Substance use disorder recently became a wide-spread epidemic that is difficult to address. According to a 2014 survey (SAMHSA, 2015), substance use disorders affect approximately 21.5 million people in the United States 12 years and older. The economic burden in the United States related to tobacco, illicit drugs, and alcohol abuse is $740 billion annually (National Institute on Drug Abuse, 2017). A prevalent intervention used to support treatment of people with substance use disorder is Screening, Brief Intervention, and Referral to Treatment (SBIRT). SBIRT was launched by the American Substance Abuse and Mental Health Administration (SAMHSA) as a preventative initiative with aims to improve identification, brief intervention, and referral to treatment for individuals with alcohol and/or substance use (Brereton & Gerdtz, 2017). Positive social and health outcomes have resulted from implementation of SBIRT (Bray, Cowell, & Hinde, 2011; Désy, Howard, Perhats, & Li, 2010; Madras et al., 2009). Despite supportive evidence, the rate of SBIRT implementation is low (Agley et al., 2018).
BACKGROUND & SIGNIFICANCE
SBIRT provides an evidence-based approach for substance use screening and intervention recommended for substance screening in patients age 12 and above and can be used in multiple healthcare settings (SAMHSA, n.d.). Identification, delivery of a brief intervention, and connection to a potential referral to treatment for substance abuse is the purpose of SBIRT (Rosenthal, 2018). Nurses are well-positioned to identify and intervene with patients at risk for alcohol and/or substance use due to their frequent interaction with health care consumers (Finnell et al., 2014). The American Nurses Association has endorsed nursing as a necessary role in the prevention of harm related to substance use (Finnell et al., 2014). Nurses have opportunity to identify at risk individuals to provide prevention, intervention, and treatment for alcohol, tobacco, and other drugs (Finnell et al., 2014). As nurses and other healthcare providers implement SBIRT in different settings, it is important to evaluate the implementation process. An understanding of the process can inform strategies to promote adoption, implementation, and sustainability of SBIRT. In a parent study of SBIRT implementation, nurse leaders within 14 acute care facilities identified a leader to coordinate implementation within the facility and champion the change. These site coordinators received training about SBIRT and a toolkit to facilitate implementation, and then each site coordinator adapted SBIRT delivery based on the structural characteristics and available resources within their facility. Because the parent study included critical access hospitals, community hospitals, and academic health centers with a variety of structural characteristics and resources, the implementation process varied among the facilities. The purpose of this study was to identify and describe the delivery of SBIRT at 14 different facilities. Study aims include: (1) Illustrate the various patterns of SBIRT delivery across facilities; (2) Describe how each facility implemented SBIRT based on available resources.
METHODS
This was a quality improvement project examining the process of SBIRT delivery at 14 diverse facilities within one hospital system. Semi-structured interviews were completed with the site coordinator at each facility to identify the process steps taken at the local level. Responses from each interview were compiled into an excel spreadsheet. Two of the authors collaborated to identify similarities and differences between the two facilities, generating a diagram to depict process owners for screening, brief intervention, and referral to treatment.
FINDINGS
Alcohol and drug use processes were similar, but different from tobacco. Screening was consistently completed by the admitting nurse, with some variance identified in the brief intervention process as social workers emerged as owners in addition to nurses. The most variance in process ownership was in the referral to treatment. Seven unique processes were identified for alcohol and drug use and five process for tobacco. Process owners for alcohol and drug use referral to treatment were social workers at nine facilities (64%), registered nurses at three facilities (22%), and case managers at two facilities (14%). Process owners for tobacco were respiratory therapists at 6 facilities (50%), registered nurses at 3 facilities (25%), case managers at two facilities (17%), and social work in one facility (8%).
DISCUSSION
Each facility localized the SBIRT process based on available resources. Some facilities chose to train all nurses for each step of SBIRT and some trained and implemented specific nurse roles to deliver the brief intervention and referral to treatment component. Additionally, many facilities identified supporting resources including social work, case management, and respiratory therapy to own the brief intervention or referral to treatment process steps. It is important to note that nurse-led referral to treatment was interdisciplinary and not completed by the nurse alone. Nurse-led referral included provider notification and either social work or case management consultation to complete the referral process.
CONCLUSION
Implementation of any evidence-based intervention should consider localization within each practice environment. Substance use is an important issue, requiring an interprofessional team approach. This implementation description is an excellent example of collaboration between multiple disciplines to recognize, address and arrange treatment for people that use substances.