5 essential steps for trauma centers to meet SBIRT standards

Authored by:
Theresa Radeker, MHA, BSN, RN, TCRN
Vice President and Managing Partner

According to the Verification Review Committee (VRC) Resources for Optimal Care of the Injured Patient (2022), trauma centers are required to screen at least 80% of admitted trauma patients over 12 years old for alcohol misuse, either using a validated tool or a blood alcohol content test. Additionally, they must provide a documented brief intervention for at least 80% of patients who screen positive, conducted by trained staff before discharge. Failure to meet these standards may result in two Type II deficiencies.

To maintain compliance with Screening, Brief Intervention, and Referral to Treatment (SBIRT) requirements, focusing on five essential steps can help ensure that all Level I, II, and III centers, including pediatric Levels I and II, meet the standards for alcohol misuse screening and intervention.

  1. Implement routine screening protocols: Trauma centers should establish a standardized screening process to identify alcohol misuse among all admitted patients aged 12 and older. Using validated screening tools, such as the AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) or the CAGE questionnaire, can help efficiently identify patients who may benefit from an intervention. Incorporating this step into the admissions process ensures consistent screening for every eligible patient. Many hospitals utilize social workers to complete the screening tools.
  2. Ensure staff training for brief interventions: Compliance requires that at least 80% of patients who screen positive for alcohol misuse receive a brief intervention. Training staff—including nurses, social workers, and physicians—in brief intervention techniques is essential. Techniques like motivational interviewing can effectively encourage patients to reflect on their alcohol use and consider positive changes. Regular training ensures that staff are equipped to deliver these interventions skillfully.
  3. Document interventions and outcomes consistently: Trauma centers should have a reliable documentation process for recording screening outcomes and brief interventions. Electronic health records (EHR) can be configured to prompt staff to complete required SBIRT fields, making it easier to track compliance and ensure accurate intervention records. Detailed documentation is crucial for patient continuity of care and audit compliance, and it can be tracked on your monthly dashboard.
  4. Establish referral systems for long-term support: For patients who need more than a brief intervention, trauma centers should establish referral pathways to connect them with long-term support services, such as substance abuse counseling or rehabilitation programs. Developing relationships with community resources or in-house behavioral health services ensures patients receive the support they need beyond their trauma care.
  5. Monitor compliance and provide feedback: Trauma centers should continuously monitor compliance with SBIRT standards, such as the percentage of patients screened and the number receiving brief interventions. Regular audits and feedback sessions help identify process gaps and enable necessary adjustments. By creating a feedback loop, trauma centers can improve compliance rates and enhance patient care over time.

By implementing these steps, trauma centers not only ensure SBIRT compliance but also elevate the quality of care for patients struggling with alcohol misuse. This proactive approach reduces the risk of repeat trauma incidents, promotes lasting behavioral change, and reinforces a trauma center’s commitment to holistic, patient-centered care. Ultimately, these efforts contribute to healthier long-term outcomes and demonstrate the center’s dedication to the well-being and recovery of every patient it serves.