The 3rd National Emergency Department survey of Alcohol Identification and Intervention activity

Patton, R. and Green, G. (2017). Alcohol identification and intervention in English emergency departments. Emergency Medicine Journal Online First.

Alcohol identification and brief advice (IBA) remain an effective and cost-effective method to reduce alcohol consumption and alcohol-related harm in Emergency Departments (Schmidt et al., 2015, Woolard et al., 2011). Recommendations suggest screening followed by simple clinical feedback to be the most efficacious form of IBA in the ED (Drummond et al., 2014). These findings reflect the UK Alcohol Strategy (2012), advocating the use of local public health grants to facilitate the implementation of alcohol IBA and specialist nurses within the ED (HMSO, 2012). The most recent guidelines by NICE (2010) and SIGN (2004), as well as a report by the Royal College of Emergency Medicine (2015), also support the continued use of screening tools and IBA within the ED. To determine the extent to which the continuing recommendations for the provision of alcohol IBA have been adopted by EDs, a new survey of all English Emergency Departments was undertaken. This survey followed up on the preceding National Surveys (Patton & O’Hara 2013, Patton et al., 2007) exploring the implementation of alcohol screening activity for adult and adolescent patients, with additional focus on older drinkers and people frequently attending EDs for alcohol-related reasons.

A total of 147 departments (of 180 contacted) responded to the survey (81.6% response rate). There was no change in the proportion of participating departments in comparison to the previous National Survey, with over 80% of EDs completing the survey.

In comparison to the previous National Survey, there have been significant increases in routine questioning about alcohol consumption among adults (+15.9%), informing patients’ GPs about alcohol-related attendance (+10.2%) and access to Alcohol Health Workers or Clinical Nurse Specialists (+13.4%). Modest increases were also found in access to brief advice training (+9.7%) and the use of formal screening tools in adults (+9.7%).

Every department asked adult patients about their alcohol consumption, with almost two-thirds doing so as a matter of routine (63.6%) and using a formal screening tool (61.4%). The most frequently used measures were the AUDIT-C (33.7%) and the Paddington Alcohol Test (PAT) (31.4%), which accounted for almost two-thirds of screening activity.

The majority of departments asked young people (aged under 18 years) about their alcohol consumption (83.8%), however, less than one in six did so as a matter of routine (11.6%). When screening young people, about one in seven departments (15%) used a standardised screening tool, the most common being the AUDIT-C (53.3%) and the PAT (26.7%).

Nearly all departments asked older adults (aged 65+) about their alcohol consumption (94.9%), with around half doing so as a matter of routine (52.7%). About half of these departments used an alcohol screening tool, the most common being the AUDIT-C (35.4%), the PAT (21.5%) and the CAGE (21.5%).

About three-quarters of departments recorded an alcohol-related attendance in the patient’s notes, and of these almost all (90.4%) informed the patient’s GP about such attendances. There was a significant association between departments recording attendances and informing GPs of an alcohol-related attendance.

Nearly every department (97.3%) offered help or advice for patients, who might have an alcohol use disorder. The help / advice provided by about half of all departments was a referral to their own “in house” specialist team, with about a quarter referring patients to an external agency. Some departments provided an intervention themselves in the form of a leaflet or brief advice. The majority of departments had access to either an Alcohol Health Worker or a Clinical Nurse Specialist (85.2%), typically based on-site.

Almost half of departments (40%) offered an Assertive Outreach service for patients with alcohol-related problems and the same proportion of departments offered a programme that aimed to reduce alcohol-related attendance among frequent attenders. There was a significant association between departments offering assertive services and those that had a programme to reduce alcohol-related attendances.

While there has been little change in the proportion of EDs who identified an ‘Alcohol Champion’, we note that the presence of a senior staff member who takes responsibility for dealing with alcohol issues is significantly associated with access to IBA training. There remains scope for more Champions to be created, and this ought to further increase alcohol IBA activity.

Departments should use AUDIT-C or PAT to identify patients in need of help or advice about their drinking.

Screening should be undertaken routinely across all patient age groups.

Departments should seek to identify an ‘Alcohol Champion’ to consolidate current screening and intervention activity.

This 3^rd National Emergency Department survey of alcohol identification and intervention activity shows that, in comparison to the previous 2011 survey, changes in alcohol IBA activity remain positive. Routine questioning about alcohol consumption (in adults), the number of GPs being informed by EDs of patient’s alcohol-related attendances, and having access to Alcohol Health Workers or Clinical Nurse Specialists all significantly increased. Additionally, modest increases in the provision of training on alcohol screening and brief advice, and the use of a formal alcohol screening tool for adult attendees have been observed.

Departments should be praised, as it seems that alcohol screening and either referral or intervention is becoming a more accepted component of routine practice. Nearly half of all departments are now implementing strategies to tackle re-attenders. Improved communication with GPs highlights a move towards multidisciplinary care and integration across primary and secondary care services. This highlights the potential for GPs to become more involved in the wider implementation of alcohol IBA and interventions, given that primary care has been deemed a more suitable setting for more in-depth interventions.

Routine questioning about alcohol use is fairly high among adults (aged 18-65 years), which is encouraging given that this has been a consistent recommendation in relevant reports and guidelines over the last 5 years (NCEPOD, 2013, RCEM, 2015, Nice, 2010, Nice, 2011, PHE, 2014). However, the limited routine questioning observed among under 18’s marks room for improvement, particularly since those aged 15-24 years provide the greatest volume of Emergency Department attendances (Currie et al., 2015).

Dr Bob Patton, School of Psychology, University of Surrey

Drummond, C., Deluca, P., Coulton, S., Bland, M., Cassidy, P., Crawford, M., Dale, V., Gilvarry, E., Godfrey, C., Heather, N., Mcgovern, R., Myles, J., Newbury-Birch, D., Oyefeso, A., Parrott, S., Patton, R., Perryman, K., Phillips, T., Shepherd, J., Touquet, R. & Kaner, E. (2014). The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial. PLoS One, 9, e99463.

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