INJURY PREVENTION

IMPLEMENTING AN SBIRT (SCREENING, BRIEF

INTERVENTION, AND REFERRAL TO TREATMENT)
PROGRAM IN THE EMERGENCY DEPARTMENT:
CHALLENGES AND REWARDS
Author: Susan Barnard, RN, MS, FNP-BC, Nashua, NH
Section Editors: Tomi St. Mars, RN, MSN, CEN, FAEN and Anna M. Valdez, RN, PhD, CEN, CFRN

Earn Up to 8.5 CE Hours. See page 597.

magine if a brief, respectful conversation involving

listening, providing feedback, motivation, and advice
could be considered an effective, evidence-based injuryprevention strategy. Now consider this it is! Screening,
brief intervention, and referral to treatment (SBIRT) is an
injury-prevention strategy that focuses on identifying individuals at risk for alcohol disorders and providing information, tools, and resources aimed at reducing alcohol intake
and preventing alcohol-related injuries. Why? Because alcohol intoxication is the leading risk factor for injury it
offers the most promising and obvious target for injuryprevention programs.1 Nurses working in the emergency
department are the first and may be the only providers who
many individuals encounter in an increasingly complex
health care system. Emergency nurses can positively impact
patients alcohol intake patterns through implementation of
SBIRT in the emergency department. SBIRT allows emergency nurses to intervene early with a disease that contributes to illness, injury, and death.
The first step in implementing an SBIRT program is to
develop a planning checklist. The SBIRT checklist should
include the following:

A protocol or policy outlining how your facility will

implement the program

A determination of which health care providers will

perform the brief interventions

A confidential area in your department where the brief

interventions will occur

Patient confidentiality strategies

Documentation protocols that adhere to the policies of

your facility
Methods for evaluating the program and collecting data
Performance improvement measures and outcomes
Patient education and resource materials
A reimbursement plan2

doi: 10.1016/j.jen.2009.07.009

For American College of Surgeonsverified level I or

II trauma centers, there is a requirement that the trauma
center has a mechanism to identify patients who are problem drinkers, and Level I centers must have the capability
to provide intervention or referral for patients identified as
problem drinkers.3
When defining the target population, you must
identify available resources for screening and performing
brief interventions and the number of hours that can reasonably be allotted for the program. Having well-defined
inclusion criteria (such as all trauma patients) and exclusion criteria will be valuable in creating a clear focus for
your program. Alcohol screenings should identify not
only acutely intoxicated patients but also those at-risk
drinkers who were not drinking at the time of their
injury.3 It is important to remember that most alcohol-related injuries do not involve dependent drinkers
(patients with alcoholism) but more often include hazardous or high-risk drinkers.
SBIRT screening tools come in all shapes and sizes.
There are multiple screening tools already developed,
validated, and available for use including questionnaires
that contain anywhere from 1 to 10 screening questions.

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A definition of the target population

A screening tool appropriate for your facility and identified population
Susan Barnard, Member, New Hampshire Emergency Nurses Association, is
Trauma Coordinator, St Joseph Hospital, Nashua, NH.
For correspondence, write: Susan Barnard, St Joseph Hospital, Nashua, NH
03061; E-mail: sbarnard@sjhnh.org.
J Emerg Nurs 2009;35:561-3.
Available online 26 September 2009.
0099-1767/$36.00
Copyright 2009 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.

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Screening instruments such as the CRAFFT (Car, Relax,

Alone, Forget, Friends, Trouble) tool, developed by Knight
et al4 are more specific for the adolescent population,
whereas the CAGE (Cut-down, Annoyed, Guilty, Eyeopener) test or Alcohol Use Disorders Test (AUDIT)5
can be applied to any age group. Each tool has its own scoring system and method for calculating the score and determining implications for the patient. Some of these screening
tests are designed to be flexible in their application because
they may be self administered by the patient or administered by a health care professional. Important considerations
for nurses developing SBIRT programs would include
choosing a screening tool that not only will be appropriately applied to the ED target population but will also
obtain the patient information desired for data collection
and evaluation. An evidence-based, no-fee SBIRT toolkit
and educational resources are available on the ENA Web site
at http://www.ena.org/ipinstitute/SBIRT/.
Alcohol intervention policies or guidelines are usually
facility specific and serve to educate providers about the
functioning of the SBIRT program. Motivational interviewing, the backbone of SBIRT, can be enhanced through
training members of your SBIRT team. ED and trauma
health care providers are in unique positions to provide screening and brief negotiated interviews because of the high incidence of substance disorders in this patient population, but
social workers, case managers, and spiritual care providers
may bring exceptional skills to your program as well.
Asking about a patients alcohol and substance use
patterns is considered confidential and can be difficult
or uncomfortable. Provide a private setting, even in the
midst of a busy emergency department, will help your
patient feel more comfortable and receptive to screening
and education around substance use. If the screening tool
is to be self administered, allow the patient time in a
quiet area to answer the questions either on paper or on
a computer. If a provider will be administering the tool,
ensure that your session is done in an area where voices
will not carry from the room and allow one-on-one time
with the patient for the brief intervention.6 Provide reassurance to your patient that this intervention will remain
confidential and be truthful in how patient confidentiality
will be maintained.
The educational component of SBIRT should include
information on what constitutes a standard drink according to nationally established standards such as those of
the National Institute on Alcohol Abuse and Alcoholism.7
It may also be helpful to provide education on state laws
regarding legal alcohol limits and age restrictions. Compile
a list of local community resources, outpatient programs,
and support groups before the start of your SBIRT pro-

gram and give this to each patient who tests positive on

your screening tool.
Choosing a reimbursement strategy can be a daunting
task. Medical records and finance department personnel are
great resources in determining how to bill and receive
reimbursement for SBIRT performance. Become familiar
with your state laws regarding insurance companies practices
for reimbursing hospital stays associated with alcohol-related
injuries. Reviews of state statutes have found provisions that
allow third-party payers to deny payment for injuries sustained while intoxicated.8 Be sure to research state laws
and Current Procedural Terminology codes that have been
assigned for screening and brief intervention and decide
what methods will be best used by your program. One
option for receiving compensation for alcohol interventions
while protecting the privacy of your patients is to attach your
SBIRT activities to your emergency departments evaluation
and management codes.
Emergency departments are an important location for
identifying high-risk alcohol use. One compelling reason
for this is that a large number and variety of patients are
seen in emergency departments across the country each
year, many of whom do not have their hazardous drinking patterns detected in primary care settings. The immediacy between the event(s) bringing the patient to the
emergency department with illness or injury and the possible identification of an alcohol disorder creates a teachable moment and opportunity for intervention.9 Emergency
nursing has taken a lead role in promoting SBIRT in the
emergency setting and should continue to expand its contribution in the areas of evidence-based research, training,
and advocacy.

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REFERENCES
1. Gentilillo LM, Ebel BE, Wackezer TM, Salkever DS, Revaror
FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann
Surg 2005;241:541-50.
2. Dunn CW, Field CA. Screening and brief intervention training
for trauma care providers. Boston: BNI-ART Institute; 2007.
3. Alcohol screening and brief intervention (SBI) for trauma
patients: Committee on Trauma quick guide. Rockville (MD):
Center for Substance Abuse Treatment, Substance Abuse &
Mental Health Services Administration; 2007. p. 3.
4. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156:
607-14.
5. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant
M. Development of the alcohol use disorders identification test
(AUDIT): WHO collaborative project on early detection of per-

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9. Hungerford DW, Pollack DA. Alcohol problems among emergency department patients: proceedings of a research conference
on identification and intervention. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2001.

sons with harmful alcohol consumptionII. Addiction 1993;88:

791-804.
6. American Public Health Association and Education Development Center. Alcohol screening and brief intervention: a guide
for public health practitioners. Washington DC: National Highway Traffic Safety Administration, US Department of Transportation; 2008.
7. National Institute on Alcohol Abuse and Alcoholism of the
National Institutes of Health. What is a standard drink?
Available at: http://pubs.NIAAA.NIH.gov/publications/Practitioner/pocketguide/pocket_guide2.htm. Accessed June 19, 2009.
8. Gentilello LM, Samuels PN, Henningfield JE, Santora PB. Alcohol screening and intervention in trauma centers: confidentiality
concerns and legal considerations. J Trauma 2005;59: 1250-5.

Submissions to this column are encouraged and may be sent to

Tomi St. Mars, RN, MSN, CEN, FAEN
tst33@aol.com
or
Anna Maria Valdez, RN, PhD, CEN, CFRN
Anna_valdez@reachair.com

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