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Aims Determine if the language in which brief intervention (BI) is delivered influences drinking outcomes among Mexican-origin young adults in the emergency department when controlling for ethnic matching. Short summary Aim of study was to determine if a patient's preferred language of intervention influences drinking outcomes among Mexican-origin young adults in the emergency department. Results indicate no significant differences in drinking outcomes among those who received BI in Spanish and BI in English. Methods This is a secondary data analysis on data from 310 patients randomized to receive a BI completed in Spanish (BI-S) or English (BI-E), with 3- and 12-month follow-up. Outcome measures of interest were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking. Results There were no significant differences in drinking outcomes among those who received BI in Spanish and BI in English. Conclusions Reduced drinking outcomes following BI among Mexican-origin young adults in the emergency department may not have been due to the language used to deliver intervention. Thus, our results provide evidence that language of intervention is not a crucial factor to achieve cultural congruence. In addition, our findings suggest that receiving the intervention is beneficial regardless of language, thus, facilitating real-world implementation.

Background and Objectives: There is a limited evidentiary base on the development of family medicine in different contexts and countries. The lack of evidence impedes our ability to compare and characterize family medicine models and identify areas of success that have led to the effective provision of care. This paper offers a comparative compilation and analysis of the development of family medicine training programs in seven countries: Brazil, Canada, Ethiopia, Haiti, Indonesia, Kenya, and Mali. Methods: Using qualitative case studies, this paper examines the process of developing family medicine programs, including enabling strategies and barriers, and shared lessons. An appreciative inquiry framework and complex adaptive systems thinking inform our qualitative study. Results: Committed partnerships, the contribution of champions, health policy, and adaptability were identified as key enablers in all seven case studies. The case studies further reveal that some enablers were more salient in certain contexts as compared to others, and that it is the interaction of enablers that is crucial for understanding how and why initiatives succeeded. The barriers that emerged across the seven case studies include: (1) resistance from other medical specialties, (2) lack of resources and capabilities, (3) difficulty in sustaining support of champions, and (4) challenges in brokering effective partnerships. Conclusions: A key insight from this study is that the implementation of family medicine is nonlinear, dynamic, and complex. The findings of this comparative analysis offer insights and strategies that can inform the design and development of family medicine programs elsewhere.

Introduction: Little has been reported on the efficacy of brief intervention (BI) among heavy episodic drinkers, although this drinking style is known to be especially harmful in relation to negative consequences including alcohol-related injuries. The comparative efficacy of BI is analysed in two similar randomised controlled clinical trials of emergency department (ED) patients in different cultures, both exhibiting similar styles of heavy episodic drinking: Polish and Mexican-Americans in the U.S. Methods: Improvements in drinking and problem outcomes are analysed at 3-month and 12-month follow-up, using random effects modelling, among 446 Polish patients and 698 Mexican-American patients, randomised to screened-only, assessment, and intervention conditions in each study. Results: In Poland significant improvement was observed in all outcome measures for the assessed condition at 3 months compared to baseline, but only in the two problem variables at 12 months, while for the intervention condition, significant improvement was found in all outcome measures at both time periods; however, estimates of the interaction terms were not statistically significant. In the Mexican-American study, while significant improvement in nearly all outcome measures were observed at 3 months and 12 months for both conditions, estimates of the interaction terms suggest that for all drinking variables, but not problem variables, outcomes were significantly improved for the intervention condition over the assessed condition at 12 months, suggesting a 12-month intervention effect. Conclusions: Findings here are non-conclusive regarding a treatment effect of BI for heavy episodic drinking in ED patients. Given the mixed findings for BI in other ED studies, future studies need to explore the efficacy of BI in other populations and cultures exhibiting different drinking patterns to help identify what type of drinker would most benefit from BI in the ED setting.

In this study, we investigate the role of gender in prevalence and consequences of binge drinking and brief intervention outcomes among Mexican-origin young adults aged 18-30 years at the U.S.-Mexico border. We conducted a secondary analysis, stratified by gender, from a randomized controlled trial of a brief motivational intervention in a hospital emergency department. Intervention effects for males included reductions in drinking frequency, binge drinking, and alcohol-related consequences. For females the intervention was associated with reduction in drinking frequency and binge drinking but did not have a significant effect on alcohol-related consequences. Results suggest a new direction for tailoring interventions to gender.

Background Motivational interviewing (MI) is widely used for adolescent smoking cessation but empirical support for this approach is mixed. Methods Adolescent cigarette smokers 14–18 years old ( N = 162) were recruited from medical, school, and community settings and randomly assigned to enhanced MI or brief advice (BA) for smoking cessation. MI comprised an in-person individual session, a telephone booster session one week later, and a brief telephone-based parent intervention. BA consisted of standardized brief advice to quit smoking. Assessments occurred at baseline, post-treatment and at 1-, 3-, and 6-month follow ups. Results Biochemically-confirmed 7-day point prevalence abstinence rates were low (e.g., 4.5% for MI; 1.4% for BA at 1 month) and did not differ significantly by group at any follow up. Only those in MI reported significant decreases in cigarettes smoked per day (CPD) from baseline to 1 month. At 3 and 6 months, smokers in both groups reported significantly reduced CPD with no differences between groups. MI reduced perceived norms regarding peer and adult smoking rates, while BA had no effect on normative perceptions. No group differences emerged for self-reported motivation or self-efficacy to quit smoking. Conclusions Findings support the efficacy of MI for addressing normative misperceptions regarding peer and adult smoking and for modestly reducing CPD in the short-term; however, these effects did not translate to greater smoking abstinence. MI may have more promise as a prelude to more intensive smoking intervention with adolescents than as a stand-alone intervention.

Background Decreasing Injuries from ALcohol (DIAL) is a randomised control trial of a telephone brief intervention (BI) with injured emergency department (ED) patients with high-risk alcohol use. Here the authors examine 12-month outcomes of the intervention’s effect on alcohol use, alcohol-related injuries and alcoholrelated negative consequences. Methods ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, all participants received by telephone an assessment of their alcohol use, alcohol-related injuries, and alcoholrelated negative consequences and then were randomised to treatment or standard care. Treatment consisted of two telephone sessions of BI focusing on risky alcohol use. Both groups were reassessed after 12 months. Results At 12 months, 249 (89%) participants completed follow-up assessments. After using a log transformation, the difference in alcohol-related injuries between baseline and 12-month follow-up was greater in the BI group than the standard care group (p¼0.04); this is an effect size of Cohen’s d¼0.21. No difference between groups was found when comparing change in alcohol consumption and other alcohol-related negative consequences at 12 months. Conclusions These findings suggest that a telephone BI with injured ED patients may decrease alcohol-related injuries. Identifying patients with risky alcohol use in the ED and then subsequently delivering the intervention by telephone after discharge has promise as a model for BI and deserves further study.

OBJECTIVES: The objectives of the study were to investigate the attitudes and practices of pediatric emergency department (PED) physicians (MDs), MD extenders (MD’s assistants [PAs], nurse practitioners [NPs]), and nurses (RNs) regarding their counseling of alcohol using adolescent PED patients and to determine which, if any, PED clinician characteristics predict current counseling practice. METHODS: An Internet based survey of PED clinicians (MDs, PAs, NPs, and RNs) from 11 academic US PEDs was conducted. Respondents were asked about their counseling training, current counseling practices, confidence in their counseling skills, importance of counseling, attitudes and beliefs about counseling, and demographic information. Univariate and multivariate analyses were performed to determine the relationship between clinician characteristics and counseling practice. RESULTS: Counseling practice was strongly associated with one’s profession; PED MDs/PAs/NPs reported significantly higher rates of counseling alcohol using adolescents than PED RNs. These 2 groups differed significantly in terms of counseling training and experience. Counseling training and experience remained significant predictors of counseling practice, even after controlling for profession and other covariates. Both groups had similar views on the importance of counseling, confidence in their ability to counsel, and counseling substance using adolescent PED patients. CONCLUSIONS: Pediatric ED MDs/PAs/NPs differ significantly from PED RNs in their counseling training, experience, and practice. These findings have important implications for the training and support necessary to successfully implement PED counseling. Specifically, formal training in counseling during professional schooling and garnering counseling experience after completing training may be critical factors in promoting PED counseling.

Few studies have examined the effects of brief motivational intervention components, such as change-plan completion, on treatment outcomes. This secondary analysis of an opportunistically recruited emergency-department sample of hazardous injured drinkers examines the potential predictive role of an alcohol-related change plan on treatment outcomes after accounting for pretreatment readiness. Written change plans were independently rated.A mediational analysis framework tested directional hypotheses between pretreatment readiness, change plan, and treatment outcomes using linear regressions. The baseline total Drinker Inventory of Consequences (DrInC) score was covaried on 12-month DrInC total score, in all analyses. Participants who completed a brief motivational intervention and a change plan were included (N = 333).Pretreatment readiness was negatively associated with alcohol consequences at 12 months, (beta = -.09, t(254) = -2.07, p.05, and good-quality change plans, (beta = .18, t(320) = 4.37, p.001. With change plan and readiness in the same model, the relationship between readiness and treatment outcomes became nonsignificant, but change plan remained a significant predictor of treatment outcomes in the expected direction, beta = -.17, t(254) = -2.89, p.01. Follow-up generalized linear modeling including an interaction term (change plan and pretreatment readiness) revealed that those with high readiness and a good-quality change plan versus those with low readiness and a poor-quality change plan had better-than-predicted outcomes for either readiness or change plan alone.Study findings suggest that the change plan in brief motivational intervention may be an active ingredient of treatment associated with better outcomes over and above the influence of pretreatment readiness.

Background: There is a lack of information about the prevalence of stress and types of stressors experienced by Emergency Department (ED) patients. Objective: The present aim is to study the prevalence of stress, types of stressful situations and the relationship with other health issues within the ED population. Materials and Methods: This is a cross-sectional study performed in an ED at a level-1 urban trauma center for four months. An anonymous survey was offered to adult non critically ill patients who were admitted in the ED. They were divided on the basis of gender, age and level of stress and were asked about their demographics, reasons for their ED visit and health issues including stress, tobacco, alcohol and marijuana use, weight concern and health. Chi-square for the categorical variables and unpaired t-tests for continuous variables were conducted. Results: We interviewed 1797 patients, over 66% reported that they felt stressed on at least a weekly basis, and over 45% indicated that they felt stressed more than twice per week. While both young and old were equally stressed, females reported significantly more stress. Family, finances and work are the most frequently cited stressors. Different age groups reported different types of stressors. Overall, those patients reporting being stressed more frequently reported more high risk behaviors including cigarette and marijuana use and health problems including being overweight, being depressed, and having sleeping problems and chronic fatigue. Conclusions: Considering the high frequency of ED patients that report frequent stress and high risk behaviors, their ED visit may be an excellent opportunity to provide a referral or an intervention for stress reduction.

Objective Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience improves provider beliefs and practices. Methods ED faculty, residents, nurses, physician extenders, social workers, and Emergency Medical Technicians (EMTs) were surveyed prior to participating in either a two hour interactive workshops with case simulations, or a web-based program ( www.ed.bmc.org/sbirt ). A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure. Results Among 402 ED providers, 74% reported Conclusions ED providers respond favorably to SBIRT. Changes in utilization were substantial at three months post-exposure to a standardized curriculum, but less apparent after 12 months. Booster sessions, trained assistants and infrastructure supports may be needed to sustain changes over the longer term.

Aim To establish the efficacy of a brief motivational intervention compared to feedback only when delivered in an emergency department for reducing alcohol use and problems among young adults. Design Two-group randomized controlled trial with follow-up assessments at 6 and 12 months.Setting Level ITrauma Center.Participants A total of 198 18-24-year-old patients who were either alcohol positive upon hospital admission or met screening criteria for alcohol problems. Intervention Participants were assigned randomly to receive a one-session motivational interven- tion (MI) that included personalized feedback, or the personalized feedback report only (FO). All participants received additional telephone contact 1 month and 3 months after baseline. Measurements Demographic information, alcohol use, alcohol problems and treatment seeking. Findings Six months after the intervention MI participants drank on fewer days, had fewer heavy drinking days and drank fewer drinks per week in the past month than did FO patients.These effects were maintained at 12 months. Clinical significance evaluation indicated that twice as many MI participants as FO participants reliably reduced their volume of alcohol consumption from baseline to 12 months. Reductions in alcohol-related injuries and moving violations, and increases in alcohol treatment-seeking were observed across both conditions at both follow-ups with no differences between conditions. Conclusions This study provides new data supporting the potential of the motivational intervention tested to reduce alcohol consumption among high-risk youth.

Objectives: Efforts to mitigate unexpected problems during transition of an active emergency department (ED) to a new physical plant are imperative to ensure effective health care delivery and patient safety. The authors used advanced medical simulation (SIM) to evaluate the capacity of a new ED for emergent resuscitative processes and assist facility orientation before opening day. Methods: Operational readiness testing and orientation to the new ED of a large academic center were arranged through a Transportable Enhanced Simulation Technologies for Pre-Implementation Limited Operations Testing (TESTPILOT) project. Using a portable life-sized computerized manikin, the project required participants to perform assorted patient care interventions on-site. Cardiac arrest, multitrauma, uroseptic shock, and pediatric toxicology scenarios elicited the dynamics of real-life ED activities. Debriefings and surveys assessed participants' perceptions of the new facility's clinical readiness and identified areas needing administrative attention. Subjective utility of SIM orientation was compared with that of standard facility orientation. Results: Fourteen ED clinicians and five SIM facilitators participated over two sessions. The new facility received mean (± SD) and median five-point Likert scale scores of 4.4 (± 0.8) and 5 for ability of clinical staff to perform resuscitations. The respective scores for ability of simulated scenarios to prepare staff for new ED function were 4.6 (± 0.5) and 5, compared with 4.2 (± 1.0) and 4 for non-SIM orientation (p = 0.22; not significant). Problems with equipment location, inadequate procedural surfaces, and insufficient orientation were discovered and rapidly corrected. Conclusions: Transportable SIM was used to evaluate the clinical functions of a new ED. Significant operational issues identified by participants were corrected before opening of the facility. Limited comparison did not reveal SIM enhancement of orientation.

IN THE PAST decade, significant advances have been made in understanding how genetic and environmental factors contribute to alcoholism and other psychopathology among children of alcoholic individuals. Potential biopsychosocial markers of risk (e.g., low level of response to alcohol, behavioral undercontrol, and family functioning variables) have been identified and indicate that both individual and environmental variables are highly relevant. Despite these advances, studies have predominantly focused on examining outcomes among sons of alcoholic individuals, with the consequence that relatively little is known about the risk for alcoholism and other psychopathology among daughters. Effective prevention and treatment strategies are predicated upon further knowledge of these risks among daughters as well as sons. This symposium will present recent findings using family, prospective, and cross-sectional research to elucidate the biopsychosocial correlates and the moderators of risk for alcoholism and other psychopathology among daughters from developmental trajectories spanning the periods of childhood, adolescence, and adulthood. This symposium begins with a presentation by John Kramer in which high-risk daughters’ and sons’ alcohol and drug involvement are compared with respect to their predictors, drawn from demographic, familial, and personal domains. Next, Serena King focuses on the correlates of disinhibited behavior in males and females from adoptive and biological families, with an emphasis on parental alcoholism, genetic versus environmental influences, and differences between genders. This talk is followed by a presentation by Kristina Jackson, who examines the predictors of alcohol use disorders among young adults from high-risk and control families, including such factors as family history, negative affect, behavioral undercontrol, and childhood stressors. Finally, Aruna Gogineni addresses the familial predictors of adult daughters’ alcohol problems and depression, focusing on the effects of maternal versus paternal alcoholism as well as family density of pathology.

This study examined the extent to which alcohol-related expectancies were associated with assaults among 278 injured drinkers in the emergency department setting. Results of logistic regression analyses indicated that patients who were male, had high blood alcohol levels and who expected alcohol to make them more careless were more likely to report being assaulted. Conversely, among males, patients who expected to become more powerful and aggressive when drinking were less likely to be assaulted. These findings suggest that helping patients understand how expectancies surrounding alcohol use shape drinking and its behavioral concomitants may circumvent their risk for future assaults.

Our objective was to examine attitudes on reporting alcohol–impaired drivers by physicians of different specialties who are most likely to treat motor vehicle crash (MVC) patients. Specific objectives included examining 1) degree of comfort with reporting to police or Department of Motor Vehicles (DMV), 2) variability in attitudes across specialties surveyed, 3) perceived barriers to reporting, and 4) general attitudes on treating alcoholism. Physicians reported that they felt more comfortable with reporting to a medical review board of DMV than to police in all three of the case examples, which included treating a patient who is a clinically diagnosed alcohol–impaired MVC driver (66% DMV report, 36% police report), MVC driver at legal limit of blood alcohol concentration (63% DMV report, 32% police report), and an MVC driver with a very high blood alcohol concentration (81% DMV report, 53% police report). There was no difference between specialties in comfort with reporting, though emergency medicine physicians were less likely to screen and refer patients for counseling. The primary reasons given for not reporting an alcohol–impaired driver were physician–patient confidentiality and perceived threat of civil action by patients.

This study assessed whether the addition of a brief (60-minute) CBT intervention delivered in an emergency department improved outcomes for patients seeking services there for noncardiac chest pain. Patients (N = 59) were recruited after their medical evaluation and randomized to CBT intervention (involving psychoeducation, diaphragmatic breathing exercises, and cognitive restructuring about physical symptoms) or treatment-as-usual control. The principal hypothesis that the CBT group would show greater improvement relative to controls was partially supported. The CBT group demonstrated a greater decrease in frequency of chest pain episodes, anxiety sensitivity, and fear of cardiac symptoms at 1- and 3-month follow-up assessments, although there were no differences on chest pain severity, cardiac-related avoidance or attention, quality of life, or general psychological distress.

Objectives: The purpose of this paper is to better understand marijuana use among injured problem drinkers in the emergency department (ED). The specific objectives are: 1) to assess the prevalence of marijuana use; 2) to identify factors associated with marijuana use; 3) to determine whether prior injury is associated with marijuana use; and 4) to determine whether marijuana-using problem drinkers want to change behaviors. Methods: The authors conducted a post-hoc analysis on data obtained prospectively. Subjects had injury and problem drinking: either measurable alcohol level (blood alcohol concentration, BAC), report of drinking, or an Alcohol Use Disorders Identification Test (AUDIT) score of $8. The study was conducted on weekend nights; 3,776 injured ED patients were screened, 383 refused, 578 were enrolled, and 433 had complete data. Results: Of the 433 subjects, 48.3% reported using marijuana in the three months prior. Marijuana-using problem drinkers had more hazardous drinking, higher AUDIT scores (14.0 vs. 11.4, p < 0.001), and higher risk-taking scores (12.4 vs. 10.1, p < 0.001). More used other drugs (69.7% vs. 30.3%, p < 0.001). In regression analyses, marijuana use remained an independent predictor of prior injury (OR = 2.16, 95% CI = 1.25 to 3.75), particularly prior alcoholrelated (OR = 2.26, 95% CI = 1.45 to 3.53) and motorvehicle-related (OR = 1.69, 95% CI = 1.03 to 2.79) injury. Readiness-to-change scores were similar (4.14 vs. 4.22, p = 0.21) between users and nonusers. Conclusions: Marijuana use among injured problem drinkers is prevalent. Their risk of prior injury is increased. Counseling for alcohol and injury should address marijuana use. Key words: alcohol use; marijuana use; substance abuse; injury prevention; emergency medicine; brief intervention. ACADEMIC EMERGENCY MEDICINE 2003; 10:43‐51.

Characteristics associated with intention to change drinking were examined in 254 adolescents treated in an emergency department for alcohol. Younger age, living at home, lower baseline level of drinking and drinking problems, greater depression, having penalties for breaking family drinking rules, higher injury severity, being frightened, and being admitted to the hospital predicted greater intention to change drinking at the time of the event. Baseline characteristics related to being in the action stage of change 3 months later were younger age; lower drinking; having penalties for breaking family drinking rules; injury severity; and number of anticipated consequences, including being in trouble with parents. This study has implications for brief interventions that capitalize on potential teachable moments with problem-drinking adolescents.

Objective The value of electrocardiogram (ECG) overreads of emergency department (ED) tracings have been questioned in the literature. This review was designed to assess the validity of this criticism. Methods In this university teaching hospital ED, following the normal quality assurance protocol, each abnormal ECG is reviewed the following day against the corresponding chart; and if the official reading from cardiology is discordant from the initial clinical one, the patient and/or their physician is contacted. If necessary, the patient is instructed to return to the ED or to their private physician's office. This study is a retrospective review of those ECG overreads for a 21-month period, as well as a summary of those patients who required follow-up care. Results There were 38,490 patients seen with ECGs performed during the study interval. Of these, 16,011 were discharged and 22,479 were admitted from a total patient volume of 117,407. Of those 16,011 patients discharged, follow-up was deemed necessary in 22 patients whose official readings were discordant from the interpretation of the original clinician. Three patients were lost to follow-up (no phone, no address). Review of the tracings and patient/physician follow-up of the 19 remaining patients resulted in a significant change of therapy in 2 patients (admission). The remainder of the abnormal tracings were deemed, after patient or private physician follow-up, to be not significant or to mandate no change in management. Conclusion Official cardiology overreads seldom affect the clinical outcome of patient care delivered in the ED setting.

Medical and social problems related to alcohol use are frequently seen in the ED. Often, the tempo of emergency medicine practice seems to preclude assessment beyond that required by the acute complaint. However, detection of ED patients with alcohol problems can occur using brief screening tools. This article was developed by members of the SAEM Substance Abuse Task Force, and describes screening tools that have been used successfully to identify at-risk and dependent drinkers. Their brevity, reproducibility, and accuracy vary somewhat, but screening can be realistically performed in the busy ED setting. The early detection of patients with alcohol problems would provide the opportunity for early intervention, and may reduce subsequent morbidity and mortality in this patient population.

Early intervention and appropriate refer- ral of patients with alcohol problems have the poten- tial to reduce alcohol-related morbidity and mortality. Part 1 of this series introduced screening tools that can be applied in the ED to allow early detection of at-risk drinkers. This article was developed by mem- bers of the SAEM Substance Abuse Task Force and describes assessment and intervention techniques once the at-risk or dependent drinkers has been iden- tified. Appropriate aftercare and referral of patients found to have alcohol problems are also discussed. Key words: alcohol abuse; ED screening; interven- tion; ED referral. ACADEMIC EMERGENCY MED- ICINE 1998; 51210-1217

The Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency care Trial of very early intravenous glucose-insulin-potassium (GIK) for acute coronary syndromes (ACS) in out-of-hospital emergency medical service (EMS) settings showed 80% reduction in infarct size at 30 days, suggesting potential longer-term benefits. Here we report 1-year outcomes. Prespecified 1-year end points of this randomized, placebo-controlled, double-blind, effectiveness trial included all-cause mortality and composites including cardiac arrest, mortality, or hospitalization for heart failure (HF). Of 871 participants randomized to GIK versus placebo, death occurred within 1 year in 11.6% versus 13.5%, respectively (unadjusted hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.57 to 1.23, p = 0.36). The composite of cardiac arrest or 1-year mortality was 12.8% versus 17.0% (HR 0.71, 95% CI 0.50 to 1.02, p = 0.06). The composite of hospitalization for HF or mortality within 1 year was 17.2% versus 17.2% (HR 0.98, 95% CI 0.70 to 1.37, p = 0.92). The composite of mortality, cardiac arrest, or HF hospitalization within 1 year was 18.1% versus 20.4% (HR 0.85, 95% CI 0.62 to 1.16, p = 0.30). In patients presenting with suspected ST elevation myocardial infarction, HRs for 1-year mortality and the 3 composites were, respectively, 0.65 (95% CI 0.33 to 1.27, p = 0.21), 0.52 (95% CI 0.30 to 0.92, p = 0.03), 0.63 (95% CI 0.35 to 1.16, p = 0.14), and 0.51 (95% CI 0.30 to 0.87, p = 0.01). In patients with suspected acute coronary syndromes, serious end points generally were lower with GIK than placebo, but the differences were not statistically significant. However, in those with ST elevation myocardial infarction, the composites of cardiac arrest or 1-year mortality, and of cardiac arrest, mortality, or HF hospitalization within 1 year, were significantly reduced.

A randomized controlled trial of screening, brief intervention, and referral to treatment (SBIRT) for drinking and related problems among at-risk and dependent drinkers was conducted in an emergency department (ED) at the US-Mexico border among Mexican-origin young adults. Data collection over a period of 17 months resulted in 698 patients recruited into the study and randomized to one of three conditions: screened only (n=78), assessed (n=310), and intervention (n=310). Patients in the assessment (77%) and intervention (72%) conditions were blindly reassessed at three months via one telephone interview. No difference was found in baseline demographic or drinking characteristics between the assessment intervention groups. At follow-up, the intervention group showed significantly greater decreases in five of six outcome variables: number of drinking days per week, average number of drinks and per drinking day, maximum number of drinks, RAPS4 score as an indicator of alcohol dependence and number of negative consequences related to drinking. Using analysis of covariance to control for baseline measures, the intervention group was lower on all drinking and problem measures than the assessment group, and significantly so on four of the measures. When the interaction of intervention by injury status (injury vs. non-injury), drinking within six hours prior to the event, causal attribution of the event to drinking and risk taking disposition were examined, only causal attribution had a significant effect for two of the problem measures – the intervention effect for the RAPS4 and negative consequences was greater for those who believed their injury or illness was related to their drinking. Findings here suggest that brief intervention was effective in this population compared to assessment at three month follow-up, and may be most effective for those linking the reason for their ED visit to their drinking.

A 40-year-old man with diabetes and seizure disorder was found at home unresponsive and "very hot to touch" by his father 40 minutes before emergency medical services arrival. His usual medications included topiramate, divalproex sodium, and rosiglitazone/metformin. Paramedics administered oxygen, intravenous fluids, and naloxone. They did not witness or report seizure activity. Upon emergency department arrival, the patient was unresponsive (Glasgow Coma Scale 3), hypotensive (94/50 mm Hg), and tachypneic (32 breaths per minute), with a heart rate of 60 beats per minute and elevated rectal temperature peaking at 43.2°C. His skin was hot and dry, without rash; physical examination was otherwise normal. Laboratory studies revealed severe metabolic acidosis with acute renal failure and rhabdomyolysis. In spite of sedation, intubation, and aggressive cooling measures, the patient had cardiac arrest and died approximately 2 hours after arrival. Serum topiramate and valproate concentrations were within therapeutic ranges at 8.8 μg/mL (therapeutic 2-12) and 97 μg/mL (therapeutic 50-100), respectively.

Objectives: To determine the incidence of alcohol use in subcritically injured patients presenting to the ED, by using a saliva alcohol test (SAT) at ED triage during the ED initial assessment; to compare the incidence of alcohol use revealed by the SAT with documentation of alcohol use by ED nurses and emergency physicians (EPs) blinded to the SAT results; and to describe the demographics of the SAT-positive, subcritically injured population. Methods: A blinded, prospective, observational evaluation of ED patients presenting with subcritical injuries was performed. The patients were tested for alcohol use with an SAT, and a subsequent record review was conducted for extraction of demographic data and evidence of documentation of alcohol use by ED nurses and EPs blinded to the SAT results. Results: During the study. 791 subcritically injured patients had SATs performed. Twenty-one percent of these patients were found to be alcohol-positive by SAT. Either the ED nurse or the EP documented a clinical impression of alcohol use for 52% of the SAT-positive patients. There were higher SAT-positive rates among men (24%), victims of assault (47%), and patients arriving at night (41%). Conclusions: While the SAT identified 21% of the subcritically injured patient population as alcohol-positive, ED nurse and EP documentation did not identify half of these alcohol-positive patients. Many of these patients may be at risk for additional injuries related to their drinking behavior.

Study objective Brief interventions (BI) for alcohol misuse and recently for marijuana use for emergency department patients have demonstrated effectiveness. We report a 12-month outcome data of a randomized controlled trial of emergency department (ED) patients using a novel model of BI that addresses both alcohol and marijuana use. Methods ED research assistants recruited adult patients who admitted alcohol use in the last month, and marijuana use in the last year. In the ED, patients received an assessment of alcohol and marijuana use and were randomized to treatment (n = 249) or standard care (n = 266). Treatment consisted of two sessions of BI. At 3 and 12 months, both groups had an assessment of alcohol and marijuana use and negative consequences of use. Results 515 patients were randomized. We completed a 12-month follow-up assessments on 83% of those randomized. Measures of binge drinking and conjoint marijuana and alcohol use significantly decreased for the treatment group compared to the standard care group. At 12-month binge alcohol use days per month in the treatment group were (M = 0.72:95% CI = 0.36–1.12) compared to standard care group (M = 1.77:95% CI = 1.19–1.57) Conjoint use days in the treatment group (M = 1.25.1:95% CI = 0.81–1.54) compared to standard care group (M = 2.16:95% CI = 1.56–2.86). No differences in negative consequences or injuries were seen between the treatment and standard care groups. Conclusions BI for alcohol and marijuana decreased binge drinking and conjoint use in our treatment group. BI appears to offer a mechanism to reduce risky alcohol and marijuana use among ED patients but expected reductions in consequences of use such as injury were not found 12 months after the ED visit.

This article reviews studies and current practices of brief motivational intervention in the emergency department and identifies factors related to the effectiveness of brief intervention. Studies of brief intervention in the emergency department have had mixed results with most studies showing improvements in both intervention and control groups. Most report brief intervention reducing alcohol's negative consequences without reducing consumption. Clinical practice is incorporating brief intervention as part of emergency treatment and further research is needed to determine the factors most responsible for the improvements noted in most studies.

This article summarizes the work and discussions of the funding and sustainability work group at the 2009 Academic Emergency Medicine consensus conference "Public Health in the ED: Surveillance, Screening, and Intervention." The funding and sustainability session participants were asked to address the following overarching question: "What are the opportunities and what is needed to encourage academic emergency medicine (EM) to take advantage of the opportunities for funding available for public health research initiatives and build stronger academic programs focusing on public health within EM?" Prior to the session, members of the group reviewed research funding for EM in public health, as well as the priorities of federal agencies and foundations. Recommendations for actions by EM summarize the findings of workshop.

This article is a product of a breakout session on injury prevention from the 2009 Academic Emergency Medicine consensus conference on "Public Health in the ED: Screening, Surveillance, and Intervention." The emergency department (ED) is an important entry portal into the medical care system. Given the epidemiology of substance use among ED patients, the delivery of effective brief interventions (BIs) for alcohol, drug, and tobacco use in the ED has the potential to have a large public health impact. To date, the results of randomized controlled trials of interventional studies in the ED setting for substance use have been mixed in regard to alcohol and understudied in the area of tobacco and other drugs. As a result, there are more questions remaining than answered. The work group developed the following research recommendations that are essential for the field of screening and BI for alcohol, tobacco, and other drugs in the ED. 1) Screening--develop and validate brief and practical screening instruments for ED patients and determine the optimal method for the administration of screening instruments. 2) Key components and delivery methods for intervention--conduct research on the effectiveness of screening, brief intervention, and referral to treatment (SBIRT) in the ED on outcomes (e.g., consumption, associated risk behaviors, and medical psychosocial consequences) including minimum dose needed, key components, optimal delivery method, interventions focused on multiple risk behaviors and tailored based on assessment, and strategies for addressing polysubstance use. 3) Effectiveness among patient subgroups--conduct research to determine which patients are most likely to benefit from a BI for substance use, including research on moderators and mediators of intervention effectiveness, and examine special populations using culturally and developmentally appropriate interventions. 4) Referral strategies--a) promote prospective effectiveness trials to test best strategies to facilitate referrals and access from the ED to preventive services, community resources, and substance abuse and mental health treatment; b) examine impact of available community services; c) examine the role of stigma of referral and follow-up; and d) examine alternatives to specialized treatment referral. 5) Translation--conduct translational and cost-effectiveness research of proven efficacious interventions, with attention to fidelity, to move ED SBIRT from research to practice.

[Wears RL, Janiak B, Moorhead JC, Kellermann AL, Yeh CS, Rice MM, Jay G, Perry SJ, Woolard R. Human error in medicine: promise and pitfalls, part 2. Ann Emerg Med. August 2000;36:142-144.]

[Wears RL, Janiak B, Moorhead JC, Kellermann AL, Yeh CS, Rice MM, Jay G, Perry SJ, Woolard RJ. Human error in medicine: promise and pitfalls, part 1. Ann Emerg Med. July 2000;36:58-60.]

Screening and brief intervention (SBI) for alcohol problems in the emergency department (ED) is effective. The objective of this study was to examine the translation of SBI into a busy community ED environment. The authors assessed key stakeholders views of SBI delivery model, then utilized feedback to adapt model. Adoption of SBI was recorded, with data collected on use of screening tool, and referral for a BI. Model was modified due to physicians’ and nursing resistance; physicians only screened and a research assistant (RA) delivered the BI. When the RA was present, screening by ED staff increased from 50% to 71% but returned to 50% after the RA left. An identified opportunity was increased nursing interest after observation of SBI, with 15 nurses trained in SBI after ED intervention concluded. Important barriers to translating SBI to community ED clinical practice exist. However, with additional staff present, high levels of SBI can occur.

A substantial number of the injured patients who go to the emergency department (ED) for treatment will have alcohol use issues and may be intoxicated at the time of treatment (Becker et al., 1995; Cherpitel, 1999; Freedland et al., 1993), and they are at risk from continuing to experience adverse health and psychosocial consequences (D’Onofrio et al., 2005; Dinh-Zarr et al., 2000; McDonald et al., 2004). As ED treatment presents a brief opportunity for the health-care professional to screen for and to address patients’ hazardous alcohol use, it is important that emergency-care professionals determine the most efficacious way to help individuals who may be amenable to changing their alcohol-related behaviors and reduce the likelihood of future negative consequences (Crawford et al., 2004; D’Onofrio et al., 2005). Brief motivational interviewing (BMI) is a therapeutic approach that has been employed to change patient behavior in a variety of clinical settings. This brief client-centered intervention focuses on helping patients identify behaviors that need to be changed, increased patient ambivalence, motivation, and planning for changing identified behaviors (Field et al., 2005;Miller and Rollnick, 2002). A meta-analysis on the use of BMI in randomized clinical trials in primary care settings has demonstrated effectiveness in reducing alcohol consumption in patients when compared with standard care (Burke et al., 2003; Moyer et al., 2002; Rounsaville et al., 2001). A more recent review of the literature suggests that BMI is generally more effective than standard care in the ED for reducing hazardous alcohol use, such as binge drinking, and in reducing alcohol-related injuries and negative consequences (P. Nilsen et al., unpublished data). However, treatment regimes such as BMI should not only demonstrate efficacy but also should provide an explanation of the mechanisms by which the treatment facilitates change in the patient (Rounsaville et al., 2001). In reviewing research on the treatment components for alcohol use, Miller (1985) concluded that therapist characteristics were seldom investigated as a predictor of patient motivation and treatment compliance (Miller, 1985). In explaining how treatments such as BMI work, it is important to understand what works by also looking at therapists’ behaviors, rather than only focusing on the patient characteristics that moderate treatment. This current investigation was conducted as a secondary analysis of data from a large-scale randomized clinical trial which demonstrated that injured ED patients, randomized into BMI with a booster BMI session, experienced better long-term outcomes than ED patients receiving standard care (SC), including reduced alcohol-related injuries and negative consequences (Longabaugh et al., 2001). Using an intention-to-treat model, the original study compared treatment effectiveness of injured ED patients (n = 539) randomization to: (1) SC (n = 188), (2) 1 session of BMI delivered in the ED setting (BI; n = 182), and (3) 2 sessions of BMI (BIB; n = 169) (one delivered in the ED and a later booster session delivered outside of the ED). In the original study, all recruited participants were at-risk drinkers by virtue of having a score of 8 or greater in the AUDIT, and/or having alcohol in their system at the time of injury or ED visit. The Institutional Review Board of the hospital and university approved the original research protocol. The outcome data analyzed in the present paper were provided by those participants recruited into the study who were interviewed 12 months after their initial injury-related ED visit (84%). These follow-up interviews were conducted by research assistants who were blinded to participant group assignment. The original study demonstrated that those participants assigned to the BIB condition as compared with those assigned to the SC, had fewer alcohol-related injuries and negative consequences during the 12 months after treatment (Longabaugh et al., 2001). However, because only 68% of the participants assigned to the BIB condition actually received the second BMI session, it is important to examine why some participants did not complete the second BMI session and to determine if completion of the second BMI was important in predicting treatment outcomes. As participants were demonstrating a selection bias in deciding whether or not to return to complete the treatment assignment, it was important (1) to determine what effect that this lack of treatment completion had on participant outcomes and (2) to examine what therapists behaviors may have influenced the decisions of the participants to complete treatment, after we have ruled out competing theories of participant characteristics that were associated with treatment completion.

We determine the impact of a screening, brief intervention, and referral for treatment (SBIRT) program in reducing alcohol consumption among emergency department (ED) patients.Patients drinking above National Institute of Alcohol Abuse and Alcoholism low-risk guidelines were recruited from 14 sites nationwide from April to August 2004. A quasiexperimental comparison group design was used in which control and intervention patients were recruited sequentially at each site. Control patients received a written handout. The intervention group received the handout and a brief intervention, the Brief Negotiated Interview, to reduce unhealthy alcohol use. Follow-up surveys were conducted at 3 months by telephone using an interactive voice response system.Of 7,751 patients screened, 2,051 (26%) exceeded the low-risk limits set by National Institute of Alcohol Abuse and Alcoholism; 1,132 (55%) of eligible patients consented and were enrolled (581 control, 551 intervention). Six hundred ninety-nine (62%) completed a 3-month follow-up survey, using the interactive voice response system. At follow-up, patients receiving a Brief Negotiated Interview reported consuming 3.25 fewer drinks per week than controls (coefficient [B] -3.25; 95% confidence interval [CI] -5.76 to -0.75), and the maximum number of drinks per occasion among those receiving Brief Negotiated Interview was almost three quarters of a drink less than controls (B -0.72; 95% CI -1.42 to -0.02). At-risk drinkers (CAGE2) appeared to benefit more from a Brief Negotiated Interview than dependent drinkers (CAGE2). At 3-month follow-up, 37.2% of patients with CAGE less than 2 in the intervention group no longer exceeded National Institute of Alcohol Abuse and Alcoholism low-risk limits compared with 18.6% in the control group (delta 18.6%; 95% CI 11.5% to 25.6%).SBIRT appears effective in the ED setting for reducing unhealthy drinking at 3 months.

Alcohol, tobacco, and other drug use is a significant societal problem. Individuals who use these substances are frequently seen in emergency departments at rates disproportionately greater than their population prevalence. This article highlights the impact of these drugs on patients and on emergency departments, including common presenting problems of individuals on these substances. Also discussed is how to help and to refer individuals with substance abuse problems through brief motivational interventions.

Pneumothorax and pneumomediastinum are rare complications of athletic activity. Spontaneous pneumothorax has been reported in association with several sports, but reports of pneumothorax associated with blunt trauma sustained during sporting activity are rare. We present a case series of patients in whom pneumothorax or pneumomediastinum developed as a result of blunt trauma sustained during participation in a contact sport.

Although the Short Index of Problems (SIP) is often used, little is known about the psychometric properties of the SIP in special populations. The present study seeks to determine the following: (1) whether it is possible to substitute items to enhance the psychometric properties of the SIP and (2) whether the SIP, or improved scale, is as sensitive as the Drinker Inventory of Consequences (DrInC) to assess intervention effectiveness.The sample consisted of 404 injured patients who were treated in the Emergency Department (ED) of a major teaching hospital that serves southern New England. Three approaches were used to guide development of the 3-month SIP-R, the potential alternative to the SIP. Cronbach's alpha assessed intrascale reliability; hierarchical multiple regression assessed construct validity; performance of the scales assessing intervention change were compared to the total 3-month DrInC as a function of intervention using analysis of covariance (ANCOVA).There was no evidence that changing the current SIP items will significantly improve performance. The 3-month SIP performed as well as the 3-month DrInC-2R in predicting 12-month DrInC scores and in determining intervention change at 12 months. Of the 45 DrInC items, 31 also predicted a difference across intervention groups.These results suggest there is no advantage to changing the current SIP items. The 3-month SIP is a psychometrically sound measure for assessing consequences of alcohol consumption in an ED sample and is almost as sensitive to intervention change as the full DrInC.

Study objective: This study compares the effect of a brief motivational intervention for alcohol plus a booster given to emergency department (ED) patients with subcritical injuries from a motor vehicle crash with the effect of brief motivational intervention for alcohol plus a booster in patients treated for non-motor vehicle crash-related injuries. Methods: A randomized controlled trial (n=539) was conducted at an urban Level I trauma center of brief intervention (1 ED session of brief intervention), brief motivational intervention for alcohol plus a booster (1 ED session plus booster session), or standard care for injured ED patients with an alcohol use problem who were being discharged home. At 12 months, alcohol-related negative consequences and injuries were measured. We performed a secondary analysis comparing motor vehicle crash–injured patients and non–motor vehicle crash–injured patients in the study sample. Results: Subcritically injured ED patients with harmful or hazardous alcohol use who received brief motivational intervention for alcohol plus a booster had fewer alcohol-related negative consequences and alcohol-related injuries than those receiving brief intervention or standard care at 12-month follow-up (previously reported). A secondary analysis of this result showed that motor vehicle crash patients (n=133) given brief motivational intervention for alcohol plus a booster (n=34) had fewer alcohol-related injuries than those receiving standard care (n=46; P=.001). Moreover, there were no significant differences in alcohol-related injuries among the non–motor vehicle crash–injured patients who received brief intervention or standard care. Conclusion: Brief motivational intervention for alcohol plus a booster is a useful intervention for subcritically injured ED patients with harmful or hazardous alcohol use. Its effects may be moderated by the cause of injury. [Ann Emerg Med. 2005;45:620-625.]

In summary, RIDI is a multi-year research project to identify and develop solutions to some of the challenges posed by disaster response, with a focus on WMD incidents. September 11, 2001, changed the RIDI timeline with increased pressure to produce tangible results and recommendations rapidly. Phase 1 was an effort to identify problems and potential solutions through vulnerability assessment, literature review and expert panel discussion. Many disaster response "solutions" may fail because of a rush to use untested equipment or processes. RIDI is working cooperatively with other Rhode Island disaster experts to avoid these failures. Informed by Phase 1, RIDI Phase 2 will carefully and progressively test potential "solutions" during research trial disaster drills. Only after research can RIDI identify best practices in disaster response. As RIDI progresses to Phase 3, the demonstration project phase, specific improvements are expected in Rhode Island's readiness for disaster. A main feature of Phase 3 is use of a RIDI demonstration vehicle to bring identified solutions to the scene as requested by Rhode Island EMS agencies. Together with others working to improve Rhode Island readiness for disaster threats, RIDI hopes to improve the outcome for patients and providers in Rhode Island as they face the current disaster threats.

Patients treated in an urban emergency department were studied to determine if college status, gender and having alcohol as a reason for medical treatment were related to alcohol use and related problem behaviors.Patients ages 18-19 years (N = 250; 55% men) who had or had not been drinking alcohol prior to the event that precipitated their medical treatment were assessed on their alcohol use, alcohol-related problems and drug use.There were high levels of alcohol use, tobacco use and other drug use in the sample, regardless of the reason for medical treatment. Analyses consistently showed that patients treated for alcohol-related reasons had more severe drinking patterns and problems than patients who were alcohol negative. Patients not enrolled in college showed similar patterns of alcohol consumption as their college-attending peers, but bad more severe alcohol-related behaviors and problems. Few gender differences were found and no interactions were found between gender, alcohol status and college status.Findings indicate that older adolescents who receive medical treatment for alcohol use are not inexperienced drinkers. Furthermore, in this convenience sample, college students did not appear to be at greater risk for substance use or problems. Findings underscore the potential usefulness of alcohol intervention programs for alcohol-involved medical patients, and the need to attend to the alcohol and drug use of nonstudent populations.