APPENDIX C

Notes from the breakout sessions on developing best practices.

Recommended Best Practices 
for Pre-Hospital Professionals

Dan Manz, EMS Director, Vermont Department of Health; 
Gail F. Cooper, Public Health Administrator, 
County of San Diego Health and Human Services Agency; 
Marilyn B. Thompson, RN, CEN, Charge Nurse Emergency Department, 
Kootenai Medical Center, Idaho State Emergency Nurses Council President, 
EN CARE Provider;
George F. Rice, Jr., NREMT-P, Deputy Director, Richland County Emergency Services

1. Assess the patient(s) and document for signs and symptoms of alcohol use problems and assess the environment for alcohol-related risk factors, e.g., alcohol bottles or cans at the scene. 
   (Removed "crash" from the strawman, as it was perceived that the patient population was broader than alcohol involved drivers. The role of EMS was discussed as assessing the patient for illness/injury and the environment for related risks or other observations that will lead to improved patient management.)
2. Report information on Alcohol Use Problems (AUP) to hospital personnel.
   (On this point it was agreed that the role of the pre-hospital providers is to transfer information learned in the pre-hospital environment to the emergency department staff. The breakout group originally felt that references to mandatory reporting of alcohol involved crashes should be broadened to a more generic reference on mandatory reporting in the event reporting laws are expanded in the future. In follow up discussion, it was agreed that the original reference to pre-hospital providers following laws regarding mandatory reporting of unsafe drivers was adequate in that alcohol-related driving is likely to remain the primary legal obligation.)
3. Assist with on scene information and referrals for AUP patients.
4. Provide care for the alcohol-impaired patient(s) in a professional and non-judgmental manner.
   ("Appropriate" care is assumed and the term was perceived as vague. "Patient" was expanded to "patient(s)" as alcohol-involved emergencies may involve multiple patients (e.g., family members, multiple patient crashes, etc.). "Professional and non-judgmental" was added during discussion with the larger group in an effort to clarify the medical approach to the alcohol problem instead of taking a moral tone.)
5. Advocate in the community for public education, prevention programs, public policy, and treatment programs for AUPs.⁵
   Participate in collaborative research, education and data gathering to improve the care of patients with AUPs.
   Integrate alcohol screening and alcohol education into curricula, continuing education, and standards for emergency health care professionals.
   (This point was added given the recognition that the current knowledge base about management of alcohol-related emergencies is not exhaustive and warrants further research, education and surveillance.)
   

Recommended Best Practices for Nurses

Laurie Flaherty, RN, MS, Traffic Safety Consultant, 
National Highway Traffic Safety Administration, Emergency Nurses Association; 
Janet Lassman, RN, BS, Director of Provider Services, 
EN CARE- Emergency Nurses Associations Injury Prevention Institute; 
Mary McCue, RN, CEN, NHTSA Office of Communication and Outreach; 
Benjamin Marett, RN, MSN, CEN, CNA, COHN-S, 
President, Emergency Nurses Association, 
Clinical Nurse Specialist Emergency Care Consultants of the Carolinas

1. Listen to prehospital professionals’ report and elicit patient information indicative of AUP.
   (Prehospital professionals often have information related to the patient’s circumstances and surroundings that can be key in identifying an AUP. Listening for this information and eliciting this information from prehospital professionals is an important and necessary method of completing a patient assessment.)
2. Identify alcohol-related events in initial assessment of the patient.
   (The nurse should use all 5 senses during the initial assessment, and ask the patient/family/caregiver/EMS professionals direct questions to identify alcohol-related visits to the ED.)
3. Perform an assessment using appropriate tools, such as history, physical examination, and screening tools.
   (Patients with AUP often have specific physical attributes, and can develop specific chronic health problems related to their AUP. Assessment should include physical examination and history-taking, looking for the presence of these signs, symptoms, and chronic physical problems. Assessment should also include the use of a screening tool to identify patients with AUP, whose AUP may not be readily apparent, or to assess the extent of the AUP. With multiple other checklists to perform, and numerous other patient groups to care for, group also discussed potential reluctance of some emergency nurses to do "one more thing." Strategies for implementation of assessment tools will have to address this potential barrier.)
4. Document objective findings of assessment, interventions, and plan of care for patient with AUP.
   (All findings of physical exam, history-taking, and screening should be documented, as well as any interventions that are implemented, and the plan of care for the patient with AUP. This documentation will serve as a reference for those rendering care to the patient, once they are transferred or discharged from the ED.)
5. Collaborate with health care team to implement interventions, such as brief interventions, discharge planning, and referral.
   (All aspects of care related to the patient with AUP, such as the use of screening tools, the use of brief interventions, discharge planning, and referral for treatment, should be part of an standardized approach, agreed to by all members of the health care team.)
6. Communicate plan of care to appropriate services, such as physicians, substance abuse counselors, referral agencies, and inpatient caregivers.
   (By definition, emergency care is brief, episodic, and crisis-oriented. AUP and its treatment will not be a resolved issue by the time treatment is completed in the ED. Therefore, it is imperative to communicate the plan of care for the AUP to all members of the health care team that will care for the patient upon discharge or transfer. The goals are a seamless continuum of care of the AUP, and the patient with an AUP.)
7. Provide care for the alcohol-impaired patient(s) in a professional and non-judgmental manner.
   (It is absolutely inappropriate for the health care professional to treat the patient with an AUP in any way that might be considered judgmental or unprofessional.)
8. Advocate in the community for public education, prevention programs, public policy, and treatment programs for AUPs.
   (Since hospital policy and public policy both have a direct effect on the nurse, in the nurse’s ability to render comprehensive care to the patient with AUP, and to find the resources to meet the needs of the patient with AUP, it behooves the nurse to become actively involved in the hospital and in their community, to advocate for public education, prevention programs, public policy, and treatment programs for patients with AUP.)
9. Participate in collaborative research, education and data gathering to improve the care of patients with AUPs.
   (As with any other form of health care, research is necessary to ensure maintenance of the "state of the art." Nurses should conduct and participate in research to improve identification and care of the patient with AUP.)
10. Integrate alcohol screening and alcohol education into curricula, continuing education, and standards for emergency health care professionals.
    (The knowledge base of health care professionals must be elevated, to include more information on AUP. Alcohol screening and education regarding comprehensive care of the patient with AUP should be included in the curricula of nursing schools, medical schools, residency training, EMS training, continuing education for practicing nurses, emergency physicians, trauma surgeons, and prehospital professionals; and should be an established and documented standard of nursing care, medical care, and prehospital care of the patient with AUP.)
    

Recommended Best Practices for Physicians

Herbert G. Garrison, MD, MPH, Professor of Emergency Medicine, East Carolina University; 
Sue Nedza, MD, Chair, Alcohol Reporting Task Force, 
American College of Emergency Physicians; 
Jeffrey W. Runge, MD, Assistant Chair, Emergency Medicine and Director, 
Carolinas Center for Injury Control, Carolinas Medical Center; 
Phillip Brewer, MD, FACEP, Assistant Professor, Yale University School of Medicine; 
Carl Soderstrom, MD, Professor of Surgery, R. Adams Cowley Shock Trauma Center, 
University of Maryland Medical Center; 
Gail D’Onofrio, MS, MD, Associate Professor, Section of Emergency Medicine, 
Yale University School of Medicine; 
Larry M. Gentilello, MD, Associate Professor of Surgery, Harborview Medical Center, 
University of Washington School of Medicine

1. Physicians should incorporate screening for alcohol use problems (AUPs) into the routine care of injured patients.
   (The use of alcohol as it is related to the health of the patient has always been an important part of the history obtained by the physician. As part of that questioning, the physician should routinely include it as part of the patient assessment, particularly in cases where alcohol use or abuse may have contributed to the emergency medical condition.)
2. Physicians should document history and physical findings consistent with AUPs
   (As the medical record reflects the interaction and care given to a patient, it is important for the physicians to document the response to the above queries and to physical examination findings. The group did clearly voiced concerns about the location of such documentation and the issues about the possible misuse of this information in the medical record. Should this information be documented on a separate record? Should it be in a separate record? It was agreed that there exists a legitimate concern about the possible misuse of this information if it is accessible to employers or insurers. Attempts should be made to quantify this risk and to ensure that this does not occur.)
3. Physicians should provide for a brief intervention for patients who screen positive for alcohol use problems.
   (Physicians should be active in ensuring that patients who screen positive receive a brief intervention. The treating physician will not necessarily do this. For patients who are going to be discharged to home from the ED, it would ideally be provided immediately in that setting, if such resources are available. For patients admitted to the hospital, intervention may be provided as an inpatient service. If this cannot be accomplished prior to discharge, then intervention should be provided by a physician, or other clinician, during outpatient follow-up visits. If the patient is referred to a social service program or setting it might occur at that location. The variability of possible times, sites and level of the intervention highlights the need for local policies and procedures specific to that hospital. The type of brief intervention will also be resource and institution specific.⁶ This recommendation emphasizes that the responsibility to act upon screen positive results for a possible AUP resides with the treating physician. The group recognized that this is a resource issue that must take into account time and available treatment options for patients. Physicians should be encouraged to seek solutions to barriers that preclude treatment that are workable in their institution and community.)
4. Physicians should be aware of state laws and consider the reporting of alcohol use problems in accordance with these laws.⁷
   (The group recognized the fact that laws exist in many states that govern the reporting of various medical conditions to specified authorities. In many cases, physicians are not aware of these requirements or their state or institution may not have a method in place that will allow for compliance with these laws. This may be reflected in the forms required for reporting or the availability of services for after hours reporting. It is imperative that physicians become knowledgeable about these statutes and be in compliance with them. In addition if, in the physician’s judgment, the presence of an alcohol abuse problem that may impair the patient’s ability to drive exists, the physician should consider initiating this type of report. The group recognized that in many cases the emergency department physician might not have the skills necessary or time to make this type of determination with certainty. When there is uncertainty as to the presence of an AUP, mechanisms should be in place to refer the individual for a more in-depth evaluation.)
5. Provide care for alcohol-impaired patient in a professional and non-judgmental manner.
   (As a profession, the practice of medicine should be held to the highest standards of practice. Every patient should be treated with respect, with dignity, and in a non-judgmental manner. This professional behavior should be stressed in the care of the alcohol-impaired patient. Substance abuse, like mental illness represents a disease state. The idea that patients who have AUP are flawed or of poor character should not be tolerated in the practice of medicine. The group recognized that in many cases this change in attitude and behavior would require increasing education throughout the medical system and in the education of emergency physicians, trauma surgeons, nurses and other clinicians providing care to the injured patients or other patients requiring emergency medical care. The types of didactic programs about alcohol should be expanded in scope. In addition, training physicians in methods specifically designed to aid in the care of these individuals is necessary.)
6. Advocate in the community for public education, prevention programs, public policy, and treatment programs for AUPs.
   (Emergency departments and hospitals (including trauma centers) do not exist in a vacuum. In order to diminish the injuries and illnesses related to AUPs, physicians must seek solutions outside of their departments. As highly respected individuals, they can take part in public education programs within the community.⁸ In order to impact on many illnesses or disease states, physicians must take a public health approach and advocate for prevention of alcohol-related illnesses, including injury. This type of activity can be modeled after or in coalition with other organizations. Physicians should continue to advocate for changes such as parity for substance abuse treatment benefits by health plans. They should also play an active role in the development and monitoring of laws that effect their treatment of these patients. Finally, many communities have little to no resources for treating those individuals who screen positive for alcohol use problems, or for those who seek treatment options. This is especially true for the Medicaid and uninsured population. The screening of these individuals without the availability of treatment solutions will seriously impact on the success of these efforts. It may also discourage practitioners from screening. It is important that physicians, nurses and other clinicians advocate for the funding and support of these urgently needed programs.)
7. Participate in collaborative research, education and data gathering to improve the care of patients with AUPs.
   (Validation and acceptance of treatment practices requires data based on clinical research. A first step must be to conduct research efforts to document that identifying and treating patients with AUPs leads to reductions in alcohol-related illness and social consequences.)
8. Integrate alcohol screening and alcohol education into curricula, continuing education, and standards for emergency health care professionals.⁹
   (As mentioned previously, it is important to change the culture of caring for patients with AUPs. Physicians must advocate for increasing education for our colleagues already in practice and for those in the foundational stages of their training. This is not limited to physicians engaged in the practice of emergency medicine or trauma surgery but to all providers who care for these patients.¹⁰ Physicians who directly interface with other groups such as EMS personnel and nursing personnel should advocate for this education in their curriculum.)

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