This is the author’s version of a work that was submitted/accepted for pub-lication in the following source:

Lee, Kai H., Bobinskas, Alex, & Sun, Jiandong(2015)Addressing alcohol related harms within maxillofacial trauma practice.Journal of Oral and Maxillofacial Surgery, 73(2), 314.e1-e6.

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Accepted Manuscript

Addressing Alcohol Related Harms within Maxillofacial Trauma Practice

Kai H. Lee, Alex Bobinskas, Jiandong Sun

PII: S0278-2391(14)01533-X

DOI: 10.1016/j.joms.2014.09.026

Reference: YJOMS 56517

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 3 July 2014

Revised Date: 17 September 2014

Accepted Date: 30 September 2014

Please cite this article as: Lee KH, Bobinskas A, Sun J, Addressing Alcohol Related Harms withinMaxillofacial Trauma Practice, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/j.joms.2014.09.026.

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Addressing Alcohol Related Harms within Maxillofacial Trauma

Practice

Kai H Lee

Consultant Oral & Maxillofacial Surgeon

Geelong Hospital

Victoria Australia

westgatesurgical@gmail.com

Alex Bobinskas

Formerly Oral & Maxillofacial Surgery registrar

Geelong Hospital

Victoria Australia

Jiandong Sun

Postdoctoral Research Fellow

School of Public Health and Social Work

Queensland University of Technology

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Abstract

Background: A brief intervention, conducted in the acute setting care setting after an alcohol-related

injury, has been reported to be highly beneficial in reducing the risk of re-injury and in reducing

subsequent level of alcohol consumption. This project aimed to understand Australasian Oral and

Maxillofacial Surgeons' attitudes, knowledge and skills in terms of alcohol screening and brief

intervention within acute settings for patients admitted with facial trauma.

Materials and Methods: A web-based survey was made available to all members (n=200-250) of the

Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS), promoted

through a number of email bulletins sent by the Association to all members. Implied consent is

assumed for participants who complete the online survey. The survey explored their current level of

involvement in treating patients with alcohol-relatd facial trauma, as well as their knowledge of and

attitudes towards alcohol screening and brief intervention. The survey also explored their

willingness for further training and involvement in implementing a SBI program. Parts of the survey

were based on a hypothetical case with facial injury and drinking history which was presented to the

participants and the participants were asked to give their response to this scenario.

Results: A total of 58 surgeons completed the on-line survey. 91% of surgeons surveyed were males

and 88% were consultant surgeons. 71% would take alcohol history; 29% would deliver a brief

alcohol intervention and 14% would refer the patients to an alcohol treatment service or clinician.

40% agreed to have adequate training in managing patients with alcohol-related injuries, while 17%

and 19% felt they had adequate time and resources. 76% of surgeons reported the need for more

information on where to refer patients for appropriate alcohol treatment.

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Conclusion: The study findings confirm the challenges and barriers to implementing brief alcohol

intervention in current practice. There are service gaps that exist, as well as opportunities for

training.

Keywords: Maxillofacial, trauma, fractures, alcohol intervention

Introduction

Facial fractures are a common injury seen in emergency departments across Australia, with alcohol

identified as a major contributing factor1. Alcohol has strong association with facial injuries

secondary to interpersonal violence and motor vehicle accidents1. Hazardous consumption of

alcohol is a leading modifiable determinant of facial injury, highlighting the need for interventions

that address the individual’s drinking behaviour to reduce the risk of re-injury.

Brief alcohol intervention (BAI) typically involves a form of motivational interview aimed to educate

patients on the harmful effect of current drinking behaviour to prevent future harms. Its common

structure is a patient based interview delivered by health professionals and lasting about 5 to 10

minutes either in a single or multiple sessions2,3

. Within acute settings following trauma, clinicians

have the opportunity to assess patients’ level of harmful drinking and provide screening and brief

intervention (SBI). Performing a brief alcohol intervention is a small progression from a standard

consultation. It requires a small investment in terms of time and there is evidence suggesting that it

would motivate about 10% of this patient group to reduce their drinking to recommended limits3.

SBI is routinely implemented in the US and has been recommended by the College of Surgeons as a

standard management of trauma patients4. However, these practices are not routinely implemented

in Australia and New Zealand. As yet, no studies have examined why they are not routinely delivered

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within trauma practice within Australasia, including identifying potential barriers or opportunities for

training. Given the growing level of alcohol-related trauma in the community, it is essential that

surgeons involved in facial injuries should play a role in delivering effective and timely opportunistic

interventions to reduce re-injury and other alcohol-related harms.

This study will seek to explore barriers to and BAI and SBI implementation in Australasia by

investigating practitioners’ attitudes, knowledge and competence in delivering these practices. The

principal investigator is an oral and maxillofacial surgeon who is a member of the ANZAOMS

(Australia and New Zealand Society of Oral and Maxillofacial Surgeons). A detailed survey will be

sent to ANZAOMS members to understand how these clinicians approach trauma cases involving

alcohol, with the aim of identifying where service gaps may occur. Findings from this work will

contribute to the development and implementation of an intervention strategy for patients who

sustain facial fractures from alcohol-related injuries.

Material and Methods

A web-based survey will be made available to all members (n=200-250) of the Australian and New

Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS), promoted through a number of

email bulletins sent by the Association to all members. Implied consent is assumed for participants

who complete the online survey. The survey will explore their current level of involvement in

treating patients with alcohol-related facial trauma as well as their knowledge of and attitudes

towards alcohol screening and brief intervention. The survey will also explore their willingness for

further training and involvement in implementing a SBI programme. Simple descriptive summary

statistics (means, standard deviations for continuous variables and proportions for categorical

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variables) will be used to describe the characteristics of the sample, as well as their responses to the

survey questions.

The project findings will inform the development of an intervention for patients who sustain facial

fractures associated with alcohol-related injuries, as well as a template for preventive service

delivery across Australia and New Zealand.

Analyses were mainly descriptive and were undertaken using the R Software (The R Project,

Auckland, New Zealand). We assessed the degree of understanding and confidence in conducting six

activities for alcohol-related injuries. A summary score with a possible range of 1 (poorest

understanding or lowest confidence) to 5 (highest understanding or confidence) was calculated by

averaging all the item scores. The relationship of the two summary scores was tested using Pearson

correlation coefficient. The differences in these scores across demographic groups were tested using

t-test or one-way ANOVA test when appropriate. A significance level of p<0.05 was employed for

these tests.

This project was approved by Eastern Health Board. It is conducted in compliance with the World

Medical Association Declaration of Helsinki on medical research protocols and ethics.

Results

A total of 58 surgeons completed the on-line survey. Based on the assumption that the College

newsletter was emailed to the 200 members of the College, a response rate of 29% is recorded. The

demographic characteristics of the sample are presented in Table 1. The vast majority of participants

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were males (91%) and consultant surgeons (88%). Sixty nine percent were from the three eastern

states of Australia (Victoria, Queensland, and New South Wales) and 21% were from other

Australian states and New Zealand.

Most of the surveyed surgeons had considerable experience in dealing with patients presented with

traumatic injuries, with 76% reporting over 10% of their patients were those with traumatic injuries.

The proportion of these patients with alcohol involvement varied from one surgeon to another. On

average, around 48% of these injury presentations were considered by participants to be alcohol

involved.

Nearly all respondents reported ever taking alcohol history when dealing with such injuries, but 47%

“often or always” perform this practice. Nine percent stated “often or always” providing a brief

intervention; 83% of participants would refer less than 20% of their patients for further alcohol

treatment.

A hypothetical case with facial injury and drinking history was presented to the participants and they

were asked to give their response to this scenario. It is noteworthy that 71% would take alcohol

history, but only 29% would deliver a brief alcohol intervention, and only 14% would refer the

patient to an alcohol treatment service or clinician.

Information collected by a further question showed 43%, 45%, 29% and 28% of the respondents

stated they would likely or very likely fully assess the patient’s alcohol history, discuss the link

between levels of alcohol consumption and risk of assault, offer a brief intervention for alcohol, and

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refer the patient for further assessment or treatment of their alcohol use, respectively. Others

maintained neutral or unlikely to do so.

Less than half (47%, 43% and 48%, respectively) considered 1) screen patients for risky levels of

alcohol use; 2) provide a brief alcohol intervention to such patients; and 3) refer such patients to an

appropriate alcohol treatment service or clinician to be their responsibility in treating patients with

alcohol related inquiries.

Although 40% agreed (or strongly agreed) that they had adequate training in managing patients with

alcohol-related injuries in their practice, only 17% and 19% reported that they had adequate time

and resources when facing such patients, respectively. The need for more information on where to

refer patients for appropriate alcohol treatment was of highest demand, reported by 76% of the

participants. Around half (45% and 53%, respectively) agreed that they needed more training in

screening patients for at risk drinking and on delivering brief intervention.

The majority (79%) of respondents indicated they were more likely to deliver an alcohol intervention

if it could be delivered in 5 minutes.

With regard to alcohol screening and management, 57% of respondents agreed or strongly agreed

that they had a good understanding of and were confident in implementing “conducting relevant

laboratory tests”. However, only a small proportion (<16%) of participants reported good

understanding of the last three approaches (Table 2), and consequently, they were less likely to be

confident in implementing these compared to the first three approaches. As shown in Table 2,

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“Conducting relevant laboratory tests” had the highest understanding and confidence scores, while

“Providing web-based brief interventions” had the lowest scores.

The aggregated understanding score ranged from 1 to 5 with a mean (SD) of 2.55 (0.81). The total

confidence score had a same range and a mean (SD) of 2.58 (0.88). The two scores were significantly

correlated (r=0.67, p<0.001), indicating better understanding may facilitate higher confidence or vice

versa. There were no significant differences in these two scores between genders, practice status

(consultant or trainee) and groups of years of practice (Table 3). However, there was a significant

effect of age on both scores, with those aged >50 years having significantly lower scores than other

two groups. A significant difference in confidence score between states of practice was also

observed (Table 3).

The mean scores of understanding and confidence were higher among those who considered 1)

screen patients for risky levels of alcohol use; 2) provide a brief alcohol intervention to such patients;

and 3) refer such patients to an appropriate alcohol treatment service or clinician to be their

responsibility in treating patients with alcohol related inquiries compared with those who did not

(Table 4), suggesting that a lack of understanding and confidence may drive a lack of a feeling of

responsibility.

Discussion

Alcohol is heavily implicated in facial injuries and alcohol involvement has been associated with

more severe facial injuries and greater likelihood for surgical intervention5. Recognising the

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underlying aetiology and providing an appropriate intervention programme is crucial in development

of an effective preventative strategy6,1

.

The period immediately after the injuries presents the clinicians with a window of opportunity or

“teachable moment” to educate the patients on the harmful effect of alcohol7. Patients do not

change habit because of fine or punishment, but rather the occasion of an alcohol-related injury8.

Therefore, injury reduction is not necessarily related to reducing alcohol consumption but

opportunity to educate patients on future harm minimisation strategies9,10

. Studies focusing on

result of motivational interview on patients with facial injuries have reported definite benefit11-13

.

Acute setting such as the emergency department or trauma centre provides an ideal setting for

implementing brief alcohol intervention because some patients use the emergency department for

primary care due to lack of access to general practice. One study indicated that only 45% of trauma

patients presenting to an acute setting had a primary care physician, and only 10% had ever spoken

to their physicians about alcohol use14

. Such acute presentation may be the only chance to

implement a brief intervention for these patients.

SBI involves assessment of risk status, the provision of personalised feedback and advice from a

healthcare worker either face-to-face, via mail, or by web-based correspondence and cost effectively

reduces hazardous drinking and the risk of re-injury15,16

. There are however, significant difficulties in

implementing SBI as part of routine medical care due to practitioners’ time constraint, training, and

acceptability to patients17

. Further compounding problems are lack of space in acute settings,

attitude of health professionals towards alcohol issues and lack of interest among ED staff and

trauma surgeons17

. Despite a lack of randomised controlled trials supporting the efficiency and

efficacy of the method of delivering this brief intervention, BAI is considered a routine practice for

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trauma patient care as recommended by the College of Surgeons in the US. It is possible to

overcome such obstacles (limited clinician time, limited resources, clinician ambivalence and patient

resistance) by formulating time saving and low cost interventional strategies that are effective,

acceptable to busy clinicians and accessible to patients.

Studies reporting on the different format of BAI have shown that shorter intervention lasting a few

minutes can be as effective as longer interventions lasting from 20 minutes to hours18,19

. Written

self-help literature can also be beneficial in helping patients with reducing their drinking habit

without a face-to-face interview with a therapist20

. Use of computerised screening and personalised

written advice from treating doctors prior to discharge from the emergency department can be

another effective way to educate these patients21

. Such simple intervention methods provide a cost-

effective alternative to motivational interview.

This study highlights the attitude and practice of oral and maxillofacial surgeons in managing

patients with alcohol related facial injury and tests their knowledge and willingness to participate in

a brief intervention programme. Majority of the surgeons who responded to this survey are

consultant surgeons and have considerable experience in managing facial trauma. Although majority

of surgeons are familiar with the association between alcohol intoxication and facial injuries, have

the ability to recognise at risk patients through history taking and are prepared to raise concern to

these patients, only a small proportion understand the process of SBI and are knowledgeable of the

resources available after patients are discharged from their care. This lack of confidence and

understanding accounts for the confidence score of the >50% of respondents who did not feel it was

their responsibility to screen patents and provide intervention or referral.

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Although the American College of Surgeons Committee on trauma implemented a requirement that

Level I trauma centres must have a mechanism to identify and provide an intervention for problem

alcohol drinkers, it must be noted that facial injuries are frequently secondary to interpersonal

violence and patients do not always present to Level 1 trauma centres. Patients with such injuries

may present to outpatient clinics or referred to surgeons via their general medical practitioners. Oral

and maxillofacial surgeons should be able to perform BAI to provide optimal standards of patient

care, and to prevent further injury. Results of this survey pointed to potential “service gaps”.

The methods of brief alcohol interventions such as written alcohol advice with or without individual

feedback, formal consultation, educational pamphlets, web-based package are not routine part of

these surgeons’ practices. Interestingly, 40% of respondents agreed that they have adequate

training in managing these patients in their practice, but yet majority have no knowledge of the

resources available. This survey in particular highlighted a lack of understanding of “providing web-

based brief intervention”. This finding is not unexpected as there is currently no web-based

programme available to ANZAOMS members and no standard educational literature tailored to

educate these patients. Having a personalised written alcohol advice letter, educational pamphlets

and access to a web-based programme will allow the surgeons to individualise a package of

intervention delivery to suit each patient requirement. Training in ultilising this pool of information

will not demand substantial time with minimal cost incurred. The surgeons will be trained to

familiarise with the resources available instead of undergoing a substantial course in psychological/

motivational interview techniques.

Surgeons’ responses to the survey questions also confirmed lack of time to be a well-recognised

barrier to effective BAI delivery. Majority of surgeons surveyed are prepared to deliver a BAI if it can

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be completed within 5 minutes. Having a variety of written literature and web-based programme

eliminates the need for a lengthy face to face interview.

Perceived lack of time was also identified as a barrier to providing BAI by Johnson et al. who also

identified a perceived lack of knowledge and confidence as another potential barrier for clinicians

provding BAI22

. This was potentially a factor the oral and maxillofacial surgeons surveyed. Johnson et

al also reported clinician concerns regarding the appropriateness of providing BAI to patients who

are traumatised or acutely ill as another potential barrier in an emergency department setting and

though not specifically examined, similar concerns may exist amongst the oral and maxillofacial

surgeons surveyed.

This study is exploratory in nature. The response rate of an online survey such as one conducted

here was low. Accordingly, statistical insignificant (in table 3 and 4) was likely due to the small

sample size. Significant results in the setting of small sample size indicates a "robust" finding/ effect

and the issue is more that if results were not significant then it is possible the small sample size leads

to missing an association where one actually existed.

Conclusion

Oral and maxillofacial surgeons have close relationship with their patients after maxillofacial injuries

and are in good position to identify alcohol-related health problems and offer guidance and support.

Major finding of this study is that time constraint and lack of resources are main obstacles to an

effective alcohol intervention. A possible solution is to design a web based programme and a

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personalised and standardised written advice pamphlet from the surgeons which can help to bridge

this chasm by providing the patients with helpful advice and directing patients to useful resource22

.

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Table 1. Description of the sample (N=58)

n(%) n(%) Gender State of practice

Male 53 (91.38) New Zealand 2 (3.45) Female 5 (8.62) Australian Capital Territory 2 (3.45)

Age New South Wales 8 (13.79) < 30 years 2 (3.45) Victoria 21 (36.21) 30-40 years 20 (34.48) Queensland 11 (18.97) 40-50 years 13 (22.41) South Australia 3 (5.17) > 50 years 23 (39.66) Western Australia 3 (5.17)

Consultant or trainee Tasmania 1 (1.72) Consultant 51 (87.93) Northern Territory 1 (1.72) Trainee 7 (12.07) Missing 6 (10.34)

Years of practice < 5 years 17 (29.31) 5-10 years 9 (15.52) 10-20 years 12 (20.69) 20 years 20 (34.48)

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Table 2 Number (%) of participants agreed or strongly agreed with their understanding and confidence

in undertaking activities for alcohol-related injuries

n (%) agree or strongly agree

Understanding Providing screening tools and questionnaires 21 (36.2) Conducting relevant laboratory tests 33 (56.9) Delivering a brief alcohol intervention 17 (29.3) Conducting motivational interviewing 6 (10.3) Providing written self-help pamphlets 9 (15.5) Providing web-based brief interventions 4 (6.9)

Confidence Providing screening tools and questionnaires 21 (36.2) Conducting relevant laboratory tests 33 (56.9) Delivering a brief alcohol intervention 15 (25.9) Conducting motivational interviewing 8 (13.8) Providing written self-help pamphlets 14 (24.1) Providing web-based brief interventions 7 (12.1)

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Table 3. Mean understanding and confidence scores (SDs) by demographic characteristics

Understanding a Confidence a Gender

Male 2.53 (0.84) 2.55 (0.91) Female 2.77 (0.35) 2.93 (0.44)

Age <40 years 2.68 (0.46) *** 2.57 (0.62) * 40-50 years 3.22 (0.86) 3.15 (1.02) > 50 years 2.04 (0.74) 2.28 (0.90)

Consultant or trainee Consultant 2.56 (0.84) 2.58 (0.93) Trainee 2.45 (0.61) 2.62 (0.44)

Years of practice < 5 years 2.92 (0.49) 2.60 (0.39) 5-10 years 2.83 (0.60) 2.72 (0.93) 10-20 years 2.70 (1.26) 2.90 (1.22) 20 years 2.27 (0.76) 2.32 (0.92)

State of practice New South Wales 2.56 (0.41) 2.77 (0.45) * Victoria 2.38 (0.73) 2.18 (0.89) Queensland 2.50 (0.63) 2.41 (0.74) All others b 2.76 (1.10) 3.07 (0.89)

a Ranged is from 1 (poorest understanding or lowest confidence) to 5 (highest understanding or confidence). b including other Australian states (n=10), New Zealand (n=2) and missing (n=6) * p<0.05; *** p < 0.001 in t-test or one-way ANOVA test

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Table 4. Mean understanding and confidence scores (SDs) and perceived responsibility

N (%) Understanding a Confidence a Consider screening patients for risky levels of alcohol use as a responsibility

Agree or strongly agree 27 (47) 2.80 (0.86) * 2.96 (0.84) ** Disagree or neutral 31 (53) 2.32 (0.71) 2.58 (0.88)

Consider providing a brief alcohol intervention to such patients as a responsibility Agree or strongly agree 25 (43) 2.79 (0.80) * 2.93 (0.83) ** Disagree or neutral 33 (57) 2.36 (0.78) 2.32 (0.84)

Consider referring such patients to an appropriate alcohol treatment service or clinician as a responsibility

Agree or strongly agree 28 (48) 2.63 (0.85) 2.80 (0.91) Disagree or neutral 30 (52) 2.46 (0.78) 2.38 (0.82)

a Ranged is from 1 (poorest understanding or lowest confidence) to 5 (highest understanding or confidence). * p<0.05; *** p < 0.001 in t-test