Home Addiction Medicine Time to bring alcohol and drug screening in-house?

Time to bring alcohol and drug screening in-house?

November 2013

Published in the November 2013 issue of Today’s Hospitalist

YOU MAY HAVE NEVER HEARD OF SBIRT, a screening tool and intervention process that addresses drug and alcohol use. But chances are, it may be coming soon to a hospital near you.

SBIRT is an inelegant acronym for Screening, Brief Intervention and Referral to Treatment. While it is standard practice in level 1 trauma centers and hundreds of EDs, its use on inpatient medical/surgical units is still spotty.

Hospitalists may wonder why they would be expected to worry about drug and alcohol screening in the inpatient setting. The main goal of SBIRT, after all, is primary prevention for patients with risky alcohol and substance use who don’t yet have addiction. A secondary goal is to find addiction among those seeking health care for other conditions.

But according to Eric Goplerud, PhD, a senior vice president and addiction expert with the independent research organization NORC at the University of Chicago, brief screenings on all inpatients “or at least high-risk individuals “for drug and alcohol use is going to become mainstream.

“Comorbid substance use increases average length of stay, the risk of post-surgery infections and unstable discharges,” says Dr. Goplerud, who is heading up a national initiative to bring SBIRT into hospitals and has worked with the Joint Commission on its substance abuse performance measures. He says that hospitals that identify patents with comorbid substance abuse have found that initiating treatment when patients are still in the hospital significantly reduces inpatient average length of stay, as well as the risk of ICU use or a return to the OR.

No one-size-fits-all
The SBIRT program has been championed for the past decade by trauma surgeons and ED and primary care physicians, and it is now part of many community health and employee assistance programs. While evidence shows that the program can help identify risky alcohol and drug use and reduce costs, there is no one-size-fits-all approach to implementing SBIRT in hospitals outside the ED or trauma center.

Some hospitals, which first integrated SBIRT screening into their EMR for trauma admissions, have simply adopted that screen for all inpatient admissions. Other hospitals use SBIRT for targeted screening and intervention on high-risk patients who report problematic alcohol or substance use or have a substance use diagnosis.

In some hospitals, SBIRT screening is done in the ED, with information about positive screens passed to hospitalists to help facilitate a brief intervention on the wards and appropriate discharge planning. But in other facilities, floor nurses work screening into routine care, or screening and brief interventions are provided on the wards by physical therapists, social workers, psychologists or personnel from outpatient treatment services.

Hospitals can also choose from different SBIRT screening instruments. Several screening tools have been validated, Dr. Goplerud points out, although he strongly recommends using AUDIT-C, a tool that includes the first three questions of the 10-item AUDIT questionnaire.

For the brief intervention, individual hospitals can likewise develop their own protocols. Interventions typically include counseling and, if warranted, initiating treatment with medications. Patients are then linked to treatment services and/or ongoing medication management at discharge.

Reducing readmissions and complications
One reason more hospitals may be incorporating some version of SBIRT is the growing presence of EMRs. Hospitals can now easily build alcohol and drug screens ” as well as ones for tobacco use and depression “into electronic admission protocols.

But Dr. Goplerud admits EMR screens may also be a barrier to SBIRT being adopted more readily. “There are so many things that people are trying to build into EMRs,” he points out, “and this is not seen as the thing that’s going to kill somebody if providers don’t screen.”

Still, SBIRT may soon be making more inpatient inroads. The prevalence of substance use disorders among med/ surg patients, says Dr. Goplerud, is 8%. Given the current reimbursement environment, hospitals are now highly motivated to identify patients with extended lengths of stay and at higher risk of both readmissions and complications.

According to Dr. Goplerud, long-term hospital projects with SBIRT have delivered great outcomes. For instance, one three-year project at the Christiana Care Health System in Delaware, which includes Christiana Hospital and Wilmington Hospital, found significant reductions in both the number of admissions and ED visits among at-risk patients identified through targeted SBIRT screening.

Another program in a regional medical center in Kansas helped dramatically reduce the length of stay associated with inpatients going through alcohol withdrawal, a big concern for hospitals. That hospital also saw an alcohol or drug DRG go from being its second most frequent reason for readmission to its 13th. Hospitals are also identifying more patients on long-acting opiates through SBIRT screening, reducing those patients’ inpatient risk of respiratory complications.

And in the growing marketplace targeting ACOs and bundled payments, more companies are being launched “to bring in people with the skills to treat high-end, high-risk and high-cost patients who have a problem with comorbid substance use,” says Dr. Goplerud. More hospitals may want to collaborate with such outside treatment programs on either a contractual or fee-for-service basis to implement screening and treatment.

“These hospital-based programs are going to hospitalists and saying, ‘We can help you with some of your most difficult patients,’ even without universal screening,” he says.

“It’s going to be increasingly important that hospitals and ACOS manage the care of medically complex patients who have a behavioral component.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Asking the right questions

WHEN IT COMES TO SCREENING, Brief Intervention and Referral to Treatment (SBIRT) programs, no one is expecting physicians to do the brief screening and interventions. But Eric Goplerud, PhD, a senior vice president with the independent research organization NORC at the University of Chicago, which is championing implementation of SBIRT in hospitals, notes that there are many excellent resources to train those who will provide the services.

The National Institute on Alcohol Abuse and Alcoholism, for instance, has developed free online training materials and videos, as has the Emergency Nurses Association.

Boston University’s BNI ART Institute has a video series on SBIRT dos and don’ts, while NORC’s Web-based program uses natural language processing software to allow learners to interact with standardized patients.

In states that require training for providers to bill Medicaid for SBI services, the required training time is usually three or four hours, Dr. Goplerud points out.

“How questions are phrased can have a big impact on whether or not someone reports alcohol or drug use,” he says. He also notes that the brief intervention techniques rely on motivational interviewing.

“That’s a technique that many nurses are either trained in in nursing school or they’ve learned through diabetes education or other patient counseling that focuses on helping patients make choices,” Dr. Goplerud says. “The program employs skills that many clinicians already have and just adapt for use in alcohol interventions.”