Table Of ContentJayarajetal.BMCPublicHealth2013,13:49
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STUDY PROTOCOL Open Access
Prevention of Alcohol-Related Crime and Trauma
(PACT): brief interventions in routine care
–
pathway a study protocol
Rama Jayaraj1*, Megan Whitty2, Mahiban Thomas3, David Kavangh4, Didier Palmer5, Valerie Thomson2,
Carolyn Griffin2, Luke Mayo2, Peter D’Abbs2 and Tricia Nagel2
Abstract
Background: Globally, alcohol-related injuries cause millionsof deaths and huge economic loss each year . The
incidence of facial (jawbone) fractures inthe Northern Territory of Australia is second only to Greenland, due to a
strong involvementof alcohol inits aetiology, and highlevels ofalcohol consumption. The highest incidencesof
alcohol-related trauma in theTerritoryare observed amongst patients inthe Maxillofacial Surgery Unit of theRoyal
Darwin Hospital. Accordingly, this projectaims to introduce screening and brief interventions intothis unit, with the
aims of changing health service provider practice, improving access to care, and improving patient outcomes.
Methods: Establishment of Project Governance: The projectgovernance team includes a project manager, project
leader, an Indigenous Reference Group (IRG) and an Expert Reference Group (ERG).
Development of abest practice pathway: PACT projectresearchers collaborate with clinical staff to develop a best
practice pathway suited to thesetting of thesurgical unit. The pathway provides clear guidelines for screening,
assessment, interventionand referral.
Implementation: The developed pathway is introduced to the unitthrough staff training workshops and associate
resources and adapted inresponse to staff feedback.
Evaluation: File audits,post workshop questionnaires and semi-structured interviews are administered.
Discussion: Thisprojectallows direct transfer of research findingsintoclinical practice and can inform future
hospital-based injury prevention strategies.
Keywords: Alcohol-related trauma, Screening, Brief intervention, Dissemination
Background at risk of short-term harm at least once a month [4], and
Half of alcohol-attributable deaths are a result of injury ratesinitsNorthernTerritory(NT)areespeciallyhigh.In-
worldwide [1]. Alcohol-related harm is a major cause of digenous Australians who constitute a substantial propor-
mortality and morbidity in Australia, causing around tion of residentsofNT(32%) andtheyaresix times more
3,000 deaths and 65,000 hospitalisations every year [2]. likely to drink at high-risk levels than non-Indigenous
Alcohol-related injuries are more commonly caused by Australians [5]. In consequence, Indigenous Australians
heavy drinking than by people with severe alcohol de- arealsoatgreaterriskofalcohol-relatedharmsthanother
pendence, and strong links exist between alcohol-related Australians. Harms associated with high-risk alcohol con-
trauma,crime andbingedrinking[3]. sumption in Indigenous Australians include family con-
The most recent national survey of drug use estimates flict, domestic violence and assaults [6,7], and alcohol is
thatoneinfiveAustraliansdrinkatalevel thatputsthem the leadingcause of injury among Indigenous Australians,
followed by intimate partner violence [8]. In fact, rates of
*Correspondence:[email protected] death from exclusively alcohol-related conditions are al-
1WellbeingandPreventableChronicDiseasesDivision,MenziesSchoolof most eight times greater for Australian Indigenous males
HealthResearchandSchoolofPsychologicalandClinicalSciencesand
than for non-Indigenous males and 16 times greater for
CharlesDarwinUniversity,Darwin,NorthernTerritory,Australia
Fulllistofauthorinformationisavailableattheendofthearticle
©2013Jayarajetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
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Indigenous females than for non-Indigenous females with facial traumaandevaluatestheimplementation ofa
among residents of Western Australia, South Australia best practice pathway. The project transfers skills and
and Northern Territory [9]. The percentage of alcohol- resourcestohospitalstafftosupportdeliveryof bestprac-
related deaths among young Indigenous Australians aged tice and to evaluate progress through continuous quality
15–24 is almost three times higher than for their non- improvementstrategies.
Indigenouscounterparts[9].
Alcohol-related violence is the most common cause of EstablishmentofProjectGovernance
hospital admission for injury in the NT [10], accounting An Indigenous Reference Group and an Expert Reference
for 38% of the total injury admissions for Indigenous Group oversee the project. The IRG comprises senior
people. Further, it has been reported that most of the urban-andcommunity-basedAustralianIndigenouspeople
assaults against women in remote NT communities are and is established through Menzies School of Health Re-
perpetrated by a drunken husband or other family mem- search. The ERG includes senior representatives from the
ber. Alcohol-related facial trauma is common, with an Maxillofacial Surgery Unit and the NT Department of
estimated350casesperyearadmittedtotheMaxillofacial Health. The research team consists of a project leader and
SurgeryUnitoftheRoyalDarwinHospital(RDH)[11,12]. project manager from Menzies School of Health Research,
Manyoftheseadmissions,approximately80%areofIndi- senior representatives from the Maxillofacial Surgery Unit
genouspeople[12].Therefore,thereisanurgentneedfor and Indigenous researchers at Menzies. The day-to-day
an effective and culturally appropriate intervention to ad- management of the project is the responsibility of the pro-
dress binge drinking and alcohol-related harm in this ject leader and project manager, in collaboration with the
group. In the general population, screening and brief Indigenous research officers. The research team and ERG
counselling can reduce high-risk alcohol consumption formally meetby teleconference or face-to-faceevery three
and alcohol-related assaults associated with binge drin- tosixmonths.
king, but more research is needed on alcohol-related
trauma among the NT Indigenous people. ‘Motivational Developmentofbestpracticepathway
care planning’ (MCP) is a broad-based motivational inter- A tailored best practice pathway suited to the setting of
vention to improve health and wellbeing of Indigenous thesurgicalunitisdevelopedincollaborationwithhospital
Australians. In early research, it demonstrated acceptabi- staff, following exploration of current systems (Figure 1).
lity and an ability to engage participants [13], and it The pathway includes four key activities: (1) Brief scree-
resulted in significant improvements in wellbeing, sub- ning of all admissions, (2) An information booklet for
stance use and self-management [13,14]. This project those at risk, (3) Referral to appropriate services for those
adaptsandappliesMCPtoinpatientswithalcohol-related at risk, (4) Delivery of a culturally-adapted brief interven-
facialinjuries. tion.Staffaretrainedtoapplythebestpracticepathwayto
allpatients.
Methods All relevant services in Darwin are contacted via email
Aim and phone, informed of the project aims and invited to
The PACT project aims to introduce routine screening participate. Engagement of community services includes
and brief intervention by staff of the Maxillofacial Sur- visiting the organisation, understanding specific referral
gery Unit at Royal Darwin Hospital (RDH), in order to processes and exploring the capacity of external services
raise awareness of at-risk drinking and prevent recurrent to provide in-house services for potential clients in the
injuryininpatientswith alcohol-related facial injuries. hospital. Representatives from the various agencies
present at PACT workshops to inform and educate hos-
Thisprojectaimstoanswerthequestion pital staff about available services for patients with sub-
Will introduction of screening and brief interventions stance abuse problems and/or wellbeing concerns. A
changehealthserviceproviderpracticeandreducealcohol- pamphlet is developed containing contact information
relatedinjuriessecondarytoassault? and a brief synopsis of Alcohol and Other Drugs (AOD),
Wepredictthataparticipatoryactionapproachtoimple- mental health and domestic violence services both within
menting a best practice pathway to referral and treatment andoutsidethehospitalsystem
for high-risk alcohol users admitted to the Maxillofacial
Surgical Unit with injuries will change health service pro- Implementationofbestpracticepathway
viderpracticeandreducealcohol-relatedinjury. Implementationismulti-faceted,andincludesinformation
and consultation meetings with staff and community ser-
Researchplan vice providers, staff training workshops, key informant
This 18-month project introduces screening and brief interviews,feedbacksessionsandtheintroductionofrele-
interventions for high-risk drinkers admitted to hospital vant resources (available online and in hard copy form).
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Figure1PACTpathwayofstudy.
Theimplementationofthebestpracticepathwayincludes how interesting and useful the workshop was on a scale
threekeyactivities:(1)trainingtofamiliarisestaffwiththe from 1 (not at all) to 4 (very). The questionnaire includes
tools,(2)workshopstotrainstaffindeliveryofbriefinter- a section for attendees to comment on their experience
ventions, (3) a feedbackworkshop to review the effective- and state whether they would change their practice as a
ness of implementation through training evaluations, file result of the workshop. A joint feedback workshop in the
audits and interviews. The chosen brief intervention is last three months of the study will report on the key fin-
basedonfindingsofaprojectconductedbytheAustralian dings from staff training activities and file audits over the
Integrated Mental health initiative (AIMhi) in the NT courseoftheproject.
(Nageletal.,2009).
Resourcedevelopment
Informationandconsultationmeetingswithstaffand
Brief intervention resources and a best practice protocol
communityserviceproviders
manualareprepared.Toolsforongoingcontinuousquality
Consultation meetings are conducted with hospital staff
improvementaremadeavailabletothesurgeryunit.
and community service providers to inform the develop-
ment of best practice protocols for detection and treat-
ment of patients who demonstrate high-risk drinking.
Feedback
These meetings aim to improve understanding of the
Feedback of interview responses by key informants and
current strategies and practical issues surrounding im-
the results of the file audits allow opportunity for refine-
plementationinthehospitalsetting.
ment of the care pathway, goal setting, further training
and dissemination. Project findings will be presented at
Stafftrainingworkshops
relevant conferences within Australia and results are to
Up to six PACT training workshops, involving up to
be published in appropriate scientific journals, particu-
50 hospital-based service providers, are conducted. The
larlythose thattargethospitalcare of high-riskdrinkers.
workshops provide information about screening, referral
services and brief interventions. A post-workshop partici-
pantevaluationquestionnaireiscollectedandresultsana- Evaluationofthebestpracticepathwayprocess
lysed. The questionnaire incorporates ordinal scales and Processevaluation
open-endedquestions.Participantsareaskedaboutknow- The process activities include evaluating: (1) number of
ledge and confidence in screening, brief intervention and workshops held and workshop content and format, staff
referralforat-riskdrinkers.Knowledgeandconfidenceare trained, (2) number and type of staff attending work-
rated on a scale from 1 (not much /not confident) to 9 shops, and (3) number and type of training and educa-
(a lot /very confident). Participants are also asked to rate tion resources developed.
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Outcomeevaluation purposelysamplefive clientsand fiveservice
Outcome evaluation activities include 1) file audits, and providers toexploreenablersandchallengesand the
2)semi structuredinterviews. client experience.Wehave chosenthissamplesizein
ordertobeabletogainsome insight intothese client
Fileaudits and serviceprovider perspectives whilst keeping
The project team conducts two file audits: one at base- within theresourcesand brieftimeframesofthe
line and one at 9 months, and records the number of study.
admissions related to high-risk drinking, screenings,
patients flagged to be ‘at-risk’, brief interventions deli- Ethicalapprovals
vered, information distributed and referrals completed. The study has been granted full ethics approval by the
The review of files allows the project to monitor out- Human Research Ethics Committee of Department of
comes. This information is essential for review and feed- Health and Menzies School of Health Research (HREC-
back for quality improvement and development of care 11-1553). Data are accessible to the investigators and
processes. support investigation team only. In the audit forms, we
will not record identifiable client information such as
Keyinformantinterviews client’s names or registration numbers. Instead, a code
The project team conducts a small number of key in- will be used as identifier. This enables checking of data
formant interviews to explore client, family and service duringthe cleaning ofauditdata where necessary. Codes
provider perspectives on the process. Five key informant linked with client’s names will be retained by the re-
interviews with surgical unit staff assess confidence and search team and a copy stored electronically with the
knowledge as well as challenges and enablers to scree- rest of the data at Menzies in a separate file accessed
ning and best practice. Five key informant interviews onlybypassword.
with patientsandfamiliesexploretheirexperience ofthe
bestpracticepathway. Engagementwithstakeholders
This project is a partnership between the RDH Maxillo-
Selectioncriteria facial Surgery Unit, the Alcohol and Other Drug (AOD)
There are two target populations: (1) Service providers program NT wide, the remote AOD Workforce Program
who care for clients admitted to the Maxillofacial Surgical andMenziesSchoolofHealthResearch.TheAODWork-
Unit,and(2)PatientsorClientsadmittedtoRoyalDarwin force Program operates within a number of Aboriginal-
Hospitalwithfacialtraumaduringthestudy.Patientparti- controlled and government health centres in urban and
cipantswillneedtobeatleast18andabletogiveinformed remote settings across the NT. The NT Department of
consent. Health AOD program, the remote AOD workforce and
the RDH surgery unit are key supporting partners. The
Statisticalanalysisandsamplesize AOD programassisted inthe development ofthis project
Analysis of file audits and interviews will include descrip- outline and is committed to its success. The surgery unit
tivestatisticsandqualitativedatagroupedandanalysedby of RDH proposed the project and strongly supports the
theme. project’saims.
There are two samples: files to be audited and indivi-
dualstobeinterviewed. Discussion
Benefits
1.Thefilestobeauditedwillinclude a sampleof The project will implement and evaluate strategies for
trauma patientsadmittedto theMaxillofacialSurgery screening and intervention for reducing the harms asso-
Unitduringthe sixmonths prior tocommencement ciated with alcohol consumption in Indigenous patients
ofthestudy andthe 9monthsofthe studyfrom in the NT in line with the Aboriginal and Torres Strait
baseline (estimated160 files).Files areexaminedfor Islander Peoples Complementary Action Plan 2003–
frequencyofscreening,recorded evidenceof brief 2009. The main objectives of the action plan are control
interventionsgiven forthoseatriskand of supply, management of demand, reduction of harm,
documentation ofuptake ofthe newpathway.They early interventionandtreatment.
willalsobeexaminedforclientoutcomesinterms of Thevalueofthestudyincludesdirectbenefittopartici-
wellbeing,alcohol-relatedmedical problemsand pants through improved wellbeing, decreased recurrence
high-risk drinking. ofinjuryandlesssubstancemisuse.Thestudybenefitsthe
2.A smallsampleofclientparticipantsand service serviceproviderswhocareforhigh-riskdrinkerswhosus-
providers willbeinterviewed toassessestablishment tain injury by allowing them to provide timely advice and
ofthenew pathway within routine care. Wewill intervention.
Jayarajetal.BMCPublicHealth2013,13:49 Page5of5
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Indirectbenefittothebroaderpopulationisexpectedby andCommunityServicesNorthernTerritory;2005.http://digitallibrary.health.
improving strategies to engage and treat individuals with nt.gov.au/dspace/bitstream/10137/60/1/injury_project_report.pdf.
11. ThomasM,JamesonC:Facialtraumaandpostinterventionalqualityof
substanceabuseconcerns,refinementofeducationalmate-
lifeintheNorthernTerritory.Australia.IntJOralMaxillofacSurg2007,
rials,and development of best practiceprotocols that may 36(11):1081.
begeneralisedtoarangeofothersettings. 12. JayarajR,ThomasM,ThomsonV,GriffinC,MayoL,WhittyM,AbbsPD,
NagelT:Highriskalcohol-relatedtraumaamongtheAboriginaland
TorresStraitIslandersintheNorthernTerritory.SubstAbuseTreatPrev
Competinginterests
Policy2012,7(1):33.http://www.substanceabusepolicy.com/content/pdf/
Theauthorsdeclarethattheyhavenocompetinginterests.
1747-597X-7-33.pdf.
13. NagelT:Motivationalcareplanning:briefinterventionsinIndigenous
Authors’contributions mentalhealth.AustFamPhysician2007,37(12):996–1001.
RJ,MTandTNwerethemaincontributorstotheconceptualisationofthe 14. NagelT,RobinsonG,CondonJ,TrauerT:Approachtotreatmentof
study.DK,MW,DP,Pd,VT,CGcontributedsignificantlytothisresearch mentalillnessandsubstancedependenceinremoteIndigenous
proposal,andhavereadandapprovedthefinalmanuscript. communities:resultsofamixedmethodsstudy.AustJRuralHealth2009,
17(4):174–182.
Acknowledgements
WearegratefulforthefinancialsupportfromAttorneyGeneral’s doi:10.1186/1471-2458-13-49
Department,ProceedsofCrimeAct2002. Citethisarticleas:Jayarajetal.:PreventionofAlcohol-RelatedCrime
andTrauma(PACT):briefinterventionsinroutinecarepathway–a
studyprotocol.BMCPublicHealth201313:49.
Authordetails
1WellbeingandPreventableChronicDiseasesDivision,MenziesSchoolof
HealthResearchandSchoolofPsychologicalandClinicalSciencesand
CharlesDarwinUniversity,Darwin,NorthernTerritory,Australia.2Wellbeing
andPreventableChronicDiseasesDivision,MenziesSchoolofHealth
Research,Darwin,NorthernTerritory,Australia.3DepartmentofHeadand
NeckSurgery,RoyalDarwinHospital,Darwin,NorthernTerritory,Australia.
4InstituteofHealth&BiomedicalInnovationandSchoolofPsychology&
Counselling,QueenslandUniversityofTechnology,KelvinGrove,QLD,
Australia.5EmergencyDepartment,RoyalDarwinHospital,Darwin,Northern
Territory,Australia.
Received:24October2012Accepted:28November2012
Published:18January2013
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