C L I N I C A L

Tiffany L. OWorth, TX.

Gary WilliaWorth, TX.

Shahid Shafi

Rajesh R. GWorth, TX.

For correspoOverton, TWorth, TX

J Emerg Nu

0099-1767/

Copyright ©All rights re

http://dx.do

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UTILIZATION OF PASTORAL CARE SERVICES FOR A

SCREENING, BRIEF INTERVENTION, AND

REFERRAL-TO-TREATMENT PROGRAM AT AN

URBAN LEVEL I TRAUMA CENTER

Authors: Tiffany L. Overton, MA, MPH, CPH, Gary Williams, Shahid Shafi, MD, andRajesh R. Gandhi, MD, PhD, Fort Worth, TX

Excessive alcohol consumption is currently the thirdleading cause of preventable death within theUnited States, accounting for roughly 80,000 deaths

each year.1 Excessive alcohol consumption also takes a tollon hospitals and health care centers, specifically emergencydepartments and trauma units. Each year, over 20 millionadults in the United States sustain injuries requiringemergency care, and 15% to 20% screen positive foralcohol.2–5 These figures increase further within the traumadepartment, where up to half of all trauma accidents arelinked to alcohol use (25%-50%).4–6

Screening for excessive alcohol use and briefmotivational interventions—screening, brief intervention,and referral to treatment (SBIRT) programs—have beenshown to reduce the number of alcohol-related injuries.7–10 The American College of Surgeons has mandated theuse of SBIRT programs at all designated trauma centerssince 2008.11 The CAGE (cut back, annoyed, guilt, andeye opener) questionnaire12 and the Alcohol UseDisorders Identification Test (AUDIT)13 are used todetect individuals who may be abusing alcohol and/orother drugs.14 In 1993 an SBIRT program was developed

verton is Trauma Research Associate, JPS Health Network, Fort

ms is SBIRT Program Coordinator, JPS Health Network, Fort

is Consultant, JPS Health Network, Fort Worth, TX.

andhi is Trauma Medical Director, JPS Health Network, Fort

ndence, write: Tiffany L. Overton, MA, MPH, CPH, Tiffanyrauma Services, JPS Health Network, 1500 S Main St, Fort76104; E-mail: toverton@jpshealth.org.

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$36.00

2014 Emergency Nurses Association. Published by Elsevier Inc.served.

i.org/10.1016/j.jen.2014.01.008

to identify at-risk individuals while continually monitor-ing their progress. The CAGE and AUDIT questionnaireshave shown more efficacy in the identification of alcoholuse problems than other screening methods, even the useof direct questions about the quantity and frequency ofuse,15 with the AUDIT slightly more effective than theCAGE questionnaire.16

For the first step in the SBIRT process, the previouslymentioned screening procedures (CAGE and AUDITquestionnaires) are commonly used to assess alcoholconsumption behaviors in patients with an elevated bloodalcohol content. Brief intervention can range from briefmotivational conversations to more extensive interventions,with the ultimate goal of motivating individuals to changetheir substance use behaviors. The last step of the SBIRTprogram, referral to treatment, consists of helping clientsidentify resources to assist with alcohol or substance abuserecovery.6

Research has shown that the implementation of SBIRTprograms is associated with reductions in excessive alcoholconsumption. The implementation of SBIRT programs hasshown reductions in negative consequences associated withdrinking,7–10 as well as reduced consumption after 3months.17 Given their efficacy, SBIRT programs arerecommended by several national organizations to reducealcohol misuse among injured patients.11,18,19

SBIRT Program Using Chaplains

SBIRT programs are most frequently conducted by nursingstaff and social workers.20 In January 2010, SBIRTprotocols were implemented at our hospital and assignedto providers of pastoral care services because of their abilityto meet personnel demands without imposing additionalrequirements on clinicians. On presentation, all traumapatients are tested for drugs and alcohol, and their results arerecorded in their electronic medical records. Traumaregistrars provide daily reports of trauma patients presentingwith a blood alcohol content greater than 0.01 percentblood alcohol content, and pastoral care providers attempt

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to conduct brief visits with all listed patients who are still inthe hospital and are able to respond.

SBIRT visits are frequently 3 to 4 minutes in length,and visitors in patient rooms are asked to leave unlessgiven permission to stay by the patients. Patients areasked the CAGE questions, and if they answer yes to 2or more questions, they are asked about their consump-tion (number of drinks per session, days per week onwhich they drink, and so on). After patients are askedabout their drinking habits, they are shown how hightheir alcohol level was at the time of their injury. Levelson the scale range from 0.02 percent blood alcoholcontent (this level seldom hurts anyone) to 0.30 percentblood alcohol content (most injured patients are in thisrange) and all the way up to 0.50 percent blood alcoholcontent (breathing and heart would stop). On the backof the sheet is information for the Recovery ResourceCouncil and referral to agencies where patients can seekadditional help. Once the 3- to 4-minute SBIRTconversation is concluded, pastoral care staff typicallyexpress their interest in discussing patients’ motivationsfor drinking, allowing time for additional counseling if itis desired by patients.

After the SBIRT conversation, patients are askedwhether they would like to provide a phone number sothat they can be contacted in a few months to followup their recovery. If provided, this information isrecorded on the SBIRT tracking form, along with theanswers to the CAGE questions and the patients’ planof action—none, attend Alcoholics Anonymous meet-ings, reduce drinking, abstinence, or counseling. At theend of the visit, pastoral care services are offered becauseexcessive drinking is often a symptom of coping withemotional distress. Patients are invited to discuss theirreasons for drinking.

At 3, 6, and 12 months after the initial SBIRTinteraction, every effort is made to follow up withpatients by phone and reassess drinking behaviors. Asuccessful follow-up is recorded if patients or immediatefamily members are able to be reached and theirresponses regarding reductions in drinking behaviors (ornot) are recorded in the SBIRT database (JPS HealthNetwork, Fort Worth, TX). These data are protected andaccessible only to SBIRT chaplains for compliance andfollow-up purposes. They were not used in this study,but we received approval from our institutional reviewboard to extract overall compliance rates and shortvignettes, which have been deidentified by the pastoralcare staff.

The chaplains aim to keep the SBIRT completionrates above 90%, and they have had completion rates

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higher than 90% each month since the project’sinception. Discharged patients and those who refuse toparticipate count against the completion rates, whereaspatients who die, patients who are unable to respond(because of a traumatic brain injury or intubation), andpatients who leave against medical advice do not countagainst the completion rates.

Follow-Up Impact Stories

Since pastoral care has taken ownership of the SBIRTprogram, our chaplains have been successful at reachingpatients. From January 2010 to October 2013, 2,477patients have qualified for screening and the pastoral caredepartment has completed 2,043 SBIRT visits. Althoughdata are not available on the impact of pastoral care onthe patient’s experience, this report presents somepatients’ stories that are indicative of the impact onindividual patients.

THREE MONTHS LATER

Lee, a 28-year-old man, came in with a head injury. Hispost-anesthesia care unit nurse said, “I’m going to bejudgmental. I think it was a drug deal gone wrong. Hesaid he got hit by a car, but he wasn’t. He was hit by afist.... There was a lot of drama here yesterday betweenhis ex-wife and girlfriend asking about him and trying tosee him.”

A few days later, Lee’s mother told us that familymembers “have noticed that he has not drunk since theaccident, which is unusual for him.” Three months later,his mother said, “Oh, he’s doing so good! It’s like a realturnaround! He doesn’t drink, just coffee—he drinks a lotof coffee.... He is working 2 jobs. He’s too tired to bedrinking or anything else that he shouldn’t be doing.”When we mentioned how good sometimes comes frombad situations, she said, “And it’s given me such a peace,knowing that! I used to worry and couldn’t sleep.... Now Ihave so much more peace.” She thanked us warmly forour call.

SIX MONTHS LATER

James, a 45-year-old man, was transferred to our hospitalafter he was assaulted. When we first talked, he said he wasannoyed when people criticized his drinking, adding, “Idrink regularly. I don’t need to change.”

We lost contact with James for 6 months, but we left amessage for him a few days ago and he called back a fewminutes later. He was very friendly and told us that ourmessage was much appreciated and most encouraging. He

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Overton et al/CLINICAL

said he is healed and doing well, adding, “I had to let myfiancé go. She had too many boyfriends.... I don’t drink nomore.... Too much drama and trouble.... I don’t have todrink no more to fit in.... It sure woke me up, that’s for sure!The Lord sure works in mysterious ways.... He still workshis miracles, and I’m sure glad he does.... That’s what he didfor me.... I’m praying for you all, also.”

ONE YEAR LATER

A year ago, Jason, a 34-year-old man, said he was assaultedbecause of “some of the words” he used. At that time, he saidthat he wanted to reduce his drinking “but not today.” Sixmonths later, he said, “I’ve given up one of my vices: Istopped drinking. It’s been since March, since that night.My family wanted to see that, so that helped also.” Wecongratulated him.

A year later, Jason sounded so mellow and happy thatwe commented on that, noting that his life sounds like it isgoing well now. He said, “Well, it was going well before, butI was the one trashing it.... I’ve been 1 year sober.... Nothinglike waking up like that! Makes you think, ‘Maybe I don’twant to live like this!’”

Conclusion

Utilization of pastoral care services for SBIRT visitsserves 2 functions. First, our chaplains are able to takeadvantage of a teachable moment by helping patientsmake connections between drinking and their injuries, ifsuch connections exist. Second, pastoral care providershave the ability to talk about the emotional dynamicbehind the drinking (stress, guilt, and so on). Patientsinherently trust chaplains, and chaplains are trained tolisten and guide our patients. Our program is a perfectmatch between the two. When asked about thechaplains’ impact on patients through the SBIRTprogram, and what sets our institution apart fromother SBIRT programs, one chaplain stated, “Pastoralcare staff takes it to the next level by spending moretime with patients and exploring the motivations fordrinking.”

Unfortunately, because of recording procedures andincomplete data, we were unable to quantitativelyanalyze data regarding impacts on patients’ subsequentdrinking habits. Recently, SBIRT has become a billableprocedure and has been turned over to trained caseworkers for completion at our hospital. Before imple-mentation, we are working on developing a standardizedcollection system for patient SBIRT data so that if

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future prospective studies are conducted, they can beperformed in a way that allows for appropriate analysis.

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