IMJ
About IMJ
Disclaimer
Contact IMJ
Register as Reviewer
Register As Author
View IMJ Authors
View IMJ Volumes
View Supplement
Issue Archive 1980-1996
Subscription Detail 2010

IMJ Search

 

Advanced Search
 
 
The Burden of Alcohol Misuse on the Emergency Department   Back Bookmark and Share
MJ Hannon,LC Luke

Ir Med J. 2006 Apr;99(4):118-20



Abstract
This study had two objectives. To assess the impact of alcohol-related problems on the Emergency Department (ED) of Cork University Hospital (CUH).To assess the non-acute impact of alcohol-related problems on CUH.One hundred patient ED records were chosen at random from each of three study periods – December 23rd 2002 to January 2nd 2003, April 20th 2003 to April 30th 2003, and December 23rd 2003 to January 2nd 2004. Each patient record was examined individually to determine the rate of alcohol-related attendances at CUH ED. Overall, alcohol related attendances accounted for 14.66% of ED attendances. 22.73% of these patients were admitted and 27.27% received an out-patient department appointment. The results of this study were broadly in keeping with previous large-scale studies; it is clear that alcohol-related attendances, admissions and OPD appointments are putting a large strain on EDs and the whole hospital system.


Introduction
Between 1989 and 1999, alcohol consumption per capita in Ireland increased by 41%, and the alcohol consumption patterns of Irish adults compare poorly with other European countries 1, as shown in Tables 1 and 2.

Table 1 Drinking patterns among men in Ireland in comparison with other European countries (All respondents aged 18 to 64 years) 1

Country

Drinking everyday (%)

Drinking at least once a week (%)

Binge drinking at least once a week (%)

Mean drinking occasions past 12 months

Mean binge drinking occasions past 12 months

Binge per 100 drinking sessions

Ireland

1.6

69

48

78

45

58

Finland

4

60

16

70

20

29

Sweden

3

47

8

37

12

32

Germany

12

60

9

97

13

13

UK

9

74

38

118

47

40

France

21

68

8

121

11

9

Italy

42

76

11

179

23

13

Nowadays, more females than males in the 18-24 age group are likely to engage in excessive drinking, and it has been shown that alcohol consumption in the young is increasing 2. In the Health Behaviour in School Aged Children survey 3, 33% of the 15-16 year old age group reported binge drinking three or more times in the last month.

Table 2 Drinking patterns among women in Ireland in comparison with other European countries (All respondents aged 18 to 64 years) 1

 

Drinking everyday (%)

Drinking at least once a week (%)

Binge drinking at least once a week (%)

Mean drinking occasions past 12 months

Mean binge drinking occasions past 12 months

Binge per 100 drinking sessions

Ireland

0.2

51

16

46

14

30

Finland

2

33

3

35

6

17

Sweden

1

24

1

24

4

17

Germany

5

40

2

54

4

7

UK

5

51

12

73

16

22

France

9

38

2

62

3

5

The National Alcohol Strategy was unveiled in 1996 to address the above problems. To determine if the government are succeeding in their aims, one needs to have accurate data and this data is probably best collected in the hospital system, and especially the hospital ED, as this is an area where the adverse effects of alcohol are very keenly felt. To this end, an ED records review was undertaken in December 2003 and January 2004 in the ED of CUH.

Methods
The study looked at patients who attended the CUH ED during three periods:

  1. between December 23rd 2002 and January 2nd 2003 (inclusive)
  2. between April 20th 2003 and April 30th 2003 (inclusive)
  3. between December 23rd 2003 and January 2nd 2004 (inclusive)

100 patients were selected at random from each of the above three periods using the www.random.org online number randomisation tool. The ED records of these patients were then studied. Three distinct study periods were used to reduce as much as possible any bias that might arise from the fact that more people drink excessively at certain times of the year e.g. St. Patrick’s Day and New Year’s Eve.

For each study period, information was gathered to address the two main objectives of this study:

  1. To assess the effect of alcohol-associated problems on the ED of CUH. Patients’ attendance at the ED was classified as“alcohol- related” if:
    1. they were under the influence of alcohol at the time of attendance

    2. they were suffering from a health problem for which there is good evidence to implicate alcohol in its aetiology 4

    3. they had suffered trauma as a result of excess alcohol consumption

    4. they were an innocent third party who had sustained trauma as a result of excess alcohol consumption by another individual. (from Pirmohamed et al.,5)

  2. To assess the medium term impact of alcohol-related problems on CUH. This was done by determining if:
    1. the patient received an out-patients appointment as a result of their ED attendance

    2. the patient was admitted to hospital as a result of their ED attendance.

Results
In total, alcohol accounted for 14.66% of ED attendances among the 300 charts sampled. The overall mean age of alcohol-related attendees was 27.24, and the overall median age was 23.5. The overall age range was 14 to 62, with patients aged between 18 and 39 accounting for 84.1% of alcohol-related attendances and patients between 18 and 25 accounting for 52.3%. Only two were aged less than 18. Males accounted for 72.7% of alcohol-related ED attendances. There were no significant demographic differences between the three study groups, but it is clear that the alcohol related attendees predominantly come from the young adult group and are male.

The most common causes of attendance overall were minor injuries sustained while intoxicated (especially falls) and injuries sustained in assaults. Among the younger age groups there was a preponderance of attendances caused by acute intoxication and assaults, whereas among the over 40s, the commonest cause of attendance was injuries caused by falls while intoxicated.

A very worrying finding was that 50% of people attending with acute intoxication had also consumed large amounts of prescription and/or over-the-counter medication in an attempt to harm themselves. Almostall of these patients were young, male and from lower socio-economic backgrounds

Table 3 The Impact of Alcohol Related ED Attendees on Acute Hospital Admissions

 

Admitted To Hospital

Received OPD Appointments

% of Total Alcohol

22.7

27.27

Age Range

14 to 54

23 to 62

Mean Age

28.7

30.08

Median Age

24.5

26

The effect of alcohol on acute hospital admissions and OPD referrals is clearly seen in Table 3. Most patients admitted with alcohol related problems were simply admitted for overnight observation or for a plastic surgery consultation the next morning. The majority of the OPD appointments made for alcohol related ED patients were for the fracture clinic, with others being for the ED out-patient or specialist clinics. However, although proportionally more of the non alcohol related group were admitted, it is very interesting to note that only 15.6% of non alcohol related ED attendees received OPD appointments. This may be because
many of the injuries sustained while intoxicated (e.g. sprains and fractures) require OPD follow up more so than many other conditions.

Discussion
As mentioned earlier, the results of this study confirm what has been proven by other large-scale studies – that alcohol places a major burden on the EDs of modern hospitals and on the hospital system as a whole. Overall, this study found that 14.66% of ED attendances were alcohol-related.

Many previous studies on this topic have only focussed on one specialty or restricted themselves to hospital admissions only, not looking at all ED attendances, such as Taylor et al 6. Other studies have simply examined hospital in-patients to determine if these patients have an issue with“problem drinking” 7, 8. Differing results between studies may be partly due to the fact that contrasting approaches have been used in the study of alcohol-related problems.

Some studies have used screening tools such as the MAST or CAGE questionnaires8,9. Other studies have used a chart review approach; Pirmohamed et al. 5, used a design which flagged all ED records and the “flag” (a bright sticker) was not removed until the attending doctor had decided if the patient’s attendance was alcohol related. This study showed that alcohol accounted for 12% of all ED attendances, but as this study design was impossible for one person to undertake, a chart review approach was adopted. Obviously this is affected by the quality of the records – some attendances may be alcohol-related but the doctor may not have written as much in the chart. Also, an individual may be a victim of an assault by a drunken person and, although this qualifies as an alcohol-related attendance, the doctor may not record it as such. The sample size of this study was also quite small, which did not permit formal statistical analyses such as chi-squared tests to be performed. However, despite these faults, the results of this study stand up to comparison with other chart-review studies.

Combining statistics from Alexandre et al. 10, with results from this study, this means that approximately 1562 new admissions and 1388 new OPD appointments are generated per year in CUH by alcohol-related ED attendances.

As other studies have shown, a large number of underage drinkers are now being seen in the EDs of the developed world 5, a fact confirmed in this study. A recent study by Maisey and Davies 11, centred on the area around the South Bank University in London, showed that less than 10% of children under 16 did not drink, and this abstinence is usually for religious reasons 2. A recent study in the Cork area showed that excess alcohol consumption and smoking are becoming more common in females than in males 12. More young people are also engaging in so-called “binge drinking”; the commonly used definition of “binge drinking” is of a male having five or more drinks in a row, or of a female having four or more drinks in a row, and we would agree with this. Chassin et al. 13, found that all types of binge drinking raised the risk of later alcohol dependence compared with non-drinkers and non-binge drinkers.

The results of this study suggest that excessive alcohol consumption is closely linked with suicide and deliberate self-harm. As mentioned earlier, 50% of people attending the ED with acute intoxication in this study had also consumed large amounts of prescription and/or over-the-counter medication in an attempt to harm themselves. McMahon and McGarry 14 found that alcohol was simultaneously consumed by 51% of patients presenting to Navan hospital with drug overdose, and 17% of patients treated for drug overdose fulfilled criteria for alcohol dependency. Larger international studies have also shown a link between alcohol overuse and increased suicide risk. Chronic alcoholism certainly increases suicide risk, as shown by both ante-mortem 15 and post-mortem 16 studies. However, the evidence for a link between acute alcohol intoxication and suicide is less definite. Some studies have shown a link between inebriation and suicide or attempted suicide 17, but a recent study by Cherpitel et al 18 suggested that much research still needs to be done on this hypothesised causal link using appropriate study designs. Using the case crossover study design, Borges, Cherpitel et al did show an association between acute alcohol intoxication and suicide 19, and it seems safe to say that excess alcohol intake is certainly a risk factor for suicide and suicidal ideation.

As regards alcohol and deliberate self harm, it again seems that both chronic alcohol abuse and acute alcohol overdose contribute greatly 20. Deliberate self harm is especially common in young females and alcohol is again a contributory factor in this group. A recent large study in Britain showed that deliberate self harm, especially multiple episodes in young females is associated with an increased risk of successful suicide and so these patients need careful monitoring 21.

Ireland endorsed the European Charter on Alcohol and the European Action Plan on Drugs in 1995. Following this, and on the recommendation of the Commission for Liquor Licensing, the Department of Health and Children set up a National Alcohol Strategy Task Force, which produced a final report in April 2003.

As part of the above government strategy, the ED is an ideal setting to screen patients for alcohol-related problems. It has been shown that the majority of patients would readily consent to being screened and would accept advice 22, and numerous screening tools can be employed. The Paddington Alcohol Test (PAT) was validated over a one-year period by Smith et al. 23, and the WHO AUDIT questionnaire was described bySaunders et al.24, who showed it to be 94% specific and 92% sensitive. However, not all screening tools or interventions are equally effective, and may need to be adapted to cater for variations in patient demographic groups 25. A recent study by Crawford et al showed that health promotion advice offered to patients with hazardous drinking habits (identified by the PAT) was certainly of benefit, but that its impact was variable, with those presenting after a fall, a head injury or a crash least likely to benefit 26. In terms of intervention, a single blind randomised control trial conducted in 2004 showed that hazardous drinkers who presented to the emergency department and were given advice and referred to an alcohol health worker reduced their overall alcohol intake and had a reduced rate of ED reattendance versus those who just received advice 27. Wright et al. 28 used the PAT to facilitate early intervention in the ED by an alcohol health worker and also found that the early intervention was very successful. Significantly in today’s cost conscious world, such intervention has also been shown to be quite cost effective 29.

However, it can often be difficult to effectively screen patients in the busy and overworked setting of a large modern ED 30. Also, even if patients are effectively screened, any future ED service that involves the use of an alcohol health worker must ensure that waiting times for the service do not become prolonged, as happens with many other hospital services, as the waiting time for an alcohol health worker appointment has been shown to be inversely proportional to the patients chance of keeping the appointment 31.

However, it certainly seems safe to say that well organised screening of patients with validated screening tools, followed by advice in the ED and prompt referral to an alcohol health worker, are effective interventions in reducing patients’ alcohol consumption and rates of ED reattendance. Discussion (contd.)

To conclude, it is clear that alcohol-related problems are a major cause of morbidity and mortality in Ireland, and EDs have to deal with many of these problems on a daily basis. It seems that the best way to reduce this load is

  1. to implement a co-ordinated alcohol awareness educational strategy at government level, as per the recommendations of the National Alcohol Strategy Taskforce report

  2. to screen hospital inpatients, primary care patients and ED patients for alcohol-related problems

  3. to intervene effectively where alcohol-related problems have been found.

References

  1. Ramstedt M, Hope A. The Irish drinking culture – drinking and drinking-related harm, a European comparison. Department of Health, 2002.
  2. Miller P, Plant M. Drinking, smoking, and illicit drug use among 15 and 16 year-olds in the United Kingdom. Br Med J 1996; 313: 394-7.
  3. Health Behaviour in School Aged Children, Department of Health, 1998.
  4. Lieber CS. Medical disorders of alcoholism. N Engl J Med. 1995; 333(16): 1058-65.
  5. Pirmohamed M et al. The burden of alcohol misuse on an inner-city general hospital. QJM. 2000; 93: 291-5.
  6. Taylor CL, Kilbane P, Passmore N, Davies R. Prospective study of alcohol-related admissions in an inner city hospital. Lancet. 1986; 2: 265-8.
  7. Jarman CM, Kellett JM. Alcoholism in the general hospital. Br Med J. 1979; 2:469-7.
  8. Barrison IG, Viola L, Mumford J, Murray RM, Gordon M, Murray-Lyon IM. Detecting excessive drinking among admissions to a general hospital. Health Trends. 1982; 14: 80-83.
  9. Van der Pol V, Rodgers H, Aitken P, James O, Curless R. Does alcohol contribute to accident and emergency department attendance in elderly people? J Accid Emerg Med. 1996; 13: 258-60.
  10. Alexandre PK, Roebuck MC, French MT, Chitwood DD, McCoy CB. Problem drinking, health services utilization and the cost of medical care. Recent Dev Alcohol. 2001; 15: 285-98.
  11. Maisey A, Davies GJ. Lessons to be learned: a case study approach. Underage drinking in adolescents. J R Soc Health. 2003 Mar;123:52-4.
  12. McElligott-Tangney P, Morrissey PA. Nutrition and lifestyle survey of 15-17 year old second level school pupils in the Cork city area. Ir Med J. 2001; 94: 43-44.
  13. Chassin L, Pitts SC, Prost J. Binge drinking trajectories from adolescence to emerging adulthood in a high risk sample: predictors and substance abuse outcomes. J Consult Clin Psychol. 2002 Feb; 70: 67-78.
  14. McMahon GT, McGarry K. Deliberate self-poisoning in an Irish county hospital. Ir J Med Sci. 2001; 170: 94-97;
  15. Sher L. Alcohol use and suicide rates. Med Hypotheses. 2005; 65(6): 1010-2.
  16. Suokas J, Suominen K, Lonnqvist J. Chronic alcohol problems among suicide attempters- post-mortem findings of a 14-year follow-up. Nord J Psychiatry. 2005; 59: 45-50.
  17. Bilban M, Skibin L. Presence of alcohol in suicide victims. Forensic Sci Int. 2005; 147 Suppl: S9-12.
  18. Cherpitel CJ, Borges GL, Wilcox HC. Acute alcohol use and suicidal behaviour: a review of the literature. Alcohol Clin Exp Res. 2004; 28: 18S-28S.
  19. Borges G, Cherpitel CJ, MacDonald S, Giesbrecht N, Stockwell T, Wilcox HC. A case crossover study of acute alcohol use and suicide attempt. J Stud Alcohol. 2004 Nov; 65: 708-14.
  20. Hawton K, Harriss L, Hall S, Simkin S, Bale E, Bond A. Deliberate self harm in Oxford 1990- 2000: a time of change in patient characteristics. Psychol Med. 2003 Aug; 33: 987-95.
  21. Zahl DL, Hawton K. Repetition of deliberate self harm and subsequent suicide risk: long term follow up of 11,583 patients. Br J Psychiatry 2004; 185: 70-5.
  22. Hungerford DW, Pollock DA, Todd KH. Acceptability of emergency department-based screening and brief intervention for alcohol problems. Acad Emerg Med. 2000; 7: 1383-92.
  23. Smith SG, Touquet R, Wright S, Das Gupta N. Detection of alcohol misusing patients in accident and emergency departments: the Paddington Alcohol Test (PAT). J Accid Emerg Med. 1996; 13: 306-8.
  24. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption – II. Addiction. 1993; 6: 791-804.
  25. Maio RF, Shope JT, Blow FC, Gregor MA, Zakrajsek JS, Weber JE, Nypaver MM. A randomized controlled trial of an emergency department-based interactive computer program to prevent alcohol misuse among injured adolescents. Ann Emerg Med. 2005; 45: 420-9.
  26. Patton R, Crawford M, Touquet R. Hazardous drinkers in the accident and emergencydepartment – who accepts advice? Emerg Med J. 2004; 21: 491-2
  27. Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, Reece B, Brown A, Henry JA. Screening and referral for brief intervention of alcohol-misusing patients in a emergency department: a pragmatic randomised control trial. Lancet. 2004: 364: 1334-9.
  28. Wright S, Moran L, Meyrick M, O’Connor R, Touquet R. Intervention by an alcohol health worker in an Accident and Emergency Department. Alcohol Alcoholism. 1998; 33: 651-6.
  29. Barrett B, Byford S, Crawford MJ, Patton R, Drummond C, Henry JA, Touquet R. Cost- effectiveness of screening and referral to an alcohol health worker in alcohol misusing patients attending an accident and emergency department: A decision making approach. Drug Alcohol Depend. 2005.
  30. Peters J, Brooker C, McCabe C, Short N. Problems encountered with opportunistic screeningfor alcohol-related problems in patients attending an accident and emergency departmentAddiction. 1998; 93: 589-94.
  31. Williams S, Brown A, Patton R, Crawford MJ, Touquet R. The half-life of the “teachable moment” for alcohol misusing patients in the emergency department. Drug Alcohol Depend. 2005; 77: 205-8.
Author's Correspondence
[email protected]
Acknowledgement
The authors would like to thank the staff of CUH Emergency Department for their very helpful co-operation in the course of this research.
Other References
No References
   
© Copyright 2004 - 2009 Irish Medical Journal