Nurses Face Challenges in Implementing Alcohol Screening, Intervention, and Referral

Nurses are key partners in implementing Screening, Brief Intervention, and Referral for Treatment (SBIRT) for alcohol use disorders, but they face challenges in putting the program into practice, a new project suggests.

Cydne Perhats, MPH, Senior Research Associate at the Emergency Nurses Association in Des Plaines, Illinois headed the two-year project, which included a network of 10 mentors who guided emergency departments and their staff through the process of implementing alcohol SBIRT.

Emergency departments in the project had access to a series of five web-based seminars that explained the process of implementing SBIRT, as well as follow-up technical assistance through mentoring, both face-to-face and online. “We hoped to identify ways to facilitate the nurse-delivered SBIRT model,” Perhats said. She presented the findings at the recent International Nurses Society on Addictions annual meeting.

Almost one-third of patients treated in emergency departments and about half of severely injured trauma patients have alcohol problems, according to the National Institute on Alcohol Abuse and Alcoholism. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for people with substance use disorders, as well as those who are at risk of developing these disorders.

“Nurses are well positioned as SBIRT leaders because they are the largest group of health care providers and are in frequent contact with patients across all health care settings,” Perhats said. “With health care reform, many more people will be moved into primary care, and the nurses’ role will become even more important.” She noted that nurses, who work across the continuum of care in all health care settings, are comfortable with conducting assessments and ensuring patients are compliant with recommended care—a key skill required for SBIRT implementation. Research has patient acceptability for nurse-delivered SBIRT, making them a natural choice to implement the program.

Perhats notes that nurses see delivering SBIRT as part of their job, and are somewhat confident in screening patients. However, there was wide variation and inconsistency among project sites in terms of what nurses learned about SBIRT, and how they implemented the program. “It’s important to have a standardized protocol, so that nurses are consistently implementing the procedure in the same way,” she adds. “Nurses need targeted training that includes more practice opportunities and guidance on how to handle individual situations.” The project’s findings suggest that SBIRT education needs to be easily accessible, short-term and repetitive in order to accommodate nurses’ busy schedules and limited time and availability.

The project also found great variation in the support nurses receive from their hospital. “In some participating facilities, nurses delivering SBIRT have a lot of support from management and hospital administration, including continuing education, while others do not,” Perhats said. “It appears that once nurses have received formal training in SBIRT, emergency departments with a supportive culture that provides the necessary infrastructure, as well as more incentives to help facilitate the implementation process, would be more successful over time.”

Remote mentorship was also difficult to sustain and face-to-face guidance might be more beneficial. “ERs with a strong on-site champion were better able to sustain their efforts over time,” Perhats noted.

Billing and reimbursement are key obstacles, Perhats said. “In most states, nurses are not listed as eligible providers to be reimbursed for SBIRT services. It’s one of the key frustrations of translating SBIRT into practice, especially in emergency care.”

ERs can take steps to make it easier for nurses to implement SBIRT, such as setting up a specific private area where nurses can ask patients about their alcohol use, said Perhats. Some facilities have begun using computer kiosks or other mobile devices so that patients can answer these sensitive questions. But, it’s not certain whether this method is as effective as nurse-delivered SBIRT.

There are several larger issues that make SBIRT implementation challenging not just for nurses, but for health care facilities in general, Perhats points out. One such issue is the existence of “alcohol exclusion” laws in some states, which allow insurers to deny coverage for hospital reimbursement of medical costs if alcohol or drug use was involved.

Another issue is the lack of inclusion of SBIRT in many electronic medical record software packages. Even in hospitals that do include alcohol screening in the software used in the emergency department, there may be different software for the rest of the hospital, according to Perhats. “That means that if harmful alcohol use is flagged in the ER, it may not be seen on the inpatient record if the patient is admitted to the hospital,” she said. “Health care reform will provide a unique opportunity to address some of the policy and practice changes that will ultimately make nurse-led SBIRT implementation more likely to succeed.”

For more information about how hospitals can successfully implement SBIRT, visit the “Expanding SBIRT to Hospitals” website.