Barriers to Implementation of Screening, Brief Intervention, and Referral to Treatment in the Prehospital Setting

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework is a validated process that is used to identify individuals with substance use disorders (SUDs) and then encourage them to engage in and facilitate entry into treatment. It is not known how well SBIRT can be incorporated into prehospital practice and what barriers to Emergency Medical Services (EMS) implementation of an SBIRT program might arise. The aim of this project was to implement a pilot EMS based SBIRT program. Then, after program implementation, to identify barriers to the prehospital use of SBIRT programs.

This was a mixed methodology study utilizing a retrospective review of program quality improvement data and structured interviews to collect both objective and subjective data on the prehospital SBIRT implementation. Eight EMS agencies participated in the SBIRT pilot program. Paramedics and Emergency Medical Technicians (EMT) were trained to use the SBIRT process then asked to use the SBIRT tool during their day to day activities. The screening tools utilized were the Drug Abuse Screening Test (DAST) and the Alcohol Use Disorders Identification Test (AUDIT). Referral tools were tailored to the unique SUD treatment programs available in each community. The pilot program was run for 6 months after which time structured focus group meetings were conducted to identify barriers to broader SBIRT program utilization.

In total, 28 EMS clinicians from 8 agencies attended the train the trainer SBIRT education session. None of the agencies subsequently implemented the routine use of the SBIRT model or DAST/AUDIT tools. The agencies reported significant barriers to implementation on EMS calls, including short transport times, current drug and/or alcohol intoxication, and hesitation of patients to participate. Community paramedicine clinicians, who typically spend more time with patients, found the tools more useful but found limited opportunities to implement them. Common cited themes were the lack of local community-based organizations and frequent personnel turnover within local agencies.

Although EMS clinicians found the SBIRT training to be useful, they did not incorporate the use of the SBIRT model into their prehospital patient care, citing too many barriers to its implementation and use.