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Three Part Question

In [UK emergency departments] is the [prevalence of alcohol-related presentations] [sufficiently high to jusitfy implementation of brief intervention]?

Clinical Scenario

Another day as hotshot Clinical Director, another day of corporate meetings and complex decision-making: Is alcohol a significant contributor to ED presentations? Would I be able to justify the implementation of an Alcohol Health Service within the department? Is this really as big a priority as the Government makes out?
Luckily, you have your resident Professor to hand, a man of many talents - he is able to conduct robust literature searches at the touch of a button. You decide to find out the prevalence of alcohol misuse across UK EDs as a first step in deciding whether to jump on the 'Preventive Emergency Medicine' band-wagon and offer brief intervention to eligible patients

Search Strategy

MEDLINE 1996 to July week 1 2007
EMBASE 1980 to 2007 week 28
PsycINFO 1985 to July week 2 2007
CINAHL 1982 to July week 1 2007
MEDLINE:
{[(alcohol$.mp. OR ethanol.mp. OR exp Ethanol/ OR booze$.mp. OR exp Alcohol Drinking/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp Alcoholism/ OR exp Alcoholic Intoxication/]}
AND [exp Emergency Service, Hospital/ OR emergency department$.mp. OR (accident and emergency).mp. OR exp Trauma Centers/]
AND [prevalence.mp. OR exp Prevalence/ OR exp Cross-Sectional Studies/ OR cross sectional.mp. OR survey.mp. OR exp Data Collection/ OR exp Medical Audit/ OR audit$.mp. OR incidence.mp. OR exp Incidence/]
AND [united kingdom.mp. OR exp Great Britain/ OR uk.mp.]
EMBASE:
{[(alcohol$.mp. OR exp ALCOHOL/ OR ethanol.mp. OR booze$.mp. OR exp Alcohol Consumption/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp ALCOHOLISM/ OR exp Drug Dependence/ OR exp Drug Misuse/ OR exp Alcohol Abuse/ OR exp ALCOHOL INTOXICATION/]}
AND [exp Emergency Medicine/ OR exp Emergency Health Service/ OR emergency department$.mp. OR exp emergency ward/ OR (accident and emergency).mp. OR trauma center.mp.]
AND [prevalence.mp. OR exp PREVALENCE/ OR cross sectional.mp. OR survey.mp. OR exp HEALTH SURVEY/ OR data collection OR audit.mp. OR exp Medical Audit/ OR incidence.mp. OR exp INCIDENCE/]
AND [united kingdom.mp. OR exp United Kingdom/ OR great britain.mp. OR uk.mp.]
PsycINFO:
{[(alcohol$.mp. OR ethanol.mp. OR exp ETHANOL/ OR booze$.mp.) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp)] OR [alcoholism.mp. OR exp ALCOHOLISM/ OR exp Alcohol Drinking Patterns/ OR exp Drug Dependency/ OR exp ALCOHOL ABUSE/ OR exp Alcohol Intoxication/]}
AND [exp Emergency Services/ OR emergency department$.mp. OR (accident and emergency).mp. OR trauma center$]
AND [prevalence.mp. OR exp Prevalence/ OR exp Cross-Sectional Studies/ OR cross sectional.mp. OR survey.mp. OR exp Data Collection/ OR exp Medical Audit/ OR audit$.mp. OR incidence.mp. OR exp Incidence/]
AND [united kingdom.mp. OR exp Great Britain/ OR uk.mp.]
CINAHL:
{[(alcohol$.mp. OR ethanol.mp. OR exp Alcohol, Ethyl/ OR booze$.mp. OR exp Alcohol Drinking/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp ALCOHOLISM/ OR exp Alcohol abuse/ OR exp Alcoholic Intoxication/]}
AND [exp Emergency Service/ OR emergency department$.mp. OR (accident and emergency).mp. OR exp Trauma Centers/]
AND [prevalence.mp. OR exp PREVALENCE/ OR exp Cross Sectional Studies/ OR cross sectional.mp. OR survey.mp. OR exp Surveys/ OR exp Data Collection/ OR exp Audit/ OR audit$.mp. OR incidence.mp. OR exp INCIDENCE/]
AND [united kingdom.mp. OR exp United Kingdom/ OR exp Great Britain/ OR uk.mp.]

Search Outcome

76 papers found of which 6 were relevant and of sufficient quality for inclusion

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Simpson T et al. 2001 Scotland	544 of 638 eligible patients aged >/= years; new patients attending ED; consent/ parental consent; not direct medical referrals via ED; not GP (General Practitioner) referrals for radiological examination; not uninvited returns; not critically injured or unable to give informed consent Sampling period: 2 months mid-February to mid-April 24-hours a day*	Prospective survey	Saliva alcohol concentrations measured using either QED A-150 or QED A-350 enzymatic test device (Enzymatics Incorporated) via noting colour change on scale	Positive alcohol concentrations in 122 patients (22%, 95% CI 19 to 26%). 64% male, 6% aged 10-17 years	*90 'lost' to study as not possible to approach patients at times of high clinical activity; inter-observer differences in test reporting not examined; baseline data collected by self-report; no check for concordance against objective medical records; saliva test does not capture those presenting late after an alcohol-related event i.e. underestimates total amount consumed
Carrigan TD et al 2000 England	93 of 116 eligible patients >12 years; assessed and treated for trauma related injuries in ED resuscitation room; consenting; not tertiary referrals from outside hospital catchment area Sampling period: 6 months 01/07/97 to 31/12/97 24-hours a day	Prospective prevalence study	Blood ethanol concentration >80mg/dl using enzymatic assay (Sigma Chemical Company)	89 samples taken: 24 patients (27%, 95% CI 18 to 36%) had plasma ethanol concentrations >80mg/dl	Small sample size, wide confidence intervals; insufficient numbers in adolescent group to enable analysis by age-band; study restricted to major trauma patients; reasons for non-enrolment not stated
Hadida A et al 2001 England	413 of 429 ED patients aged >/= 12 years; consenting; well enough to interview Sampling period: 6 weeks; every 5th consecutive patient presenting during each of 6 time periods (8am-12pm, 12pm - 4pm, 4pm-8pm, 8pm-12am, 12am-4am and 4am-8am)	Representative flow sample survey	Alcohol-related attendance using CAGE questionnaire (¡Ý2 items endorsed), staff and patient assessments	115 (28%) alcohol-related attendances on basis of CAGE or staff assessment; 8.7% by CAGE and staff assessment; 9.4% by CAGE only and 9.7% by staff assessment only	'Alcohol-related' undefined; patient and staff assessments not validated; 'alcohol-related' and 'problem-drinker' used interchangeably; small sample size
			Comparison of CAGE-identified and staff-identified alcohol-related attendees by patient demographic and presentation data	CAGE-identified group more likely to be male (p<0.01), more likely to present during normal working hours (p=0.06) and more likely to acknowledge attendance as alcohol-related (p<0.01). No difference in age, alcohol consumption or day of presentation between two groups.
Pirmohamed M et al. 2000 England	All 15 931 ED patients Sampling period: 2 months 07/08/96 to 07/10/96	Prospective survey	Alcohol-related attendance using staff assessment via coloured sticker pre-affixed to case-card	1915 (12%) patients had alcohol-related attendances. Median age 36 years; range 11-90 years; 73% males	'Alcohol-related' not defined; 20% stickers not completed by staff; no validated screening tool used
Thom B et al. 1999 England	679 ED ambulant patients aged >/= 16 years across two EDs (Central and Suburban); consenting Sampling period: one week 8am-12am Sunday to Thursday and 8am-3am Friday and Saturday. Central: 03/96 7 days spread throughout month; Suburban: 05/96 7 consecutive days	Screening study	Self-report alcohol-related attendance	16-24 group significantly more likely to report alcohol-related attendance than ¡Ý25 group (15% versus 7%, p=0.004)	Total number of eligible patients not stated; varying sampling strategies across two EDs; small sample size of 16-24 year olds; no staff assessment; questionable validity of adolescent self-report
			Self-report alcohol consumption 6 hours prior to attendance	17% 16-24 year olds reported drinking 6h prior to attendance versus 13% in ¡Ý25 group (not significant)
			Alcohol consumption using Alcohol Use Disorders Identification Test - AUDIT questionnaire (¡Ý8 detects those experiencing current alcohol problems and those at risk of future harm)	16-24 group significantly more likely to score ¡Ý8 on AUDIT than ¡Ý25 group (37% versus 23%, p<0.001)
Connor J et al. 1997 England	Children (aged between 1-16 years) attending the Royal Liverpool Children's Hospital Sampling period: 12 months 01/02/96 to 31/01/97	Record review	Number of patients attending ED following ingestion of alcohol	169 (0.3%) of 61,452 new ED attendances. 75 (44%) male; age range 9-16, mode 14 years	Inclusion criteria and method of data extraction inadequately described

Comment(s)

As expected, each study produced different estimates of alcohol-related presentations - the differences being mostly attributable to the type of ED population examined and the methodology used

Clinical Bottom Line

Alcohol is a significant contributor to ED presentations. Given growing evidence for the cost-effectiveness of routine identification and intervention for alcohol misuse in EDs, implementation of such a service would be justified

References

1. Simpson T, Murphy N, Peck DF Saliva alcohol concentrations in accident and emergency attendances Emerg Med J 2001;18:250-4
2. Carrigan TD, Field H, Illingworth RN et al Toxicological screening in trauma J Accid Emerg Med 2000;17:33-7
3. Hadida A, Kapur N, Mackway-Jones K et al Comparing two different methods of identifying alcohol related problems in the emergency department: a real chance to intervene? Emerg Med J 2001;18:112-5
4. Pirmohamed M, Brown C, Owens L et al The burden of alcohol misuse on an inner-city general hospital. Q J Med 2000;93:291-5
5. Thom B, Herring R, Judd A Identifying alcohol-related harm in young drinkers: the role of accident and emergency departments. Alcohol Alcohol 1999;34:910-5
6. Connor J Children and the ingestion of alcohol: a statistical analysis of children attending an A & E department Accid Emerg Nurse 1997;5:185-8