“Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review.”

On one of my overnight shifts during my second week of rotations, a patient with a past medical history of alcohol abuse presented in the ER with a deep laceration on his finger after accidentally sticking his hand in a blender a couple of hours earlier. The ER nurses told me that this patient was a repeat patient that came in about 2-3 times per month. There are many more patients like this one that fill the ER at night detoxing from some type of substance. I looked at a 2017 systemic review that focused on whether providing brief interventions in the ER could benefit patients, who are risky drinkers or suffer from alcohol abuse. The review specifically tested the effectiveness of using SBIRT in the ED setting. SBIRT (screening to assess for severity of substance use, brief intervention to provide harm awareness and motivate for change, and referral to treatment to patients who need additional treatment) is an evidence-based approach to delivering early interventions and treatment services to patients with substance use disorders or patients who are at risk of developing such disorders.  

The researchers used Medline, EMBASE, PsycInfo, Cochrane Library, CINAHL, and Web of Science to find studies between January 1966-2016 that focused on using brief interventions in the ED for at risk patients with a primary outcome of decreasing alcohol consumption in the future. They identified 35 randomized control trials with patients ages ranging from 12-70 years old. Results showed that in 13 studies, there was a significant decrease in the number of drinking days and number of drinks per day among the participants getting the intervention compared to the control group. In 16 studies, there was a decrease in drinking in both control and intervention groups. Out of these 16 studies, 9 studies also showed secondary outcomes such as decrease in marijuana and alcohol use together, decrease in injuries, and decrease in drunk driving specifically among adolescents, young female adults (<22 years old), and low-moderate drinkers. The researchers followed up with the participants at 3 months, then 6 months, and then again at 12 months. They found that by the 6 month mark the effectiveness of the intervention had weakened.  

The ED offers a unique setting where therapeutic help can be given to these patients, especially since the ED staff are usually the first people to see alcohol-related injuries and may be the only providers these patients seek treatment from. Based on the study’s findings, there may be a possible benefit to training ED staff members to screen for alcohol use disorder and to provide brief interventions to patients before discharge because it may decrease alcohol consumption, alcohol-related injuries, and/or recurring visits to the ED at least in the short-term. More research is needed to be done to assess for long term benefits and barriers need to be addressed such as cost, time, and resource support before this practice can be fully implemented into clinical practice.

Source: Barata, I. A., Shandro, J. R., Montgomery, M., Polansky, R., Sachs, C. J., Duber, H. C., Weaver, L. M., Heins, A., Owen, H. S., Josephson, E. B., & Macias-Konstantopoulos, W. (2017). Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review.The western journal of emergency medicine, 18(6), 1143–1152. https://doi.org/10.5811/westjem.2017.7.34373

Overall, I found this course to be a helpful simulation for what I will encounter in my clinical rotations. Through this course, I was able to strengthen many of my skills, some of which include forming a complete differential diagnosis list, ordering and interpreting lab results, and utilizing outside resources such as UpToDate and Pubmed to gather information for my presentations. I’ve also learned to be more confident in my abilities and my knowledge. Though there were moments where I felt I didn’t know as much as my peers, I found that I had retained more than I thought from my didactic year and could contribute to the discussion appropriately. 

Compared to the very first semester we had this course, the instructors really challenged us this time with cases where further investigation needed to be done beyond the initial diagnostic testing. I found this to be effective in building my skills to think beyond the obvious or the expected, especially in situations where all the test results came back negative. I also found cases where the patient could only give minimal information for the HPI or where no past medical history could be provided quite challenging, but highly valuable in improving my investigational skills. Two aspects to working up a patient that was focused on by the instructors and I thought was particularly useful in staying organized was first to keep the differential diagnoses list broad and to not jump to conclusions based on the initial presentation, and second to constantly be referring back to this list to rule out or in conditions as more information is acquired. Areas that I hope to still improve on in my clinical year are knowing the order of operations for urgent patients and determining which patients need to be admitted and which ones can be discharged.

For any of the lower classmen, I would advise them to take advantage of this course because it requires you to exercise the knowledge acquired during didactic year and apply it to a clinical setting. It forces you to think about the patient as a whole and why certain tests or treatments, that we had learned in our classes, may not always be appropriate. I found it to be a valuable course to have right before going to clinical rotations.

I’ve attached my last clinical correlation reflection below.

What differences do you note between the two H&Ps?

A significant difference between writing my H&Ps in this last semester compared to spring semester (PD1) was the inclusion of an assessment, differential diagnosis list, and plan. At the beginning, I struggled a bit on how to properly document those three sections and it shows in my first H&P. My format for the assessment and differential diagnosis list was incorrect, and my plan was incomplete and unclear. When I was writing my last H&P for a patient I saw in the emergency department, I found it was much easier to write because I had a better understanding on the purpose of each section, what information needed to be included, and how to document and format each section in a clear way so that it had a logical flow. 

In what ways has your history-taking improved? Are you eliciting all the important information?

Overall, I feel confident in my history-taking skills. Being able to interact with different patients throughout the semester has strengthened my ability to elicit the information I need by hitting all the components of OLDCARTs when relevant, feeling comfortable asking the uncomfortable questions, identifying the pertinent positives and negatives, being attentive and sensitive towards the patient throughout the conversation, and guiding patients back to the conversation if they go on a tangent. 

In what ways has writing an HPI improved?

My H&Ps have become more concise and well structured. There are still some situations where the patient has two different complaints and I am unsure of the relevance to the chief complaint or if it should be included in the HPI, but overall I feel that the flow and completeness has improved. 

What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?

I feel competent and prepared to conduct a full physical exam now that all the areas have been covered in class. In this section of the course, I feel strongest in the musculoskeletal system and weakest in the neurologic exam, specifically the cranial nerve exam. At my last hospital visit in the emergency room, a patient came in complaining of symptoms of vertigo and my preceptor had asked me to briefly explain to him what parts of the cranial exam I would perform. I found it was more organized for me to start from the first cranial nerve and work my way through, but with more practice, I hope to be able to proficiently recall the tests in any order and in a timely manner 

Of course we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?

One area that I need to improve on is time efficiency, especially since my first rotation is in the emergency department. For school, I was able to organize how I would examine the patient beforehand so that I could complete the whole exam in under 20 minutes. However, in clinicals the method of examining a patient is constantly changing because it will depend on the patient’s chief complaint. I hope that as I work through my first rotation, adjusting my exam sequence in the most efficient way will become second nature. To best prepare myself, I plan to review and practice each part of the exam before my rotation so that I don’t omit anything or have to take time to remember what the next steps are.