ALCOHOL AND THE ACCIDENT AND EMERGENCY DEPARTMENT: A CURRENT REVIEW

Alcohol & Alcoholism Vol. 37, No. 4, pp. 307–312, 2002 SPECIAL ARTICLE ALCOHOL AND THE ACCIDENT AND EMERGENCY DEPARTMENT: A CURRENT REVIEW* MICHALIS P. CHARALAMBOUS Imperial College of Science, Technology, and Medicine, St Mary’s Hospital Medical School Campus, Norfolk Place, London W2 1NY, UK (Received 20 November 2001; accepted 8 January 2002) Abstract — Alcohol misuse constitutes a major problem in our modern society and both physical and mental alcohol-related harm result in a large number of Accident and Emergency (A&E) attendances, thus imposing a significant burden on the workload and financial resources of the department. The current management of problem drinking by most A&E departments could be further improved. The introduction of a holistic approach that includes efficient screening instruments and effective brief, anti-alcoholic interventions, for the management of these patients must be considered. This should strengthen the preventive role of A&E departments, and, in the long term, may result in a decrease in the number of cases of alcohol misuse and in alcohol-related attendances. INTRODUCTION ALCOHOL AND THE A&E DEPARTMENT Alcohol misuse is a major problem in our modern society, and a wide range of physical, social, and psychological problems are associated with excessive drinking. Over the last 30 years, annual alcohol consumption by the average British adult has increased considerably by ~2–3 l of pure alcohol per person (Alcohol Concern, 1999; Pirmohamed et al., 2000); and currently, 1 in 4 men, and 1 in 10 women are believed to be drinking in a ‘hazardous’ or even ‘harmful’ manner, that is >21 and >14 units a week respectively (Paton, 1994; Department of Health, 1999; Pirmohamed et al., 2000). One unit is defined in the UK as 1⁄ 2 pint of beer, a glass of wine, or a standard measure of spirits (~10 g of ethanol). People with serious drinking problems have a significantly increased morbidity and mortality, when compared to age- and sex-matched controls. Every year, overt alcohol-related problems place a significant burden on general hospitals across the country, and especially on Accident and Emergency (A&E) departments (Rhodes et al., 1990; Pirmohamed et al., 2000). A large number of attendances at A&E departments are associated, directly or indirectly, with both dependent drinking and risky single-occasion drinking, which may result in accidents, assaults, fights, and other traumatic events requiring hospital care (Green et al., 1993; Department of Health, 1993; Waller et al., 1998; Thom et al., 1999). Currently, in an attempt to decrease alcohol-related harm, A&E departments have been selected as a possible base for screening patients for alcohol misuse, and for the delivery of brief, anti-alcoholic interventions (Peters et al., 1998; Wright et al., 1998; Thom et al., 1999). The purpose of this article is to analyse the burden imposed on A&E departments by alcohol-related problems, and the appropriate management of these patients by A&E staff; finally to critically discuss the efficiency of these methods, as well as the need for, and feasibility of, any other possible measures that can be employed in order to strengthen this function of A&E departments. Acute and chronic excessive alcohol intake can lead to the development of physical and mental acute ill-health, and drinking clearly leads to many of the problems that bring patients to an A&E department (Fig. 1). Over the last 20 years, several studies have investigated the size of the alcohol consumption problem, and its effect on the use of emergency hospital services (Jariwalla et al., 1979; Jarman and Kellett, 1979; Holt et al., 1980; Barrison et al., 1982; Taylor et al., 1986; Dowey, 1993; McKnight et al., 1995; VanderPol et al., 1996; Pirmohamed et al., 2000). It is estimated that ~2–40% of all A&E attendances are due to alcohol-related problems, with the relative proportion depending on the location of the hospital and the mixture of the target population, as well as the exact investigative method used. Currently, in the UK, 1–3 million people attend A&E departments every year for a wide variety of problems due to alcohol misuse (Peters et al., 1998; Department of Health, 1999); and a significant proportion of all these attendances result in hospital admissions (with the majority for just 1 day), accounting for ~5% of all admissions into hospital (Department of Health, 1999; Pirmohamed et al., 2000). It is estimated that alcohol misuse accounts for ~12% of total NHS spending on hospitals, i.e. ~£3 billion a year (Alcohol Concern, 2001). A&E attendances due to drinking problems can occur at any part of the day, but they usually occur more often at nights and during weekends (Peppiatt et al., 1978; Yates et al., 1987; Pirmohamed et al., 2000). More than twice as many men as women attend A&E departments due to an alcohol-related problem, and the majority of these patients are young adults aged <40 years (Peppiat et al., 1978; Midford et al., 1995; Harnett et al., 1999; Pirmohamed et al., 2000). Different age groups are associated with different types of alcohol misuse and hence with different alcohol-related symptoms. Adolescents aged <18 years are associated mainly with risky single-occasion drinking (Plant et al., 1990; Moore et al., 1994; Miller and Plant, 1996; Webb et al., 1996; Harnett et al., 1999), and the commonest reasons for attendances in this age group are minor injuries (usually sustained from falls), assaults, head injuries and alcohol intoxication. At the *This paper was co-winner of the Michael Frowen Memorial Essay 2001 Award of the Medical Council on Alcohol for UK medical students. It was not peer-reviewed, but received full editorial attention. 307 © 2002 Medical Council on Alcohol 308 M. P. CHARALAMBOUS Fig. 1. The main alcohol-related health problems which can bring an alcohol-misuser to an Accident and Emergency department. other extreme, patients aged >60 years are more likely to attend the A&E department due to falling while intoxicated (Harnett et al., 1999). The great majority of alcohol-related A&E patients are 18–60 years old. About 20% of these involve a serious health problem due to long-term alcohol misuse, such as gastrointestinal bleeding, pancreatitis, liver failure and alcohol withdrawal symptoms. These patients are very likely to attend the A&E department on more than one occasion over a short period of time, and, in some or all of these attendances, be admitted into hospital for a substantial period, thus imposing a significant burden on the workload and financial resources of both the A&E department and the hospital (Holt et al., 1980; Buchan et al., 1981; Lockhart et al., 1986; Rainer et al., 1996; Pirmohamed et al., 2000). The rest of these attendances involve mainly accidents with associated injuries, episodes of deliberate self harm, and episodes of violence and assaults while being under the influence of alcohol (Dennis et al., 1997; M (...truncated)