Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Drinking Problem? Try SBI.

In I’LL Give You A Comment, White Coat Rants writes about a new counterproductive, and probably lethal, policy.

Well, if you have a drinking problem, or if you have a family member who has a drinking problem, or if you make money treating people who have drinking problems, then the latest JCAHO mandate to impair ED (Emergency Department) treatment is your kind of drug. Of course, that is assuming that the SBI (Screening and Brief Intervention)[1] becomes a mandate. Screen everyone for alcohol abuse, then provide a 15 minute intervention to stop the problem drinking. Ooops, most of them call this SBIRT, the RT for Referral to Treatment. That is where the counselors will make their money. Then there are the rest of the JCAHO screenings. Then you may receive a medical assessment for the emergency that resulted in your trip to the ED.

Looking at the web site for this, it seems to be guaranteed. I counted about a dozen people posting opposing views on this topic. Some of them were only “not completely thrilled.” They only seem to be concerned about where their money will come from. If they get their cut, that only leaves about half a dozen opposing voices. One is clearly a crackpot, linking this to a rebirth of Nazi style government, but the rest stay on topic. In favor of this are about 200 posts. Reading them is like reading the positive comments about Big Brother from the government officials in 1984,[2] so maybe the crackpot isn’t so crazy. How can so many be oblivious to the harm?

The trauma personnel in favor of this mandate deal with a situation that is different from what the ED faces. You are not presented with a triage nurse asking all of these screening questions and then performing a brief intervention before you are seen. Trauma centers tend to be much better at keeping social workers on staff (available to trauma), so they can respond with the rest of the trauma team and ask the screening barrage after the patient has been stabilized.

JCAHO (the Joint Commission for Accrediting Health Care Organization) was their old name, but they are trying for a new and improved image. Never a good sign in health care. Now they call themselves TJC (The Joint Commission). What were they thinking? Hmmm. That’s not right. What were they smoking?

Inevitably, with a bunch of bloggers who have a sense of humor, some refer to them as the Medical Marijuana Advocates. [3]

If you are unfamiliar with the topic, the Medical Marijuana Advocates are the people who the hospital calls in for prearranged inspections, so for that one week where everyone is doing everything by the book, it is because these runaways from the circus are coming to visit. They make all sorts of silly rules, as you can see from these links.[4], [5], [6]

They act as if the ED is Lake Woebegone, where all of the children are above average and giving them more and more divergent responsibilities will actually not cause competency to decrease. As if there are no lowest common denominators, who will no longer be up to that minimum standard. Now they will be more dangerous.

“Oh no! It’s Nurse X. Why do we have to work with Nurse X, nobody is worse at patient care than Nurse X.”

“Hush, Nurse X always completes the SBI thoroughly and gets such good evaluations from the patients. We are all about the Press Ganey scores, not patient care. So what if we lose a few patients, dead people don’t fill out evaluations.”

My opinion ofcross-training[7], [8], [9], [10], [11] has not changed. This is not different from the requirement that paramedics become cross-trained to satisfy somebody’s misunderstanding of medicine. The only positive I see here is that it may help others to see the problems with EMS cross-training.

Eventually, you will arrive at the ED and be asked such a ridiculous number of questions before you are treated, that most people will look for genuine alternatives. Someplace to go for real emergency care, not an emergent screening for all sorts of chronic social problems. The purpose of the ED is to keep you from immediate death or disability. Screening for smoking in the home, domestic violence, TB, suicidal ideation, alcohol consumption, . . . is not necessarily wrong. When the screening and brief intervention distract the nurse from focusing on the life and limb threats, then screening is bad. When this encourages the hiring of nurses and doctors, who are incapable of recognizing a life or limb threat, then it is very bad.

But this is just one more question, how bad can that be?

It is not one more question – it is a 15 minute intervention.

An extra quarter of an hour out of the treatment of each patient. Where are the ED nurses to find the time? If the hospitals hire more staff for this, you know that they will be the first to go when the next “belt tightening” happens.

The addiction community is lining up at the feeding trough to stuff themselves on the bacchanalia that they see as their reward for being ignored for so long. As long as nobody questions where the money or the time is supposed to come from, nobody seems to care. I see the dilution of skill, in order to include this new skill for doctors and nurses, as a bigger problem.

This is coming from you. From your wallet and from your quality of life – assuming it doesn’t kill you.

The ED cannot turn anyone away, so every “deserving” social program shall be foisted upon the ED. Eventually, the ED may have nothing to do with emergency medicine. The ED is being made to atone for the guilt of everyone else.

The ED has become the Lady MacBeth of medicine. Lady MacBeth was guilty in the death of the king. The ED has many faults, but it does not have that kind of blood on its hands – yet.

This stain will not go away.

This stain will make a mockery of emergency medicine.

No. I do not think that I am exaggerating.

Another view of the same situation is presented in the book The Victim by Saul Bellow.[12] Guilt vs. entitlement. How much do we let our guilt, or our neighbors’ guilt cause us to harm ourselves and to encourage the guilt tripper in his dissolution?

Responsibility has become a foreign concept.

No individual responsibility is to be allowed in America.

^ 1 The Joint Commission
Standards Development & Research

^ 2 From The Literature Network

^ 5 From MDOD

^ 6 From MDOD

^ 7

^ 8

^ 9

^ 10

^ 11



  1. Just popping in to say hello. I’ve been too busy to read much, but I try to check in when I can.

  2. Hello.I know the feeling.

  3. Next thing yah know, JCAHO will mandate a certain kind of cover sheet on our TPS reports. If you’re a chronic alcoholic and job loss, family issues and money problems aren’t enough to keep you from drinking to excess or seeking treatment, why will some over-burdened nurse in an ER make a damn lick of difference?

  4. Look at the bright side. You are the solution to all of the world’s problems. 🙂