The views of nurses to the conduct of a randomised controlled trial of problem drinkers in an accident and emergency department

Perceived barriers by health care providers for screening and management of excessive alcohol use in an emergency department of a low-income country

Annually, alcohol causes 3.3 million deaths; countless more alcohol-related injury patients are treated in emergency departments (EDs) worldwide. Studies show that alcohol-related injury patients reduce their at-risk alcohol-use behavior with a brief negotiational interview (BNI) in the ED. This project aims to identify potential perceived barriers to implementing a BNI in Tanzania. A knowledge, attitude, and practice questionnaire was piloted and administered to all emergency department health care practitioners, including physicians, advanced medical officers, and nurses. The questionnaire included the Perceived Alcohol Stigma (PAS) Scale. The survey was self-administered in English, the language of health care instruction, with a Swahili translation available if preferred. Data were analyzed with relative and absolute frequencies and Spearman's correlation. Thirty-four (100%) health care practitioners completed the survey. Our results found positive attitudes toward addressing alcohol misuse (88%), but very poor knowledge of recommended alcohol-use limits (24%). Participants were willing to discuss alcohol use (88%) and to screen (71%) for alcohol-use disorders. Most health care practitioners report significant stigma against those with alcohol-use disorders (39% discrimination, 53% devaluation, 71% either). Counseling patients about high-risk alcohol use was directly and positively associated with at-risk alcohol and counseling education and believing it was common to ask patients about tobacco and alcohol use; it was negatively associated with believing it was 'not my role' or that knowing about alcohol use 'won't make a difference'. Stigma was negatively and indirectly associated with counseling patients. In conclusion, in an ED in Tanzania, health care practitioners have positive attitudes toward addressing at-risk alcohol use, and endorsed having training in alcohol misuse in school. Unfortunately, participants did not demonstrate knowledge of recommended alcohol limit guidelines. Similarly, among practitioners, there is a significant discrimination and devaluation stigma against those who misuse alcohol. These factors must be addressed prior to a successful implementation of an alcohol harm reduction intervention.

DIAMOND (DIgital Alcohol Management ON Demand): a feasibility RCT and embedded process evaluation of a digital health intervention to reduce hazardous and harmful alcohol use recruiting in hospital emergency departments and online

BACKGROUND

The harmful use of alcohol is a causal factor in more than 200 disease and injury conditions and leads to over 3 million deaths every year worldwide. Relatively few problem alcohol users access treatment due to stigma and lack of services. Alcohol-specific digital health interventions (DHI) may help them, but trial data comparing DHI with face-to-face treatment are lacking.

METHODS

We conducted a feasibility RCT of an alcohol DHI, testing recruitment, online data-collection and randomisation processes, with an embedded process evaluation. Recruitment ran from October 2015 for 12 months. Participants were adults, drinking at hazardous and harmful levels, recruited from hospital emergency departments (ED) in London or recruited online. Participants were randomised to HeLP-Alcohol, a six module DHI with weekly reminder prompts (phone, email or text message), or to face-to-face treatment as usual (TAU). Participants were invited to take part in qualitative interviews after the trial.

RESULTS

The trial website was accessed 1074 times: 420 people completed online eligibility questionnaires; 350 did not meet eligibility criteria, 51 declined to participate, and 19 were recruited and randomised. Follow-up data were collected from three participants (retention 3/19), and four agreed to be interviewed for the process evaluation. The main themes of the interviews were:Participants were not at equipoise. They wanted to try the website and were disappointed to be randomised to face-to-face, so they were less engaged and dropped out.Other reasons for drop out included not accepting that they had a drink problem; problem drinking interfering with their ability to take part in a trial or forgetting appointments; having a busy life and being randomised to TAU made it difficult to attend appointments.

CONCLUSIONS

This feasibility RCT aimed to test recruitment, randomisation, retention, and data collection methods, but recruited only 19 participants. This illustrates the importance of undertaking feasibility studies prior to fully powered RCTs. From the qualitative interviews we found that potential recruits were not at equipoise for recruitment. An alternative methodology, for example a preference RCT recruiting from multiple locations, needs to be explored in future trials.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number: ISRCTN31789096.

Improving recruitment to pharmacological trials for illicit opioid use: findings from a qualitative focus group study

AIM

To explore potential study participants' views on willingness to join clinical trials of pharmacological interventions for illicit opioid use to inform and improve future recruitment strategies.

DESIGN

Qualitative focus group study [six groups: oral methadone (two groups); buprenorphine tablets (two groups); injectable opioid agonist treatment (one group); and former opioid agonist treatment (one group)].

SETTINGS

Drug and alcohol services and a peer support recovery service (London, UK).

PARTICIPANTS

Forty people with experience of opioid agonist treatment for heroin dependence (26 males, 14 females; aged 33-66 years).

MEASUREMENTS

Data collection was facilitated by a topic guide that explored willingness to enrol in clinical pharmacological trials. Groups were audio-recorded and transcribed. Transcribed data were analysed inductively via Iterative Categorization.

FINDINGS

Participants' willingness to join pharmacological trials of medications for opioid dependence was affected by factors relating to study burden, study drug, study design, study population and study relationships. Participants worried that the trial drug might be worse than, or interfere with, their current treatment. They also misunderstood aspects of trial design despite the researchers' explanations.

CONCLUSIONS

Recruitment of participants for clinical trials of pharmacological interventions for illicit opioid use could be improved if researchers became better at explaining clinical trials to potential participants, dispelling misconceptions about trials and increasing trust in the research process and research establishment. A checklist of issues to consider when designing pharmacological trials for illicit opioid use is proposed.

How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis

BACKGROUND

While the efficacy and effectiveness of brief interventions for alcohol (ABI) have been demonstrated in primary care, there is weaker evidence in other settings and reviews do not consider differences in content. We conducted a systematic review to measure the effect of ABIs on alcohol consumption and how it differs by the setting, practitioner group and content of intervention.

METHODS

We searched MEDLINE, EMBASE, PsycINFO; CINAHL, Social Science Citation Index, Cochrane Library and Global Health up to January 2015 for randomised controlled trials that measured effectiveness of ABIs on alcohol consumption. We grouped outcomes into measures of quantity and frequency indices. We used multilevel meta-analysis to estimate pooled effect sizes and tested for the effect of moderators through a multiparameter Wald test. Stratified analysis of a subset of quantity and frequency outcomes was conducted as a sensitivity check.

RESULTS

52 trials were included contributing data on 29 891 individuals. ABIs reduced the quantity of alcohol consumed by 0.15 SDs. While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity (d=-0.23, 95% CI (-0.33 to -0.13)) but not frequency of alcohol consumption. All content groups had statistically significant mean effects, brief advice was the most effective in reducing quantity consumed (d=-0.20, 95% CI (-0.30 to -0.09)). Effects were maintained in the stratified sensitivity analysis at the first and last assessment time.

CONCLUSIONS

ABIs play a small but significant role in reducing alcohol consumption. Findings show the positive role of nurses in delivering interventions. The lack of evidence on the impact of content of intervention reinforces advice that services should select the ABI tool that best suits their needs.

Randomized Controlled Trial of Mailed Personalized Feedback for Risky Drinkers in the Emergency Department: The Impact on Alcohol Consumption, Alcohol-Related Injuries, and Repeat Emergency Department Presentations

BACKGROUND

Due to the difficulty encountered in disseminating resource-intensive emergency department (ED)-based brief alcohol interventions into real-world settings, this study evaluated the effect of a mailed personalized feedback intervention for problem drinking ED patients. At 6-week follow-up, this intervention was associated with a statistically significant reduction in alcohol consumption among patients with alcohol-involved ED presentations. This study aimed to evaluate the effects of this intervention over time.

METHODS

A randomized controlled trial was conducted among problem drinking ED patients, defined as those scoring 8 or more on the Alcohol Use Disorders Identification Test. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback. Follow-up interviews were conducted over the phone, postal survey, or email survey 6 weeks and 6 months after baseline screening, and repeat ED presentations over 12-month follow-up were ascertained via linked ED records.

RESULTS

Six-month follow-up interviews were completed with 210 participants (69%), and linked ED records were obtained for 286 participants (94%). The intervention had no effect on alcohol consumption, while findings regarding alcohol-related injuries and repeat ED presentations remain inconclusive.

CONCLUSIONS

Further research in which the receipt of feedback is improved and a booster intervention is provided is recommended.

Large-scale implementation of alcohol brief interventions in new settings in Scotland: a qualitative interview study of a national programme

Background

This study aimed to explore experiences of implementation of alcohol brief interventions (ABIs) in settings outside of primary healthcare in the Scottish national programme. The focus of the study was on strategies and learning to support ABI implementation in settings outside of primary healthcare in general, rather on issues specific to any single setting.

Methods

14 semi-structured telephone interviews were conducted with senior implementation leaders in antenatal, accident and emergency and wider settings and audio-recorded. Interviews were analysed inductively.

Results

The process of achieving large-scale, routine implementation of ABI proved challenging for all involved across the settings. Interviewees reported their experiences and identified five main strategies as helpful for strategic implementation efforts in any setting: (1) Having a high-profile target for the number of ABIs delivered in a specific time period with clarity about whose responsibility it was to implement the target; (2) Gaining support from senior staff from the start; (3) Adapting the intervention, using a pragmatic, collaborative approach, to fit with current practice; (4) Establishing practical and robust recording, monitoring and reporting systems for intervention delivery, prior to widespread implementation; and (5) Establishing close working relationships with frontline staff including flexible approaches to training and readily available support.

Conclusions

This qualitative study suggests that even with significant national support, funding and a specific delivery target, ABI implementation in new settings is not straightforward. Those responsible for planning similar initiatives should critically consider the relevance and value of the five implementation strategies identified.

Uncovering the emotional aspects of working on a clinical trial: a qualitative study of the experiences and views of staff involved in a type 1 diabetes trial

Background

The perspectives and experiences of trial staff are increasingly being investigated as these can be used to improve recruitment, adherence to trial protocols and support given to future staff. We interviewed staff working on a type 1 diabetes trial in order to aid interpretation of trial findings, inform recommendations for the rollout of the treatments investigated and provide recommendations for the conduct of future trials. However, our interviews uncovered aspects of trial work erstwhile unrecognised or underreported in the trials literature, and it is these which form the focus of this paper.

Methods

In-depth interviews were conducted with (n = 18) staff, recruited from seven centres, who were involved in recruitment and trial delivery. Data were analysed thematically.

Results

Alongside logistical and practical issues which made trial work challenging, staff often talked spontaneously and at length about how trial work had affected them emotionally. Staff not only described the emotional stresses arising from having to meet recruitment targets and from balancing research roles with clinical responsibilities, they also discussed having to emotionally manage patients and their colleagues. The emotional aspects of trial work particularly came to the fore when staff notified patients about their treatment allocation. On such occasions, staff described having to employ emotional strategies to pre-empt and manage potential patient disappointment and anger. Staff also described having to manage their own emotions when patients withdrew from the trial or were not randomised to the treatment arm which, in their clinical judgment, would have been in their best interests. To help address the emotional challenges they encountered, staff highlighted a need for more practical, emotional and specialist psychological support.

Conclusions

More attention should be paid to the emotional aspects of trial work to help ensure trial staff are adequately supported. Such support could comprise: increased training for staff to improve their own and patients’ understandings of randomization, role-play to develop techniques to manage patient anger and disappointment, sharing of good practice, formalised team support with psychological input and access to specialist psychological support to troubleshoot complex emotional and ethical issues.

Translation of alcohol screening and brief intervention guidelines to pediatric trauma centers

BACKGROUND

As part of the American College of Surgeons verification to be a Level 1 trauma center, centers are required to have the capacity to identify trauma patients with risky alcohol use and provide an intervention. Despite supporting scientific evidence and national policy statements encouraging alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT), barriers still exist, which prevent the integration of SBIRT into clinical care. Study objectives of this multisite translational research study were to identify best practices for integrating SBIRT services into routine care for pediatric trauma patients, to measure changes in practice with adoption and implementation of a SBIRT policy, and to define barriers and opportunities for adoption and implementation of SBIRT services at pediatric trauma centers.

METHODS

This translational research study was conducted at seven US pediatric trauma centers during a 3-year period. Changes in SBIRT practice were measured through self-report and medical record review at three different study phases, namely, adoption, implementation, and maintenance phases.

RESULTS

According to medical record review, at baseline, 11% of eligible patients were screened and received a brief intervention (if necessary) across all sites. After completion of the SBIRT technical assistance activities, all seven participating trauma centers had effectively developed, adopted, and implemented SBIRT policies for injured adolescent inpatients. Furthermore, across all sites, 73% of eligible patients received SBIRT services after both the implementation and maintenance phases. Opportunities and barriers for successful integration were identified.

CONCLUSION

This model may serve as method for translating SBIRT services into practice within pediatric trauma centers.

2012 Update in addiction medicine for the generalist

This article presents an update on addiction-related medical literature for the calendar years 2010 and 2011, focusing on studies that have implications for generalist practice. We present articles pertaining to medical comorbidities and complications, prescription drug misuse among patients with chronic pain, screening and brief interventions (SBIs), and pharmacotherapy for addiction.

Developing a survey of barriers and facilitators to recruitment in randomized controlled trials

BACKGROUND

Recruitment to randomized controlled trials is known to be challenging. It is important to understand and identify predictors of good or poor accrual to a clinical trial so that appropriate strategies can be put in place to overcome these problems and facilitate successful trial completion. We have developed a survey tool to establish the recruitment experience of clinical teams regarding facilitators and barriers to recruitment in a clinical trial and describe herein the method of developing the questionnaire.

METHODS

A literature search was conducted to identify studies that have explored facilitators and barriers to recruitment, and a list of potential factors affecting recruitment to a clinical trial was generated. These factors were categorized in terms relating to the (i) trial, (ii) site, (iii) patient, (iv) clinical team, (v) information and consent and (vi) study team. A list was provided for responders to grade these factors as weak, intermediate or strong facilitators or barriers to recruitment.

RESULTS

A web-based survey questionnaire was developed. This survey was designed to establish the recruitment experience of clinical teams with regard to the perceived facilitators and barriers to recruitment, to identify strategies applied to overcome these problems, and to obtain suggestions for change in the organization of future trials. The survey tool can be used to assess the recruitment experience of clinical teams in a single/multicenter trial in any clinical setting or speciality involving adults or children either in an ongoing trial or at trial completion. The questionnaire is short, easy to administer and to complete, with an estimated completion time of 11 minutes.

CONCLUSIONS

We have presented a robust methodology for developing this survey tool that provides an evidence-based list of potential factors that can affect recruitment to a clinical trial. We recommend that all clinical trialists should consider using this tool with appropriate trial-specific adaptations to monitor and improve recruitment performance in an ongoing trial or conduct the survey at trial completion to gather information on facilitators and barriers to recruitment that can form the basis of interventions and strategies to improve recruitment to future clinical trials.

A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center

BACKGROUND

Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients.

METHODS

We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting.

RESULTS

A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.

CONCLUSIONS

RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.

Meeting standards set for non self-harm presentations to emergency departments

OBJECTIVES

The commonest psychiatric presentation in most emergency departments (EDs) is deliberate self-harm. However, there are other significant categories of psychiatric presentation which include alcohol and substance misuse, acute psychosis and mood disorder. In addition to the NICE Guidelines for deliberate self-harm, there are good practice guidelines available for the management of other psychiatric attendances to the ED. The aim of this study was to identify the psychiatric attendances other than deliberate self-harm to Beaumont Hospital ED over a 12-month period with the objective of studying the rates and characteristics of attendances and to investigate whether good practice guidelines were met.

METHOD

From a total of 657 psychiatric attendances other than deliberate self-harm which were recorded, data was collected on demographics, provision of a psychosocial assessment and adherence to good practice guidelines.

RESULTS

Alcohol (38%) was the most common reason for presentation. Of the total number of attendees, only 44% received a psychosocial assessment compared to 59% of attendees who had presented following deliberate self-harm during the same 12-month period.

CONCLUSIONS

The attendees who did not receive a psychosocial assessment represent a vulnerable group in which the levels of psychosocial assessment need to be improved in order to meet good practice guidelines standards of care.

Randomized controlled trial of mailed personalized feedback for problem drinkers in the emergency department: the short-term impact

BACKGROUND

Evidence exists for the efficacy of emergency department (ED)-based brief alcohol interventions, but attempts to incorporate face-to-face interventions into routine ED practice have been hampered by time, financial, and attitudinal constraints. Mailed personalized feedback, which is likely to be more feasible, has been associated with reduced alcohol consumption in other settings, but its cost-effectiveness in the ED has not been examined.

METHODS

The intervention was evaluated with a randomized controlled trial of patients presenting to 5 rural EDs in New South Wales, Australia. Patients aged 14 years and older were screened using the Alcohol Use Disorders Identification Test, and those scoring 8 or more were randomly allocated to the intervention or control group. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback.

RESULTS

Two hundred and forty-four (80%) participants were successfully followed up at 6 weeks. A significant effect of the mailed feedback was observed only in patients with an alcohol-involved ED presentation. Among this subgroup of participants, those in the intervention group consumed 12.2 fewer drinks per week than the control group after controlling for baseline consumption and other covariates (effect size d = 0.59). The intervention was associated with an average cost of Australian $5.83 per patient, and among participants with an alcohol-involved ED presentation, an incremental cost-effectiveness ratio of 0.48.

CONCLUSIONS

Mailed personalized feedback is efficacious in reducing quantity/frequency of alcohol consumption among patients with alcohol-involved ED presentations. Mailed feedback has high cost-efficacy and a low absolute cost, making it a promising candidate for integration into ED care.

Beliefs and practices of pediatric emergency physicians and nurses regarding counseling alcohol-using adolescents: can counseling practice be predicted?

OBJECTIVES

The objectives of the study were to investigate the attitudes and practices of pediatric emergency department (PED) physicians (MDs), MD extenders (MD's assistants [PAs], nurse practitioners [NPs]), and nurses (RNs) regarding their counseling of alcohol-using adolescent PED patients and to determine which, if any, PED clinician characteristics predict current counseling practice.

METHODS

An Internet-based survey of PED clinicians (MDs, PAs, NPs, and RNs) from 11 academic US PEDs was conducted. Respondents were asked about their counseling training, current counseling practices, confidence in their counseling skills, importance of counseling, attitudes and beliefs about counseling, and demographic information. Univariate and multivariate analyses were performed to determine the relationship between clinician characteristics and counseling practice.

RESULTS

Counseling practice was strongly associated with one's profession; PED MDs/PAs/NPs reported significantly higher rates of counseling alcohol-using adolescents than PED RNs. These 2 groups differed significantly in terms of counseling training and experience. Counseling training and experience remained significant predictors of counseling practice, even after controlling for profession and other covariates. Both groups had similar views on the importance of counseling, confidence in their ability to counsel, and counseling substance-using adolescent PED patients.

CONCLUSIONS

Pediatric ED MDs/PAs/NPs differ significantly from PED RNs in their counseling training, experience, and practice. These findings have important implications for the training and support necessary to successfully implement PED counseling. Specifically, formal training in counseling during professional schooling and garnering counseling experience after completing training may be critical factors in promoting PED counseling.

Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

BACKGROUND

This review aimed to synthesize qualitative evidence for barriers and facilitators to effective implementation of screening and brief intervention for alcohol misuse in adults and children over 10 years.

METHODS

A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesized thematically.

RESULTS

A total of 47 papers varying in design and quality were included in the review. Most evaluated implementation in primary care settings. Implementation was reported to be limited by lack of resources, training and support from management, as well as workload. The appropriateness of context in which discussions take place was reported as an acceptability factor for patients and practitioners. Health professionals require sufficient knowledge about alcohol guidelines and risk in order to implement screening and intervention to those most in need.

CONCLUSIONS

Whilst brief screening and brief intervention have been shown to be effective in some settings, this review has identified a number of barriers and facilitators to implementation. Adequate resources, training and the identification of those at risk without stereotyping are the main facilitators in primary care. More research is needed to assess implementation in other settings.

Strategies to engage clinical staff in subject recruitment

PURPOSE: In many countries, meeting subject recruitment goals is challenging for researchers relying on clinical staff members (CSMs) to identify or recruit subjects. This paper describes research strategies that improved staff engagement in three different studies conducted in US clinical settings. METHOD: The recruitment strategies described in this paper were identified during the process of consultation among three US researchers recruiting via CSMs. Strategies which successfully engaged CSMs are described. RESULTS: Our approach improved engagement with CSMs in three different US studies. Early engagement strategies included establishing trust, gathering input from CSMs, and using succinct training procedures as well as a study logo. Middle phase strategies included assigning recruitment, publishing a study newsletter, giving the CSMs compensation and appreciation for their participation, and expanding the subject pool. Completion strategies included closing with an appreciation meeting and adding merit letters to personnel files. CONCLUSION: Recruitment of an adequate number of subjects is often challenging, even within clinical settings where subject populations are abundant. CSMs have rightly prioritised clinical care over directing subjects to research studies. It is therefore critical that researchers recruiting in such clinical settings anticipate recruitment challenges and plan to implement appropriate engagement strategies in all phases of research.

Implementation of a computerized alcohol advice concept in routine emergency care

BACKGROUND

There is a growing body of evidence for computer-generated advice for many health behaviours. This study evaluated the implementation of a computerized concept to provide tailored advice on alcohol in a Swedish emergency department (ED).

AIM

The aim was to evaluate the usage of the concept over 12 months: participation rate among the ED population; representativeness of the participants; and participation development over time.

METHODS

The target population was defined as all patients aged 18-69 years given a card from ED triage staff with a request to conduct a computerized test about their alcohol use. After completing the 5-10-min programme, the patient received a printout, containing personalised alcohol habit feedback, as calculated by the computer from the patient's answers. Data for this study were primarily obtained from the computer programme and ED logs.

RESULTS

Forty-one percent of the target population completed the computerized test and received tailored alcohol advice. The number of patients who used the concept showed a slight decreasing trend during the first half of the year, leveling off for the second half of the year.

CONCLUSION

A computerized concept for provision of alcohol advice can be implemented in an ED without unrealistic demands on staff and with limited external support to attain sustainability.

Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries

AIMS

To critique the methodological adequacy of evaluations of emergency department (ED)-based interventions for alcohol problems and to conduct a meta-analysis to examine the extent to which interventions in this setting are effective in reducing alcohol consumption and related harm.

METHODS

An electronic search of 11 databases and a manual search of reference lists were conducted to identify studies published in peer-review journals between January 1996 and July 2007 (inclusive). Studies evaluating the outcome of an intervention designed to reduce alcohol problems in patients presenting to the ED were eligible for inclusion. Methodological data were extracted using review criteria adapted from the both the Center for Disease Control (CDC) Guide to Community Preventive Services Data Collection Instrument and the Cochrane Effective Practice and Organization of Care Review Group Data Collection Checklist. Continuous outcomes were pooled using a fixed effect inverse variance approach while binary outcomes were pooled in a generic inverse variance meta-analysis.

RESULTS

Thirteen studies were identified for inclusion in the review. Methodological quality was found to be reasonable, with the exception of poor reporting of effect-size information and inconsistent selection of outcome measures. Meta-analyses revealed that interventions did not significantly reduce subsequent alcohol consumption, but were associated with approximately half the odds of experiencing an alcohol-related injury (odds ratio = 0.59, 95% confidence interval 0.42-0.84).

CONCLUSIONS

There are few evaluations of emergency department-based interventions for alcohol problems. Future evaluations should use consistent outcome measures and report effect sizes. The existing evidence suggests that interventions are effective in reducing subsequent alcohol-related injuries.

Barriers and strategies for recruiting study participants in clinical settings

Recruiting participants for research studies is often a challenging task. Recruitment requires careful planning, collaboration, and flexibility on the part of researchers and health care providers at the recruitment sites. This article describes six major barriers to recruiting study participants as identified from a review of the literature and from the coauthors' research experiences. These barriers include challenges related to regulations of the Health Insurance Portabililty and Accountability Act (HIPAA), health care providers' work burden, providers' financial disincentives, competition, health care provider concerns regarding research, and provider protection of patients. Each barrier is described, and specific strategies are suggested based on the empirical literature. In some instances, the coauthors' experiences are also shared.

Implementation of computerized alcohol screening and advice in an emergency department – a nursing staff perspective

Changes in attitudes towards alcohol prevention among nursing staff are evaluated after implementing an opportunistic computerized alcohol screening and intervention (e-SBI) at an emergency department. After having assessed the patients in the triage room the nurses asked patients to perform the e-SBI on a touch screen computer. Before the start of the project more than 60% of the nurses expected the patients to react negatively when asked about their alcohol habits. After one year of screening only 10% reported experience of negative reactions from the patients. More than 50% of the nurses found it easy or very easy to ask the patients to perform the e-SBI and more than 75% of the nurses agreed that the e-SBI did not affect their workload. The proportion of nurses who considered alcohol prevention to be part of their duties at the emergency department did not change (40%) after implementing the e-SBI. During the two-year study period, 1982 patients completed the e-SBI which constituted 10-20% of all patients between 16 and 70 years of age attending the department for a sub critical condition. The e-SBI seems to have better potential than ordinary alcohol screening and intervention for implementation into routine emergency departments due to its simplicity and low time consumption.

Usual drinking patterns and non-fatal injury among patients seeking emergency care

OBJECTIVES

To explore the association between drinking patterns, irrespective of whether alcohol was consumed in the event of the injury or not, and different injury variables; and to identify settings and situations in which risky drinkers have an increased likelihood of injury.

STUDY DESIGN

The study population consisted of all patients aged 18-70 years registered for an injury according to ICD-10 at a Swedish emergency department during an 18-month period. After informed consent, the injury patients were screened for drinking habits by the AUDIT-C questionnaire. The gender, age and drinking pattern of injury patients were compared with the general population.

METHODS

A total of 2782 patients aged 18-70 years were registered for an injury during the study period. The number of drop-outs was 631. Drop-outs include those who did not consent to participate, were severely injured, too intoxicated or did not fill out the questionnaire satisfactory. Thus, 77.3% of the target group were included for further analysis (1944 drinkers and 207 abstainers). The patients were categorized into three drinking categories: abstainers, non-risky and risky drinkers. Risky drinkers were defined according to usual weekly consumption of 80g or more of alcohol for women and 110g or more for men and/or heavy episodic drinking (i.e. having six glasses or more one glass=12g alcohol), or both, on one occasion at least once a month, valid for both women and men. To estimate the relationship between drinking patterns and the injury variables (environment, cause of injury, activity and diagnosis), odds ratios (OR) were calculated by logistic regression. Multiple logistic regression was used in order to control for age and sex differences between the various drinking and injury categories.

RESULTS

The proportion of risky drinkers was higher in the study population compared with the general population in the same area. When controlling for age and sex, risky drinkers (OR 6.4(adj) Confidence interval CI 1.9-21.2) and non-risky drinkers (OR .4.5(adj) CI 1.4-14.5) displayed an increased risk for injury compared with abstainers, in amusement locations, parks, by or on lakes or seas, especially while engaged in play, hobby or other leisure activities (risky drinkers: OR 2.8(adj) CI 1.3-5.6; non-risky drinkers: OR 2.4(adj) CI 1.2-4.6). All differences between drinking patterns in external cause of injury disappeared when age and sex were considered. During rest, meals and attending to personal hygiene, the non-risky drinkers had a lower probability of injury compared with abstainers (OR 0.3(adj) CI 0.1-0.8). Non-risky drinkers had a higher probability than abstainers of suffering luxation (dislocation) or distortion (OR 1.6(adj) CI 1.1-2.5). Nine per cent of the study population reported that they believed that their injury was related to intake of alcohol. Half of this group were non-risky drinkers (CI for the 13.7% difference was 9.7-17.6).

CONCLUSIONS

Few significant associations between drinking pattern and injury remained when age and sex were controlled for.

Telephone screening for hazardous drinking among injured patients seen in acute care clinics: feasibility study

AIMS

We evaluated the effectiveness of telephoning injured patients after discharge, compared with contacting them in the clinic during the acute care visit, for screening for hazardous drinking and eliciting willingness to participate in a lifestyle intervention trial.

METHODS

We conducted a quasi-randomized controlled trial among acutely injured adult patients in trauma and acute care clinics, assigning telephone and clinic screening strategies systematically by week. During telephone weeks, we mailed study information to patients identified from computerized records, then telephoned them. During clinic weeks, researchers recruited patients awaiting care. We screened for hazardous drinking using the AUDIT-C (Alcohol Use Disorders Identification Test-C). We examined the proportion of all injured adult patients who were screened, the proportion of screened patients with hazardous drinking (AUDIT-C score >or=4), and the proportion willing to participate in a (hypothetical) lifestyle intervention trial. Differences were analysed with non-linear mixed models using generalized estimating equations, controlling for age, sex, and facility. Levers and barriers to screening were explored through structured interviews with research staff.

RESULTS

We enrolled 29% (469/1,609) of all injured adult patients and 76% of injured patients contacted and found to be eligible. Of screened patients, 23.1% screened positive for hazardous drinking. Telephone and clinic contact were equally effective for screening patients (OR = 1.05; 95% CI = 0.59-1.87), identifying hazardous drinking (OR=0.97; 95% CI = 0.54-1.74), and eliciting willingness to participate in an intervention trial (OR=1.49; 95% CI = 0.97-2.30). Clinic site modified results: telephone was more effective than clinic contact for screening urban patients (OR=1.99; 95% CI = 1.36-2.93), but less effective for screening suburban patients (OR = 0.70; 95% CI = 0.69-0.71). Barriers to clinic screening included lack of clinic staff support, time constraints, and difficulty recruiting elderly or acutely distressed patients. Barriers to telephone screening included erroneous contact information and failure to answer the telephone.

CONCLUSIONS

Telephone screening is a feasible and efficient method for screening moderately injured adult patients for hazardous drinking, but characteristics of the clinical site (including personnel) influence its effectiveness. Trauma and acute care clinics are likely to be fruitful sites for identification of patients with hazardous drinking, whether for enrollment into brief intervention trials or treatment programmes.

Effectiveness of nurse-led brief alcohol intervention: a cluster randomized controlled trial

AIM

This paper reports an evaluation of the effectiveness and cost-effectiveness of nurse-led screening and brief intervention in reducing excessive alcohol consumption among patients in primary health care.

BACKGROUND

Excessive alcohol consumption is a major source of social, economic and health problems. However, such consumption is responsive to brief alcohol intervention. To date, brief intervention research in primary health care has focused on general practitioner-led interventions, and there is only circumstantial evidence of effectiveness in nurse-led interventions. However, nurses are increasingly taking a lead in health promotion work in primary care.

METHODS

A pragmatic cluster-randomized controlled trial was carried out between August 2000 and June 2003 to evaluate the effects of a brief intervention compared with standard advice (control condition). A total of 40 general practice clusters (intervention = 21 and control = 19) recruited 127 patients (intervention = 67 and control = 60) to the trial. Excessive consumption was identified opportunistically via the Alcohol Use Disorders Identification Test. After baseline assessment, patients received either a 5-10 minutes brief intervention using the 'Drink-Less' protocol or standard advice (control condition). Follow-up occurred at 6 and 12 months postintervention.

RESULTS

Analysis of variance weighted for cluster size revealed no statistically significant differences between intervention and control patients at follow up. A majority of patients in both conditions reduced their alcohol consumption between assessment and subsequent measurement. Economic analysis suggested that the brief intervention led to no statistically significant changes in subsequent health service resource use relative to standard treatment.

CONCLUSION

The brief intervention evaluated in this trial had no effect over standard advice delivered by nurses in primary health care. However, there was a reduction in excessive drinking across both arms of the trial over time. Due to nurse drop-out, this trial was significantly underpowered. Future research should explore barriers to nurses' involvement in research trials, particularly with an alcohol focus. A larger trial is required to evaluate the effectiveness of nurse-led screening and brief alcohol intervention in primary care.

Barriers to interventions for alcohol problems in trauma centers

There is clear evidence that trauma-related serious injuries and fatalities can be directly linked to alcohol misuse. Because alcohol is a factor in many motor vehicle crashes (the leading cause of death for persons up to age 49), the National Highway Traffic and Safety Administration has set a high priority on decreasing alcohol-related motor vehicle crash injuries. Research now recognizes that most alcohol-impaired drivers who are injured are binge drinkers, not alcoholics. During the past decade, public health and substance treatment researchers have begun to focus on screening and early intervention in clinical settings as a means of reducing alcohol-related injuries. Trauma centers are uniquely positioned to address this problem because of the high percentage of alcohol-impaired patients admitted after motor vehicle crashes. This article discusses the barriers to implementing alcohol screening and intervention programs in trauma centers from the trauma surgeon's perspective.

Attitude changes among emergency department triage staff after conducting routine alcohol screening

Excessive alcohol consumption is common among injury patients, but routine alcohol interventions seem to be difficult to implement in emergency departments. An obstacle seen in previous studies is the limited time available in a real-world setting for staff to participate in routine alcohol screening and interventions. In the present study, ordinary staff participated in a simple alcohol screening procedure. The aim of the study was to evaluate the feasibility of this procedure and if there was any change in attitudes and practices among triage staff after the implementation. We analyzed interviews with six staff members and questionnaires completed by 29 nurses and medical secretaries before and after a period of systematic routine screening. The staff reported that the routine worked well and that few patients reacted negatively. A positive change was seen in attitudes towards alcohol preventive measures in general. However, this seems not to be sufficient for the staff to spontaneously engage more actively. In fact, more of the staff were uncertain after the study period whether the emergency department is an appropriate place for alcohol screening and intervention despite an increased role legitimacy and perceived competence. There is a need for further development of alcohol prevention models that are acceptable for the staff to implement as part of the daily routine.

Can screening and simple written advice reduce excessive alcohol consumption among emergency care patients?

AIMS

Emergency care patients have an overrepresentation of risky drinkers. Despite the evidence on the effectiveness of a short feedback on screening or self-help material, most studies performed so far have required considerable time from staff and thus been difficult to implement in the real world. The present study evaluates the effect of the screening and whether simple written advice has any additional effect on risky drinking.

METHODS

An alcohol screening routine was implemented among injury patients in a Swedish emergency care department. Over 12 months, two cohorts were invited to answer an alcohol screening questionnaire in the waiting room. In the first 6 months, 771 patients were screened without any written advice (cohort A) and in the following 6 months, 563 were screened and in addition received simple written advice about sensible drinking (cohort B). None of the patients received one-to-one feedback. Six months after the screening, a follow-up interview by telephone explored the changes in drinking.

RESULTS

In cohort A 182 (24%) of the patients were defined as risky drinkers and in cohort B 125 (22%). Reached at follow-up after 6 months were 81 (44%) risky and 278 (47%) non-risky drinkers in cohort A, and 40 (32%) risky and 220 (50%) non-risky drinkers in cohort B. The number of patients with heavy episodic drinking decreased significantly in cohort A from 76 (94% of the risky drinkers) to 49 (59%). In cohort B a similar change was seen from 37 (92%) to 27 (68%). Only in cohort B, was a significant increase in readiness to change drinking habits seen [from 3 (8%) to 9 (23%)]. The reduction in heavy episodic drinking was comparable with previous reports from more extensive interventions. However, at the time of follow-up, drinking among non-risky drinkers at baseline had increased. When considering the greater numbers of non-risky drinkers, the total consumption in the study group increased during the study period.

CONCLUSIONS

Owing to the reported difficulties of integrating more time-consuming alcohol interventions in emergency departments, it is suggested that at least screening for drinking should be implemented as routine in emergency departments. More research is needed in order to establish the optimal balance between effective alcohol intervention, and acceptable time and effort requirement from staff.

Acceptability of a computerized alcohol screening and advice routine in an emergency department setting--a patient perspective

Disseminating screening and brief alcohol intervention in routine emergency department (ED) care seems to be a demanding challenge due to the complexity of the emergency setting. Further empirical realistic intervention models need to be developed that are appropriate for staff and patients before such models are tested in large scale controlled trials. This study explores patients' acceptance of a computerized opportunistic alcohol screening, followed by a personalized printout as feedback, at an emergency department performed by ordinary emergency department staff. In all, 44 patients were interviewed after performing the computerized screening test. The majority of patients were positive about answering the questions about alcohol habits, and 95% found it easy to use the touch screen and understand the instructions, even those with little computer experience. Regarding the personalized printout of advice, 76% were positive to this kind of feedback and 93% said they would read the printout. Most patients, 74%, preferred the computerized printout instead of a more personalized feedback from staff members. Whether the computerized advice is sufficient for a change in alcohol habits among excessive drinkers is still to be shown in controlled trials, but the concept could be one means of making preventive measures more feasible in a real-world ED setting. This might provide a basis for dissemination and integration of more extensive interventions in the long term.

Feasibility of a computerized alcohol screening and personalized written advice in the ED: opportunities and obstacles

This study evaluates the feasibility of a computerized alcohol screening and intervention in patients seeking care at an emergency department. The aim of the study was to explore prevailing attitudes among nursing staff to alcohol prevention in general and the computerized screening concept before the introduction of the computerized screening procedure. Interviews were performed with six nursing staff members and a written questionnaire applied to all staff participating in training before the implementation of the concept. Observation was done in order to evaluate how the screening was performed and implemented in order to gain more knowledge about possible obstacles to alcohol screening at an emergency department. The project concept of computerized screening and low staff involvement was found to be a feasible way to overcome organizational barriers such as time limitation but there were still important attitudinal barriers among staff; thus a great disparity in practices between different staff members was observed. The results suggest that it is possible, given the time limitation, to include a computerized screening and intervention in the routines of an emergency department, when the staff regard prevention as part of their responsibilities. The findings provide evidence about the acceptability by nursing staff and feasibility of a computerized screening and personalized print out as feed back to the patients.

Recruitment into a long-term pediatric asthma study during emergency department visits

OBJECTIVE

Asthma is the most common chronic illness in childhood. Recruiting children and their parents into a research study in a busy urban emergency department (ED) is challenging. The purpose of this manuscript is to describe the recruitment process and the results of our recruitment in soliciting children and their parents to participate in an ED-based asthma research study.

METHODS

The data for this manuscript came from a National Heart, Lung, and Blood Institute-funded study: Study of Asthma Follow-up from the Emergency Department (SAFE). SAFE evaluated an ED-based intervention to link low-income urban children with asthma to their primary care providers. Two persons were assigned specifically to enrolling, which was done from 0700 to 2300 hours Monday through Friday. Data for the analysis come from the web-based database, the master log, and the hospital's patient database. A computerized randomization scheme chose 512 patients from all patients in the master log for more detailed demographic analyses.

RESULTS

Five hundred twenty-seven subjects were enrolled between February 1999 and May 2001. There were 9188 children who presented for treatment of an acute asthma exacerbation during this interval. The number of eligible parents was similar to the predicted number. Chart reviews were conducted on a subset of patients presenting to the ED to ensure that the recruitment strategy did not bias the patients enrolled. Demographic characteristics of asthma patients were similar during enrollment and non-enrollment times. Comparison of patients who were enrolled with those who were not enrolled indicated no differences by gender, race, insurance status, age, or socioeconomic status of neighborhood residence.

DISCUSSION

The high rate of enrollment was primarily due to the two dedicated enrollers. The enrollers quickly learned how to function within the ED and how to interact with both families and ED staff. Strategies identified by the enrollers as helpful in randomizing subjects included visits with the parents shortly after the physician had initiated treatment so that stability of the child had been achieved. Interacting with the child and showing concern for the comfort of both the child and parent during the ED stay were important as well.

CONCLUSION

Recruiting subjects into long-term follow-up studies in the ED setting is a departure from traditional ED studies. The ED enrollment offers the distinct advantage of capturing subjects who are unlikely to present for care in other locations. We were able to successfully recruit low-income urban parents of children with asthma for study of both short-term and long-term outcomes. Careful attention to planning and then integration of enrollers into the ED setting can result in successful recruitment of patients and their parents. The enrollment process successfully captured the subjects of interest without bias.

Accident and emergency nurses as researchers: exploring some of the ethical issues when researching sensitive topics

The breadth and complexity of accident and emergency (A&E) services is potentially a fruitful area for nursing and interdisciplinary research. A significant proportion of potential areas for research in A&E settings could be considered as 'sensitive topic areas'. Sensitive topic research raises many challenges; in particular, it raises specific ethical issues. This paper defines and identifies examples of sensitive topic area research in A&E and discusses some of the ethical issues to be considered before embarking on such research in A&E settings.

Improving detection of alcohol misuse in patients presenting to an accident and emergency department

OBJECTIVES

To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT). Design-Prospective study of the effects of audit feedback.

SETTING

An urban accident and emergency department.

SUBJECTS

Senior house officers (SHO) (n = 13).

OUTCOME MEASUREMENTS

PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT.

RESULTS

1062 of 1737 patients (61.1%) were defined as PAT possible-that is, presented with > or = one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p<0.0001). The response to audit and feedback showed marked inter-SHO variation. When feedback was withdrawn (month 4), there was a significant reduction in PAT use (p=0.003). Three other indices of detection followed this trend: (a) number of PAT positive patients identified, (b) proportion of PAT possible patients identified as PAT positive, and (c) number of PAT positive patients referred to the alcoholic health worker. The 10 most common PAT positive categories, accounting for 77% of all PAT positive complaints were: fall > collapse (including "fit", "blackout") > head injury (including "facial injury") > assault (including "domestic violence" and 'other') > nonspecific gastrointestinal problem > "unwell" > psychiatric (including "depression", "overdose", "confusion") > cardiac (including "chest pain" and "palpitations") > self neglect > repeat attendance.

CONCLUSIONS

Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.