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Judith Morgan Judith Morgan RN MA BSC CMS RN MA BSC CMS ONCONC

Consultant Nurse in Emergency Consultant Nurse in Emergency CareCare

ABM University NHS TrustABM University NHS Trust

Alcohol Misuse & ED Alcohol Misuse & ED ScreeningScreening

Alcohol Misuse & ED Alcohol Misuse & ED ScreeningScreening

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ObjectivesObjectives

Facts & figures on alcohol consumption

Brief summary of affect of alcohol on the body

Statistical impact of alcohol on providing emergency care

Welsh Assembly Government initiatives for alcohol impact in EDs

Screen tool in ED use

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Facts & FiguresFacts & Figures

• Around 10 million drinking above recommended limits.

• Between 15,000 and 20,000 premature deaths in England and Wales each year are associated with alcohol misuse.

• Alcohol can be fattening. 3 or 4 G&Ts daily diet, increase weight by 1.8kg or 4lbs in 4/52.

• Children copy behaviour from their parents

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Relevant Statistics on Alcohol Relevant Statistics on Alcohol

• Alcohol misuse cost UK £20 billion per year• 92% of men & 86% of women in Britain drink

alcohol (DH 2002)

In Wales• 40% regularly drink more than the

recommended limit• 19 % binge drinking• 44 % of 18-24y feel very drunk at least once

a month• 29.3% of 18 – 24y criminal & disorderly

behaviour during or after drinking

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Relevant Statistics on Alcohol Relevant Statistics on Alcohol

• Report Britain's Ruin (2000) alcohol abuse linked:

– 23% of child neglect calls to national help lines– 39% of fires– 15% of drownings

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Calculating the Units in a DrinkCalculating the Units in a Drink

• One UK unit is 10ml or 8g of pure alcohol (also called ethanol)

• Calculated: amount in mls x strength (ABV) / 1000

• Every % point of ABV in a litre is the equivalent of a unit e.g. a litre of a typical whisky (37.5 ABV) will contain 37.5 units.

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Units of Alcohol in Common Drinks Units of Alcohol in Common Drinks (1unit = (1unit = 8g)8g)

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1 unit = 8g

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Effects of Alcohol on the Body Effects of Alcohol on the Body (8g = ½ (8g = ½ lager)lager)

Mild intoxication: 50 - 150 mg/ 100 mls

• Emotionally labile with euphoria & melancholy, aggression & submission ~ often occurring successively

• Impaired muscle co-ordination and reaction time

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Effects of Alcohol on the Body Effects of Alcohol on the Body (8g = ½ (8g = ½ lager)lager)

Moderate intoxication: 150 - 300 mg/ 100mls: .

• Visual impairment; • Sensory loss; • Impairment of motor skills and slurred

speech.

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Effects of Alcohol on the Body Effects of Alcohol on the Body (8mg = ½ (8mg = ½ lager)lager)

Severe intoxication/ coma. 300 - 500 mg/ 100 mls.

• Hypothermia

• Motor skills markedly impaired

• Blurred vision

• Occasional hypoglycaemia & convulsions

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Effects of Alcohol on the Body Effects of Alcohol on the Body (8mg = ½ (8mg = ½ lager)lager)

Coma or Death. 400+ mg/100 mls.

• Coma

• Respiratory depression,

• Hypotension

• Hypothermia

• Depressed reflexes

• ± Death from respiratory or cardiovascular failure (aspiration)

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ED & Alcohol ED & Alcohol • 12% ED attendees alcohol presentation associated

with alcohol misuse (Huntely et al 2004)• 40% ED attendees have alcohol as a contributory

factor • Alcohol related facial injuries (Hutchinson et al

1998): – Falls ~ 11% – Assaults 55% – RTCs ~ 15% consumed alcohol

• NSW, Oz, 2000 to 2007:– 59% increase in alcohol-related cases– 200% increased in 18 to 24 year old females – Females overall from 412 to 1233 a year

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Alcohol & Falls Alcohol & Falls J J E JohnstonJ J E Johnston, , S J McGovern S J McGovern Emerg Med JEmerg Med J 2004; 2004; 2121:185-188]:185-188]

• 113/351 health adults had consumed alcohol

• Blood alcohol intake were obtained for 47.

• Group had a higher incidence of head injuries (46 (48%) versus 22 (9%))

• Lower incidence of limb injuries (39 (39%) versus 183 (76%))

• More often associated with severe craniofacial injury.

• Severity of both limb and head injury is greater and correlates directly with blood alcohol concentration

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What ED Presenting Complaints Relate What ED Presenting Complaints Relate Directly to Alcohol Directly to Alcohol

• Assault – 50 to 73% alcohol related (Luke 1998)

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Relevant Statistics on Alcohol Relevant Statistics on Alcohol

• Report Britain's Ruin (2000) Alcohol abuse linked:– 65% of suicide attempts– 76,000 facial injuries a year

• 2001 & 2003:– 12 deaths /100,000 people relating to alcohol – 30,000 hospital bed days/ year related to

alcohol

• In 2002, alcohol was involved in 41% of all fatal crashes (NIDA).

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Paediatric ED Attendances Paediatric ED Attendances Attendance ED Attendance ED summer 2004: 60 children (0.4% of new summer 2004: 60 children (0.4% of new

attendees) primarily alcohol relatedattendees) primarily alcohol related

• 12.5% + other substances further suspected 5.4%.

• Comorbidity included head injury, assault, and alleged or suspected rape.

• 25% Blood alcohol concentration between 108 and 343.5 mg/dl.

• 20% admitted. • increase from 39% in

summer 2002 to 65% in summer 2003.1% = 1.8

• 4 DNW • Age range was 10–15

years. • Female to male ratio was

1.8 to 1 • > 10% GCS 8/15

(unconscious) • 62% had drunk alcohol

previously • 7% had previous alcohol

related hospital attendances

• 16% were hypothermic; 0% were hypoglycaemic.

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Alcohol & Suicide attemptsAlcohol & Suicide attempts• Strong association between heavy

drinking, depression and suicide

• Suicide attempts: 39% of men & 8% of women - chronic problem drinkers.

• 70% of men & 40% women have alcohol before suicide attempt.

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Government screening:Government screening: April 2008: Mandatory WAG data April 2008: Mandatory WAG data

capturecapture• Data to be captured

– Alcohol related attendances– Patients who present having ingested alcohol

• Difficulty:– No change to clinical coding & systems not in

place– Subjective capture– Reliant on clinicians to ask & capture data

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Government screening:Government screening: Health & Crime Data Sharing Health & Crime Data Sharing

• The Home Office funded Targeting Alcohol-related Street Crime (TASC) project (Cardiff)

• Roll out good practice from above

• Most EDs in south Wales involved.

• Co-operation between EDs & police in sharing data of crime.

• No individual patient identification

• Reduction in wounds caused by glass or bottle injury

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Screening Screening Tool in ED Tool in ED

UseUse

Paddington Alcohol Test

(PAT)

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Paddington Alcohol Test (PAT)Paddington Alcohol Test (PAT)Complete for: Complete for:

• Recent consumption alcohol

• Fall • Collapse / seizures• Head / facial injury• Accident (burn / RTC)• Assault

• Non-specific GI problem

• Unwell (requests detox/help)

• Psychiatric• Cardiac (chest pain/

palpitations)• Self neglect• Repeat attendee

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Paddington Alcohol Test (PAT)

1. Do you drink Alcohol YesNo: (end)

2. What is the most you will drink in any one dayStandard alcohol units

see next slide for details of alcohol units

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2. What is the most you will drink in any one day? 2. What is the most you will drink in any one day? Total in one day = (standard alcohol units)Total in one day = (standard alcohol units)

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How often do you drink more than How often do you drink more than twice the recommended amount?twice the recommended amount?

• Every day = dependent drinker (PAT +ve)

• X times per week = Hazardous drinker (PAT +ve)

• Never / less than weekly

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Further questionsFurther questions

4. Do you feel that your attendance here is related to alcohol?– Yes (PAT +ve)– No

5. Would you like to see our Alcohol Liaison Nurse– Yes: give appointment date & time– No (give leaflet)

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Effects of Alcohol ScreeningEffects of Alcohol Screening

• a growing number of systematic reviews and secondary analyses have reported that brief alcohol interventions are effective and cost-effective at reducing excessive consumption in primary health care (Freemantle et al. 1993, Kahan et al. 1995, Wilk et al. 1997, Moyer et al. 2002, Ballesteros et al. 2004).

• 64% (n=281) of adult hazardous drinkers identified by PAT accepted brief advice (Patton et al 2003)