency care professionals would limit AUP to those patients with diagnosed alcoholism. Also, many of them believe there is nothing they can do to influence patients with AUP to change their behavior. Neither of these examples are true. Increased education and training are needed to increase the knowledge and skills, and change the attitudes of emergency care providers in managing patients with AUP. In the future, these professionals will become more familiar with tools to screen for AUP, more adept at performing brief interventions and referring patients for treatment.
Perceptions are real because they influence behavior and influence support or positions. Emergency care professionals need to change their views before AUP can be effectively dealt with. Many health care professionals hold patients responsible for their AUP, and negative attitudes toward patients will not result in positive steps toward resolution. Many emergency care professionals believe there is nothing they can do to influence patients with AUP to change their behavior. The action of changing clinical practice is the result of a perceived need for change on the part of the health care professional. Attitude and perception change are an integral part of this process.
Emergency care providers must not only view patients with AUP nonjudgmentally, but must also hold accurate perceptions of the AUP problem in general. We must develop an ethical imperative, and a cause for action, with evidence based data as the basis for action. We must support actions which engender ownership of the problem, and encourage partnerships to implement positive actions such as the recommended best practices contained in this report.
Any plan to address AUP in emergency care strategies must include strategies for overcoming obstacles and barriers. Not everyone or every situation is ready for change, in fact, it is human nature to resist change. Barriers may exist within the emergency care community, or within the larger health care system. Internal obstacles can undermine efforts to improve practice, and should be addressed. External obstacles can increase the difficulty of accomplishing change, and should be anticipated as much as possible before new practices are implemented. Involving all stakeholders in the process of change may make the implementation process more cumbersome and time-consuming, but may avoid later problems. There is routinely more "buy-in" from people if they are made part of the agent of change, than if change is imposed upon them. Ultimately, emergency care professionals may need to become active advocates, within their own health care system, their community, and their professions, and among public policy makers, to accomplish the goals of effectively dealing with AUP.
Once all of these steps have been accomplished, change can be implemented. Effectively dealing with patients with AUP will require emergency care providers to change their clinical practice in this area. Future directions must include all preparatory steps before change can be successfully implemented. It is the intention of this report to begin that process. We have a medical and ethical responsibility to address the AUP problem for patients we agree to care for. With the help of tools such as the recommendations for best practices and the support we can engender from committed professionals, care of patients with AUP can be improved and a reduction in AUP can be realized.
As with any other medical problem, practice changes to address the needs of the patient with AUP must be evidence based. Future directions of research will be primarily in screening and intervention strategies. Screening tools will be continually honed and improved as research is conducted that addresses issues of sensitivity and specificity, identifying the spectrum of AUP patients and their care. Interventional strategies and treatment programs need to be evaluated for effectiveness and efficiency.
Emergency medicine professionals need to become advocates within their own health care system, community, and professions to improve the care of the patient with AUP. Actively dealing with public policy makers will need to occur, to accomplish the goals of effectively dealing with AUP. Emergency care professionals should support policies that recognize AUP as a disease rather than a mental health problem, so that health insurance covers screening, counseling, referral, and treatment that is initiated within the system. Information systems must be constructed that will give us accurate and comprehensive data on the scope and nature of AUP, so that our clinical, research, education, and policy efforts are informed, and policies and prevention strategies can be developed and evaluated.
Future directions must include all preparatory steps before change can be successfully implemented. It is the intention of this report to begin that process. We have a medical and ethical responsibility to address the AUP problem of our patients. With the help of tools such as the best practices recommendations, and the support we can engender from committed professionals, care of patients with AUP can be improved, and ultimately, a reduction in AUP and its related illnesses and injuries can be realized.
The recommended guidelines which were developed at this conference are only the first step in trying to reduce alcohol-related injuries. Not all states require mandatory reporting. All States must pass laws requiring medical professionals to report alcohol-related injuries. There is also a need to finance this effort and to link screening resources. The success of this effort is directly linked to our ability to find funding partners (hospitals, trauma funding sources, national associations, governments, etc.).
Through this important effort it is hoped that the number of alcohol-related deaths and injuries can be reduced.