The Long Road Home: Starting the Journey to Sobriety

The Long Road Home: Starting the Journey to Sobriety Joanna Kallendorf RN, BSN Auburn/AUM University NURS 7946 Evidence Based Practice III Small Test of Change April 8, 2015

Background and Significance Screening, Brief Intervention, and Referral to Treatment (SBIRT) Healthy People focuses on improving Quality of Life by: Improving population health Eliminating healthcare disparities Sets out to meet 10-year goal Substance abuse destroys social conditions: Family separation Domestic Abuse Financial problems

Target Population: PICO Question (P) Case Managers in a hospital setting (I) targeted evidence-based in-service in an acute care setting (C) routine office case management procedures for transition of care (O) increased earlier interventions and referrals for treatment

Literature Search: Summary of Evidence In yet another effort to encourage change in primary care, the Agency for Healthcare Research and Quality supported the Scottish Intercollegiate Guideline Network (SIGN) in the development of guidelines for managing harmful drinking and dependency in primary care. SIGN reviewed published meta-analyses and systematic reviews and found that general practitioners (GP) and other primary care health professionals should opportunistically identify hazardous and harmful drinkers and deliver a BI (SIGN, 2003). The U.S. Preventative Service Task Force (USPSTF), developed a clinical practice guideline based on the best evidence available for implementation of SBIRT (Moyer, 2012). The guideline provides an outline for screening, diagnosing, and establishing interventions that will reduce alcohol misuse. Methods used in the development of this guideline included information from literature of 23 RCT with multiple systematic evidence review of RCT and non randomized trials with controls or comparators. Upon final review, the recommendations included screening adults 18 and older for alcohol misuse, then provide interventions to reduce the behavior. Screening tools serve as a gateway for early treatment and possible prevention of the hazardous effects of alcohol misuse. Educating patients on the harmful effects of substance use is key to reducing the numbers of people that drink alcohol. Through the systematic review of multiple databases to include MEDLINE, SCOPUS, ΕMBASE, CINAHL, and COCHRANE Stavrianopoulos 2011 was able to demonstrate the effectiveness that adherence to preventative messages can produce. There were 17 articles reviewed. This included three level one articles, two level two, four level three, and one level six article. The level one evidence included systematic reviews and two clinical practice guidelines (CPG) and the level two evidence from the randomized controlled trials helped to validate this study and support the intervention proposed in the PICO.

Recommendations with Grade Grade A: All patients will be screened using the validated screening tests: Alcohol Use Disorders Identification Test [AUDIT]. (Evidence level I) Moyer, 2013 Screen for alcohol misuse and provide brief behavioral counseling interventions to persons engaged in risky or hazardous drinking. (Evidence level I) Moyer, 2013. Grade A: Brief intervention by a primary care provider or qualified staff. (Evidence level I) Saitz, 2010, Moyer, 2013, SIGN, 2003 Grade A: The intervention should, whenever possible, relate to the patient s presenting problem and should help the patient weigh up any benefits as perceived by the patient, versus the disadvantages of the current drinking pattern. (Evidence level I) SIGN, 2003 Grade B: Abbreviated forms of AUDIT should be used when alcohol is a possible contributory factor. (Evidence level I) SIGN, 2003 Grade B: Receiving a booklet on healthy behaviors versus a personalized report, booklet on alcohol and aging, drinking diary, advice from primary care provider, and telephone counseling from health educator at 2, 4, and 8 weeks (Level of evidence II) Moore et al., 2011 Grade B: Delivering preventative messages with brief interventions. (Evidence level III) Stavrianopoulos, 2011.

Methods Setting The case management office at Medical Center Enterprise. Participants My population consisted of 6 employees that have direct involvement in the transition of care and discharge planning of patients in an acute care setting.

Implementation Steps Introduction and overview of topic Pre-test Discussion of SBIRT, Audit-C, and EBP recommendations Post-test Questions and Comments

Evaluation Outcome Measures Confidence in assessing a person for an alcohol use disorder How likely would the case manager be to originate substance abuse within the transition of care. Will the recommendation be made by case managers to initiate the AUDIT-C into their current discharge planning practice Tools A 3 question survey was completed prior to the beginning of the in-service that was designed to assess the desired outcomes of this project. After the in-service was completed a new copy the same survey was completed. The data was then entered on a spreadsheet fro further evaluation of the data.

Results Independent T-test Confidence in Assessing Mean Pre-test.500 Post-test 3.00 P< 0.001 Likelihood to initiate screening with proper tools Mean P=.022 Pre-test.667 Post-test 1.500 Willingness to recommend use of tool in practice Mean P=.0341 Pre-test.000 Post- test.167

Chi-Square Results Confidence in Assessing Crosstab Confidence in assessing Not at all Somewhat Extremely Total Pre, Post Pre-test Count 3 3 0 6 % within Pre, Post 50.0% 50.0% 0.0% 100.0% % within Confidence in assessing 100.0% 100.0% 0.0% 50.0% Post-test Count 0 0 6 6 % within Pre, Post 0.0% 0.0% 100.0% 100.0% % within Confidence in assessing 0.0% 0.0% 100.0% 50.0% Total Count 3 3 6 12 % within Pre, Post 25.0% 25.0% 50.0% 100.0% Chi-Square Tests Value df Asymp. Sig. (2- sided) Pearson Chi-Square 12.000 a 2.002 Likelihood Ratio 16.636 2.000 Linear-by-Linear Association 10.185 1.001 N of Valid Cases 12 % within Confidence in assessing 100.0% 100.0% 100.0% 100.0%

Likelihood to Initiate Chi-Square Results Crosstab Likelihood to initiate screen with proper tool Not at all Somewhat Very Pre, Post Pre-test Count 2 4 0 % within Pre, Post 33.3% 66.7% 0.0% % within Likelihood to initiate screen with proper tool 100.0% 57.1% 0.0% Post-test Count 0 3 3 % within Pre, Post 0.0% 50.0% 50.0% % within Likelihood to initiate screen with proper tool 0.0% 42.9% 100.0% Total Count 2 7 3 Chi-Square Tests Value df Asymp. Sig. (2- sided) Pearson Chi-Square 5.143 a 2.076 Likelihood Ratio 7.075 2.029 Linear-by-Linear Association 4.661 1.031 N of Valid Cases 12 % within Pre, Post 16.7% 58.3% 25.0% % within Likelihood to initiate screen with proper tool 100.0% 100.0% 100.0%

Willingness to Recommend Chi-Square Results How likely are you to recommend the tool in practice Not at all Somewhat Total Pre, Post Pre-test Count 6 0 6 % within Pre, Post 100.0% 0.0% 100.0% % within How likely are you to recommend the tool in 54.5% 0.0% 50.0% practice Post-test Count 5 1 6 % within Pre, Post 83.3% 16.7% 100.0% % within How likely are you to recommend the tool in practice 45.5% 100.0% 50.0% Total Count 11 1 12 % within Pre, Post 91.7% 8.3% 100.0% Chi-Square Tests Asymp. Sig. (2- Value df sided) Pearson Chi-Square 1.091 a 1.296 Continuity Correction b.000 1 1.000 Likelihood Ratio 1.477 1.224 Fisher's Exact Test Linear-by-Linear Association 1.000 1.317 N of Valid Cases 12 % within How likely are you to recommend the tool in practice 100.0% 100.0% 100.0%

Conclusion The Overall Goal: Case Management implementation of alcohol dependency interventions Patient education and empowerment

Questions

References Moyer, V. A. (2013). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Annals Of Internal Medicine, 159(3), 210-W-76. Retrieved from http://aumnicat.aum.edu:2762/eds/pdfviewer/pdfviewer?vid=3&sid=dd9f7059-ba70-440c-a474-54cabcc2f596@sessionmgr114&hid=115 Scottish Intercollegiate Guidelines Network (SIGN). (2003). The management of harmful drinking and alcohol dependence in primary care. A national clinical guideline. (SIGN Publication No. 74). Retrieved from http://www.guideline.gov/content.aspx?id=4233&search=audit+primary+care+and+audit+alcohol+preve ntion Skinner, H. A. (1982). Guide for using the drug abuse screening test (DAST). Department of Public Health Sciences, University of Toronto. Retrieved from http://www.emcdda.europa.eu/attachements.cfm/att_61480_en_dast%202008.pdf Stavrianopoulos, T. (2011). The risks of alcohol and effective preventive practices: A systematic review. Health Science Journal, 5(3), 188-195. Substance Abuse and Mental Health Services Administration (SAMHSA) (2011). Screening tools. Retrieved from http://www.integration.samhsa.gov/clinical-practice/screening-tools#drugs United States Department of Health and Human Services, Healthy People, 2020. (2013) Substance Abuse: Overview and Impact. Retrieved from http://www.healthypeople.gov