Stigma-related feelings, including degree of enthusiasm and willingness to work with alcohol, drug, and mental disorder (ADM) patients, as well as anticipated success in such work, will be required for the United States to be successful in its new initiatives for ADM screening, brief intervention, and effective referral to treatment and rehabilitation services (SBIRT). This study investigates students of medicine and social work with respect to their stigma-related feelings and degree of enthusiasm or willingness to treat patients affected by alcohol dependence, nicotine dependence, or major depression. Inference is strengthened by an anonymous online survey approach, with use of randomized reinforcers to gain at least partial experimental control of nonparticipation biases that otherwise are present in student survey data.
Material and methods
All students on required course rosters were asked to participate in a two-part in-class and online assessment; 222 participated, with a gradient of participation induced via randomly drawn reinforcers for online survey participation. Between-group comparisons were made with a multivariate generalized linear model and generalized estimating equations approach that adjusts for covariates.
Medical and social work students did not differ from each other with respect to their willingness to treat patients affected by major depression, alcohol dependence, or nicotine dependence, but together were less willing to treat nicotine and alcohol dependence-affected patients as compared to depression-affected patients. Personal history was not associated with the students' willingness to treat, but men were less willing to treat. Drawing strength from the randomized reinforcer experimental design nested within this survey approach, the study evidence suggests potential nonparticipation bias in standard surveys on this topic.
These results indicate that future health professionals may prefer to treat depression as opposed to drug dependence conditions. For SBIRT success, curriculum change with educational interventions may be needed to increase willingness to treat patients with neuropsychiatric conditions such as drug dependence. Future research requires attention to a possible problem of nonparticipation bias in surveys of this type.
alcohol dependence; nicotine dependence; depression; health professionals; stigma
Effective communication between clinicians is essential for safe, efficient healthcare. We undertook a study to determine the longer-term effectiveness of an education session employing a structured method to teach referral-making skills to medical students.
All final year medical students received a forty-five minute education intervention consisting: discussion of effective telephone referrals; video viewing and critique; explanation, demonstration and practice using ISBAR; provision of a memory aid for use in their clinical work. Audio recordings were taken during a subsequent standardised simulation scenario and blindly assessed using a validated scoring system. Recordings were taken immediately before (control), several hours after (intervention), and at approximately six months after the education. Retention of the acronym and self-reports of transfer to the clinical environment were measured with a questionnaire at eight months.
Referral clarity at six months was significantly improved from pre-intervention, and referral content showed a trend towards improvement. Both measures were lower than the immediate post-education test. The ISBAR acronym was remembered by 59.4% (n = 95/160) and used by the vast majority of the respondents who had made a clinical telephone referral (n = 135/143; 94.4%).
A brief education session improved telephone communication in a simulated environment above baseline for over six months, achieved functional retention of the acronym over a seven to eight month period and resulted in self reports of transfer of the learning into practice.
We have developed and assessed two innovative, case-based, interactive training programs on substance abuse, one for health professional students on alcohol and one for primary care providers on SBIRT. Both programs build skills in substance abuse screening, brief intervention, and referral to treatment (SBIRT). Real-world effectiveness trials involving medical students (n=10); nursing students (n=60) were completed; trials involving primary care providers (n=65) are in progress during 2011. Medical students and nursing students had similarly low baseline scores on assessments that benefited from training: knowledge, confidence and clinical performance measured via an online standardized patient case and encounter note all improved post-training. Preliminary results indicate that practicing providers improved on knowledge, attitude, and brief intervention skill performance after a similar training. Results suggest that SBIRT skills can be improved with this model for case-based interactive training programs, and thus, that this training has the potential to impact patient outcomes.
SBIRT; screening; brief intervention; referral to treatment; simulated clinical experience; simulated electronic medical record
Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A Federally funded Screening, Brief Intervention, Referral to Treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. We compared illicit drug use at intake and six months after drug screening and interventions were administered.
SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans, Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialty treatment). In this secondary analysis of the SBIRT service program, drug use data was compared at intake and at a six month follow-up, in a sample of a randomly selected population (10%) that screened positive at baseline.
Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialty treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6 month follow-up (4 of 6 sites), were 67.7% lower (p < 0.001) and heavy alcohol use was 38.6% lower (p < 0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialty treatment, self-reported improvements in general health (p < 0.001), mental health (p < 0.001), employment (p < 0.001), housing status (p < 0.001), and criminal behavior (p < 0.001) were found.
SBIRT was feasible to implement and the self-reported patient status at six months indicated significant improvements over baseline, for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.
services; treatment; prescription drug abuse; preventive medicine; marijuana; cocaine; heroin; methamphetamine; CPT® codes; primary health care; trauma centers
There is a significant public health burden associated with substance use in Canada. The early detection and/or treatment of risky substance use has the potential to dramatically improve outcomes for those who experience harms from the non-medical use of psychoactive substances, particularly adolescents whose brains are still undergoing development. The Screening, Brief Intervention, and Referral to Treatment model is a comprehensive, integrated approach for the delivery of early intervention and treatment services for individuals experiencing substance use-related harms, as well as those who are at risk of experiencing such harm.
This article describes the protocol for a systematic review of the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment model for reducing the non-medical use of psychoactive substances. Studies will be selected in which brief interventions target non-medical psychoactive substance use (excluding alcohol, nicotine, or caffeine) among those 12 years and older who are opportunistically screened and deemed at risk of harms related to psychoactive substance use. We will include one-on-one verbal interventions and exclude non-verbal brief interventions (for example, the provision of information such as a pamphlet or online interventions) and group interventions. Primary, secondary and adverse outcomes of interest are prespecified. Randomized controlled trials will be included; non-randomized controlled trials, controlled before-after studies and interrupted time series designs will be considered in the absence of randomized controlled trials. We will search several bibliographic databases (for example, MEDLINE, EMBASE, CINAHL, PsycINFO, CORK) and search sources for grey literature. We will meta-analyze studies where possible. We will conduct subgroup analyses, if possible, according to drug class and intervention setting.
This review will provide evidence on the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment protocol aimed at the non-medical use of psychoactive substances and may provide guidance as to where future research might be most beneficial.
Brief intervention; Drug use; Psychoactive substance; Referral to treatment; SBIRT; Screening; Substance use; Systematic review
The Screening, Brief Intervention and Referral to Treatment (SBIRT) service for unhealthy alcohol use has been shown to be one of the most cost-effective medical preventive services and has been associated with long-term reductions in alcohol use and health care utilization. Recent studies also indicate that SBIRT reduces illicit drug use. In 2008 and 2009, the Substance Abuse Mental Health Service Administration funded 17 grantees to develop and implement medical residency training programs that teach residents how to provide SBIRT services for individuals with alcohol and drug misuse conditions. This paper presents the curricular activities associated with this initiative.
We used an online survey delivery application (Qualtrics) to e-mail a survey instrument developed by the project directors of 4 SBIRT residency programs to each residency grantee's director. The survey included both quantitative and qualitative data.
All 17 (100%) grantees responded. Respondents encompassed residency programs in emergency medicine, family medicine, pediatrics, obstetrics-gynecology, psychiatry, surgery, and preventive medicine. Thirteen of 17 (76%) grantee programs used both online and in-person approaches to deliver the curriculum. All 17 grantees incorporated motivational interviewing and validated screening instruments in the curriculum. As of June 2011, 2867 residents had been trained, and project directors reported all residents were incorporating SBIRT into their practices. Consistently mentioned challenges in implementing an SBIRT curriculum included finding time in residents' schedules for the modules and the need for trained faculty to verify resident competence.
The SBIRT initiative has resulted in rapid development of educational programs and a cohort of residents who utilize SBIRT in practice. Skills verification, program dissemination, and sustainability after grant funding ends remain ongoing challenges.
To determine the effects of a brief psychological intervention (brief psychodynamic interpersonal therapy) for patients after deliberate self poisoning compared with usual treatment. To compare the impact of the active intervention and usual treatment on patients' satisfaction with care.
Randomised controlled trial.
119 adults who had deliberately poisoned themselves and presented to the emergency department of a teaching hospital.
Community based study.
Four sessions of therapy delivered in the patient's home. Control patients received “treatment as usual,” which in most cases consisted of referral back to their general practitioner.
Severity of suicidal ideation six months after treatment as assessed by the Beck scale for suicidal ideation. Secondary outcome measures at six month follow up included depressive symptoms as measured by the Beck depression inventory, patient satisfaction with treatment, and self reported subsequent attempts at self harm.
Participants randomised to the intervention had a significantly greater reduction in suicidal ideation at six month follow up compared with those in the control group (reduction in the mean (SD) Beck scale 8.0 v 1.5). They were more satisfied with their treatment and were less likely to report repeated attempts to harm themselves at follow up (proportion repeating 9% v 28% in control group; difference 19%, 95% confidence interval 9% to 30 %, P=0.009).
Brief psychodynamic interpersonal therapy may be a valuable treatment after people have deliberately tried to poison themselves.
What is already known on this topicDeliberate self poisoning is one of the commonest reasons for admission to hospital in the United Kingdom and up to 15% of patients who poison themselves eventually kill themselvesThere are no interventions of proved efficacy for these patientsMost episodes of self poisoning are precipitated by some form of interpersonal problemWhat this study addsCompared with usual treatment four sessions of psychodynamic interpersonal therapy reduced suicidal ideation and self reported attempts at self harmThe intervention also improved patients' satisfaction with care
To examine the changes in clients' health-care ratings before and after hospital workers received an HIV prevention intervention in Malawi, which increased the workers' personal and work-related HIV prevention knowledge, attitudes and preventive behaviors.
Pre- and post-intervention client surveys.
A large urban referral hospital in Malawi.
Clients at purposefully selected inpatient and outpatient units on designated days (baseline, n = 310 clients; final, n = 683).
Ten-session peer-group intervention for health workers focused on HIV transmission, personal and work-related prevention, treating clients and families respectfully and incorporating HIV-related teaching.
Main Outcome Measures
Brief face-to-face clients' interview obtaining ratings of confidentiality of HIV, whether HIV-related teaching occurred and ratings of service quality.
Compared with baseline, at the final survey, clients reported higher confidence about confidentiality of clients' HIV status (83 vs. 75%, P < 0.01) and more clients reported that a health worker talked to them about HIV and AIDS (37 versus 28%, P< 0.01). More clients rated overall health services as ‘very good’ (five-item mean rating, 68 versus 59%, P< 0.01) and this was true for both inpatients and outpatients examined separately. However, there was no improvement in ratings of the courtesy of laboratory or pharmacy workers or of the adequacy of treatment instructions in the pharmacy.
HIV prevention training for health workers can have positive effects on clients' ratings of services, including HIV-related confidentiality and teaching, and should be scaled-up throughout Malawi and in other similar countries. Hospitals need to improve laboratory and pharmacy services.
patient satisfaction; HIV; intervention studies; health personnel; Malawi
This is a report on the New Mexico Screening, Brief Intervention and Referral to Treatment (SBIRT) project conducted over five years as part of a national initiative launched by the Substance Abuse and Mental Health Services Administration with the aim of increasing integration of substance use services and medical care. Throughout the state, 53,238 adults were screened for alcohol and/or drug use problems in ambulatory settings, with 12.2% screening positive. Baseline substance use behaviors among 6,360 participants eligible for brief intervention, brief treatment or referral for treatment are examined and the process of implementation and challenges for sustainability are discussed.
SBIRT; Screening; Brief Intervention; Referral; Rural Primary Care
There is increasing emphasis on screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use in the general hospital, as highlighted by new Joint Commission recommendations on SBIRT. However, the evidence supporting this approach is not as robust relative to primary care settings. This review is targeted to hospital-based clinicians and administrators who are responsible for generally ensuring the provision of high quality care to patients presenting with a myriad of conditions, one of which is unhealthy alcohol use. The review summarizes the major issues involved in caring for patients with unhealthy alcohol use in the general hospital setting, including prevalence, detection, assessment of severity, reduction in drinking with brief intervention, common acute management scenarios for heavy drinkers, and discharge planning. The review concludes with consideration of Joint Commission recommendations on SBIRT for unhealthy alcohol use, integration of these recommendations into hospital work flows, and directions for future research.
Alcohol drinking; Alcoholism; Hospitalization; Patient discharge
Recent years have seen increased diffusion of the Screening, Brief Intervention, Referral and Treatment Initiative (SBIRT) in healthcare environments. This study examined the relationship between substance use outcomes and service variables within the SBIRT model.
Over 55,000 adult patients were screened for substance misuse at rural health clinics throughout New Mexico during the SBIRT Initiative. This naturalistic pre-post services study used administrative baseline, 6 month follow-up, and services data for adult participants in the New Mexico SBIRT evaluation (n=1,208). Changes in self-reported frequency of illicit drug use, alcohol use, and alcohol intoxication were examined as a function of service level (brief intervention– BI versus brief treatment/referral– BT/RT) and number of service sessions.
Participants reported decreased frequency of illicit drug use, alcohol use, and alcohol intoxication 6 months after receipt of SBIRT services (p<.001 for each). Compared to those who received BI, participants who received BT/RT had sharper reductions in frequency of drinking (IRR=.78; p<.05) and alcohol intoxication (IRR=.75; p<.05). Number of service sessions was associated with reduced frequency of alcohol use (IRR=.84; p<.01) and intoxication (IRR=.82; p<.05), but only among those who received BI.
Substance-using patients with disparate levels of use may benefit from SBIRT. In a real-world, multi-site rural SBIRT program, services of higher intensity and (within the BI modality) frequency were associated with greater magnitude of change in drinking behaviors. Reductions in illicit drug use, while substantial, did not differ significantly based on service variables. Future studies should identify the preferred service mix in the SBIRT model as it continues to expand.
Screening; Brief Intervention; Brief Treatment; SBIRT; Services; Rural Healthcare
Screening, brief intervention, and referral to treatment (SBIRT) is a public health approach to the delivery of early intervention and treatment services for individuals at risk of developing substance use disorders (SUDs) and those who have already developed these disorders. SBIRT can be flexibly applied; therefore, it can be delivered in many clinical care settings. SBIRT has been adapted for use in hospital emergency settings, primary care centers, office- and clinic-based practices, and other community settings, providing opportunities for early intervention with at-risk substance users before more severe consequences occur. In addition, SBIRT interventions can include the provision of brief treatment for those with less severe SUDs and referrals to specialized substance abuse treatment programs for those with more severe SUDs. Screening large numbers of individuals presents an opportunity to engage those who are in need of treatment. However, additional research is needed to determine how best to implement SBIRT.
brief intervention; referral to treatment; SBIRT; screening; substance use disorders
Screening, brief intervention, and referral to treatment (SBIRT) approaches to reducing hazardous alcohol and illicit drug use have been assessed in a variety of health care settings, including primary care, trauma centers, and emergency departments. A major methodological concern in these trials, however, is “assessment reactivity,” the hypothesized impact of intensive research assessments to reduce alcohol and drug use and thus mask the purported efficacy of the interventions under scrutiny. Thus, it has been recommended that prospective research designs take assessment reactivity into account. The present article describes the design of the National Institute on Drug Abuse Clinical Trials Network protocol, Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED), which addresses the potential bias of assessment reactivity.
The protocol employs a 3-arm design. Following an initial brief screening, individuals identified as positive cases are consented, asked to provide demographic and locator information, and randomly assigned to one of the three conditions: minimal screening only, screening + assessment, or screening + assessment + brief intervention. In a two-stage process, the randomization procedure first reveals whether or not the participant will be in the minimal-screening-only condition. Participants in the other two groups receive a more extensive baseline assessment before it is revealed whether they have been randomized to also receive a brief intervention. Comparing the screening only and screening + assessment conditions will allow determination of the incremental effect of assessment reactivity.
Assessment reactivity is a potential source of bias that may reduce and/or lead to an underestimation of the purported effectiveness of brief interventions. From a methodological perspective, it needs to be accounted for in research designs. The SMART-ED design offers an approach to minimize assessment reactivity as a potential source of bias. Elucidating the role of assessment reactivity may offer insights into the mechanisms underlying SBIRT as well as suggest clinical options incorporating assessment reactivity as a treatment adjunct.
Assessment reactivity; Brief intervention; SBIRT; Clinical trials; Research design
The Patient Protection and Affordable Care Act of 2010 supports integration of substance abuse interventions and treatments into the mainstream health care system. Thus, effective screening and intervention for substance use disorders in health care settings is a priority.
This paper reviews the prevalence of alcohol and drug use disorders (abuse or dependence) in primary care settings and emergency departments, as well as current screening tools and brief interventions.
MEDLINE was searched using the following keywords: alcohol use, alcohol use disorder, drug use, drug use disorder, screening, primary care, and emergency departments. Using the related-articles link, additional articles were screened for inclusion. This review focuses on alcohol and drug use and related disorders among adults in primary care settings.
Screening, brief intervention, and referral for treatment are feasible and effective in primary care settings, provided that funding for screening is available, along with brief interventions and treatment facilities to which patients can be referred and treated promptly.
brief intervention; emergency departments
Aims: This study aims to determine the impact of Screening, Brief Intervention and Referral for Treatment (SBIRT) in reducing alcohol consumption in emergency department (ED) patients at 3, 6, and 12 months following exposure to the intervention. Methods: Patients drinking above the low-risk limits (at-risk to dependence), as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA), were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design included sequential recruitment of intervention and control patients at each site. Control patients received a written handout. The Intervention group received the handout and participated in a brief negotiated interview with direct referral for treatment if indicated. Follow-up surveys were conducted at 3, 6, and 12 months by telephone using an Interactive Voice Response (IVR) system. Results: Of the 1132 eligible patients consented and enrolled (581 control, 551 intervention), 699 (63%), 575 (52%) and 433 (38%) completed follow-up surveys via IVR at 3, 6, and 12 months, respectively. Regression analysis adjusting for the clustered sampling design and using multiple imputation procedures to account for subject attrition revealed that those receiving SBIRT reported roughly three drinks less per week than controls (B = −3.00, SE = 1.06, P < 0.05) and the level of maximum drinks per occasion was approximately three-fourths of a drink less than controls (B = -0.76, SE = 0.29, P < 0.05) at 3 months. At 6 and 12 months post-intervention, these effects had weakened considerably and were no longer statistically or substantively significant. Conclusion: SBIRT delivered by ED providers appears to have short-term effectiveness in reducing at-risk drinking, but multi-contact interventions or booster programs may be necessary to maintain long-term reductions in risky drinking.
In a 2007 report, the US Surgeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief intervention, and referral to treatment. MEDLINE and published reviews were used to identify relevant literature. Several brief screening methods have been shown to effectively identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the initial intervention typically focuses on education, motivation for change, and consideration of treatment options. Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes in federal and commercial insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances in clinical methods and progress on reimbursement policies have made screening and brief intervention for underage drinking more feasible in general health care practice.
The study objective was to assess the feasibility of a computerized alcohol-screening interview (CASI) program to identify at-risk alcohol users among adult emergency department (ED) patients. The study aimed to evaluate the feasibility of implementing a computerized screening, brief intervention, and referral to treatment (SBIRT) program within a busy urban ED setting, to report on accurate deployment of alcohol screening results, and to assess comprehension and satisfaction with CASI from both patient and research staff perspectives.
Research assistants (RAs) screened a convenience sample of medically stable ED patients. The RAs brought CASI to patients’ bedsides, and patients entered their own alcohol consumption data. The CASI intervention consisted of an alcohol use screening identification test, a personalized normative feedback profile, NIAAA low-risk drinking educational materials, and treatment referrals (when indicated).
Five hundred seventeen patients were enrolled. The median age of participants was 37 years (range, 21-85 years); 37% were men, 62% were Hispanic, 7% were Caucasian, 30% were African American, and 2% were multiracial. Eighty percent reported regular use of computers at home. Eighty percent of patients approached consented to participate, and 99% of those who started CASI were able to complete it. Two percent of interviews were interrupted for medical tests and procedures, however, no patients required breaks from using CASI for not feeling well. The CASI program accurately provided alcohol risk education to patients 100% of the time. Thirty-two percent of patients in the sample screened positive for at-risk drinking. Sixty percent of patients reported that CASI increased their knowledge of safe drinking limits, 39% reported some likeliness to change their alcohol use, and 28% reported some intention to consult a health care professional about their alcohol use as a result of their screening results. Ninety-three percent reported CASI was easy to use, 93% felt comfortable receiving alcohol education via computer, and 89% liked using CASI. Ninety percent of patients correctly identified their alcohol risk level after participating in CASI. With regard to research staff experience, RAs needed to provide standby assistance to patients during <1% of CASI administrations and needed to troubleshoot computer issues in 4% of interviews. The RAs distributed the correct alcohol risk normative profiles to patients 97% of the time and provided patients with treatment referrals when indicated 81% of the time. The RAs rated patients as “not bothered at all” by using CASI 94% of the time.
This study demonstrates that an ED-based computerized alcohol screening program is both acceptable to patients and effective in educating patients about their alcohol risk level. Additionally, this study demonstrates that few logistical problems related to using computers for these interventions were experienced by research staff: in most cases, staff accurately deployed alcohol risk education to patients, and in all cases, the computer provided accurate education to patients. Computer-assisted SBIRT may represent a significant time-saving measure, allowing EDs to reach larger numbers of patients for alcohol intervention without causing undue clinical burden or interruptions to clinical care. Future studies with follow-up are needed to replicate these results and assess drinking reductions post-intervention.
Computerized alcohol screening; Brief intervention; Emergency department; SBIRT
To investigate a brief teaching intervention using standardized patients (SPs) trained to improve residents' detection and advising of problem drinkers.
Pretest-posttest design assessing resident behavior and skills.
Nineteen internal medicine residents in a University Hospital General Internal Medicine Clinic.
Announced SPs were interviewed by residents and presented to faculty who provided brief instruction on the National Institute on Alcohol Abuse and Alcoholism guidelines for screening and brief counseling of problem drinkers.
Unannounced SPs assessed resident behavior and skills.
Following the teaching intervention, 2 times more residents screened for alcohol use and nearly 3 times more residents did brief counseling. Residents reported that the intervention was informative and valuable.
A single, 1-hour teaching intervention lead to a 2- to 3-fold increase in resident detection and advising of problem drinkers. SPs provide effective teaching encounters and a useful measure of resident behavior.
problem drinking; standardized patients; medical education
We evaluated an outcome management program for working with staff to improve the performance of adults with severe disabilities in a congregate day-treatment setting. Initially, observations were conducted of student task involvement and staff distribution of teaching interactions across students in four program sites. Using recent normative data to establish objective goals for student performance, management intervention was warranted in two of the sites. A six-step outcome management program was then implemented in the two sites. The program involved defining desired student and staff outcomes, systematic monitoring of the outcomes, staff training, and supportive and corrective feedback. The outcome management program was accompanied by increases in student on-task behavior and staff distribution of teaching interactions in both sites. The increases brought the levels of on-task behavior above the normative average; on-task behavior was maintained above the baseline average for over 1 year in both sites. These results are discussed in terms of the benefits of relying on normative data for objectively evaluating and improving service delivery systems. Discussion of future research needs focuses on applying the outcome management program to other settings and services for people with disabilities.
We describe a system of scenario-based training using simple mannequins under realistic circumstances for the training of pre-hospital care providers.
A simple intubatable mannequin or student volunteers are used together with a training version of the equipment used on a routine basis by the pre-hospital care team (doctor + paramedic).
Training is conducted outdoors at the base location all year round. The scenarios are led by scenario facilitators who are predominantly senior physicians. Their role is to brief the training team and guide the scenario, results of patient assessment and the simulated responses to interventions and treatment. Pilots, fire-fighters and medical students are utilised in scenarios to enhance realism by taking up roles as bystanders, additional ambulance staff and police. These scenario participants are briefed and introduced to the scene in a realistic manner. After completion of the scenario, the training team would usually be invited to prepare and deliver a hospital handover as they would in a real mission. A formal structured debrief then takes place.
This training method technique has been used for the training of all London Helicopter Emergency Medical Service (London HEMS) doctors and paramedics over the last 24 months. Informal participant feedback suggests that this is a very useful teaching method, both for improving motor skills, critical decision-making, scene management and team interaction. Although formal assessment of this technique has not yet taken place we describe how this type of training is conducted in a busy operational pre-hospital trauma service.
The teaching and maintenance of pre-hospital care skills is essential to an effective pre-hospital trauma care system. Simple mannequin based scenario training is feasible on a day-to-day basis and has the advantages of low cost, rapid set up and turn around. The scope of scenarios is limited only by the imagination of the trainers. Significant effort is made to put the participants into "the Zone" - the psychological mindset, where they believe they are in a realistic setting and treating a real patient, so that they gain the most from each teaching session. The method can be used for learning new skills, communication and leadership as well as maintaining existing skills.
The method described is a low technology, low cost alternative to high technology simulation which may provide a useful adjunct to delivering effective training when properly prepared and delivered. We find this useful for both induction and regular training of pre-hospital trauma care providers.
The effect of contingent tangible and social reinforcement on academic performance was investigated in an experimental classroom of 25 selected underachieving students. Measures were taken of both teacher and child behavior during a baseline and two experimental treatment periods. During Treatment I, a point system with tangible backup reinforcers was combined with contingent social reinforcers dispensed by the teaching staff to assess the effects on three measures of academic performance (i.e., per cent of time at work, work output per minute, and accuracy). During Treatment II, the contingencies for the tangible reinforcers were terminated while social reinforcement was continued to see if the positive effects of Treatment I on academic performance would persist. The results show that with combined tangible and social reinforcers, students' work time, rate of output per hour, and accuracy in all activities substantially increased. After termination of the tangible reinforcers, the students maintained their high rates of output per hour and accuracy for the remaining period of the study while the total amount of time at work returned to the baseline level.
This study assessed college students’ reports of tobacco screening and brief intervention by student health centers providers.
3800 students from eight universities in North Carolina participated.
Web-based survey of a stratified random sample of undergraduates.
53% reported ever visiting their student health center. Of those, 62% reported being screened for tobacco use. Logistic regression revealed screening was higher among females and smokers, compared to nonsmokers. Among students who were screened and who reported tobacco use, 50% reported being advised to quit or reduce use. Brief intervention was more likely among current daily smokers compared to current nondaily smokers, as well as at schools with higher smoking rates. Screening and brief intervention were more likely at schools with lower clinic caseloads.
Results highlight the need to encourage college health providers to screen every patient at every visit and to provide brief intervention for tobacco users.
Tobacco; Smoking; Cessation
Staff who provide support services to older adults are in a unique position to detect depression and offer a referral for mental health treatment. Yet integrating mental health screening and recommendations into aging services requires staff learn new skills to integrate mental health and overcome client barriers to accepting mental health referrals. This paper describes client rates of depression and a novel engagement intervention (Open Door) for homebound older adults who are eligible for home delivered meals and screened for depression by in-home aging service programs.
Homebound older adults receiving meal service who endorsed depressive symptoms were interviewed to assess depression severity and rates of suicidal ideation. Open Door is a brief psychosocial intervention to improve engagement in mental health treatment by collaboratively addressing the individual level barriers to care. The intervention targets stigma, misconceptions about depression, and fears about treatment, and is designed to fit within the roles and responsibilities of aging service staff.
Among 137 meal recipients who had symptoms when screened for depression as part of routine home meal service assessments, half (51%) had Major Depressive Disorder and 13% met criteria for minor depression on the SCID. Suicidal ideation was reported by 29% of the sample, with the highest rates of suicidal ideation (47%) among the subgroup of individuals with Major Depressive Disorder.
Individuals who endorse depressive symptoms during screening are likely to have clinically significant depression and need mental health treatment. The Open Door intervention offers a strategy to overcome barriers to mental health treatment engagement and to improve the odds of quality care for depression.
depression; access to care; mental health intervention; engagement
Medical settings such as emergency departments (EDs) present an opportunity to identify and provide services for individuals with substance use problems who might otherwise never receive any form of assessment, referral, or intervention. Although Screening, Brief Intervention, and Referral to Treatment (SBIRT) models have been extensively studied and are considered effective for individuals with alcohol problems presenting in emergency departments and other medical settings, the efficacy of such interventions has not been established for drug users presenting in EDs.
This paper describes the design of a NIDA Clinical Trials Network protocol testing the efficacy of an SBIRT model in medical EDs, highlighting considerations that that are pertinent to the design of other studies targeting substance use behaviors in medical treatment settings.
The protocol is described, and critical design decisions are discussed.
Design challenges included defining treatment conditions, study population, and site characteristics; developing the screening process; choosing the primary outcome; balancing brevity and comprehensiveness of assessment; and selecting the strategy for statistical analysis.
Many of the issues arising in the design of this study will be relevant to future studies of interventions for addictions in medical settings.
Optimal trial design is critical to determining how best to integrate substance abuse interventions into medical care.
A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy.
The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases.
This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels.
Problem drug use; Screening; Brief Intervention and Referral to Treatment (SBIRT); Motivational Interviewing (MI); Addiction Severity Index (ASI); Safety net; Public health benefit; Cost effectiveness