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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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c© Copyright 2014 American Association of Oral and MaxillofacialSurgeons
NOTICE: this is the author’s version of a work that was accepted for publication in Jour-nal of Oral and Maxillofacial Surgery. Changes resulting from the publishing process,such as peer review, editing, corrections, structural formatting, and other quality controlmechanisms may not be reflected in this document. Changes may have been made tothis work since it was submitted for publication. A definitive version was subsequentlypublished in Journal of Oral and Maxillofacial Surgery, [VOL 73, ISSUE 2, 2015] DOI:10.1016/j.joms.2014.09.026
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http://doi.org/10.1016/j.joms.2014.09.026
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
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