Continuing Conversations about Alcohol and Drugs with Injured Adolescents

Michael J. Mello, MD, MPH
on behalf of the IAMSBIRT Study Investigators
Jermy Aidlen, MD
Janette Baird, PhD
Sara Becker, PhD
Julie Bromberg, MPH
Emily Christison-Lagay, MD
Andrew Kiragu, MD
Karla Lawson, PhD
Lois K. Lee, MD, MPH
Robert Todd Maxson, MD
Isam Nasr, MD
Charles W. Pruitt, MD
Stephanie Ruest, MD, MPH
Kelli Scott, PhD
Anthony Spirito, PhD
Mark Zonfrillo, MD, MSCE

Screening, Brief Intervention and Referral to Treatment (SBIRT) for alcohol or drug (AOD) misuse has been effective in a variety of healthcare settings. The American College of Surgeons Committee on Trauma (ACS-CoT) adopted a requirement for certification as a level one trauma center that mandated universal screening for alcohol misuse and delivery of a brief intervention for those screening positive. Our study objective was to determine if adolescent trauma patients who screened positive for AOD use were directed to and engaged in follow-up AOD conversations after hospital discharge, and if this changed after implementation of a structured SBIRT program.

This study was part of a larger implementation study of SBIRT (IAMSBIRT: NIAAA R01AA025914) with adolescent trauma patients admitted from 2018-2022 to ten level one pediatric trauma centers. The study utilized a stepped-wedge design in which sites implemented the SBIRT program at different time points. A convenience sample of adolescent trauma patients (12-17 years), which oversampled AOD positive adolescents, was enrolled to receive a survey within 30 days of discharge. Adolescents were surveyed about advice they received from trauma staff to have follow-up conversations with their primary care provider (PCP) on AOD following discharge, and whether or not they had acted on that advice. Additionally, electronic health record (EHR) data on all admitted trauma patients were collected to identify those documented as screening positive for AOD, and whether they received indicated brief intervention and referral for continued AOD discussion following discharge.

Adolescent assent and parent consent for study enrollment was obtained on 430 patients (62.6% of approached patients), 6 withdrew and 329 (77.6%) completed the 30-day post discharge patient survey. Of those enrolled before implementation, 16.7% of AOD positive adolescents reported being advised to have follow-up AOD discussions with their PCP. This increased to 21.7%, but not significantly (p=0.22), following implementation of the IAMSBIRT study protocol. AOD positive adolescents referred for other non-PCP AOD counseling was low both before (15.6%) and after (14.6%) IAMSBIRT implementation. Of those referred, 33% at baseline and 30% after IAMSBIRT had accessed AOD counseling at 30 days. EHR data demonstrated increased screening using a validated screening tool (25.5% to 47.7%, p <0.001), increased identification of AOD positive adolescent trauma patients (20.2% to 23.9%, p = 0.02) after IAMSBIRT implementation, but no change (3.1% to 2.0%) in referral to PCP or non-PCP for AOD discussions or counseling services.

Our study found encouraging increases in AOD screening, but no change in referrals for post-discharge AOD discussions or counseling services. ACS-CoT has mandated AOD screening and brief intervention for trauma patients but requiring linkage to continued AOD discussion for those adolescents screening positive may be necessary to improve referral and subsequent AOD discussion practices. Further research to best accomplish the RT part of the SBIRT model is needed.

1. Screening and brief interventions for AOD use is required for admitted patients at ACS level one trauma centers.
2. An implementation strategy can improve AOD screening and BI delivery, but challenges persist for referrals.
3. Additional efforts are needed to continue adolescent AOD discussions after trauma center discharge.