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IDENTIFYING ALCOHOL-RELATED HARM IN YOUNG DRINKERS: THE ROLE OF ACCIDENT AND EMERGENCY DEPARTMENTS

Betsy Thom, Rachel Herring, Ali Judd
DOI: http://dx.doi.org/10.1093/alcalc/34.6.910 910-915 First published online: 1 November 1999

Abstract

Data are presented from a screening study of ambulant attendees at two London Accident and Emergency (A&E) departments. Among young people (aged 16–24 years), 37.2% were drinking harmfully [an Alcohol-Use Disorders Identification Test (AUDIT) score of 8 or more]; 17.3% admitted to drinking alcohol in the 6 h prior to attendance; and 14.6% considered that their attendance was alcohol related. Young women were as likely as men to score 8 or over. This age group had nearly twice the odds of scoring highly on the AUDIT, compared to those over 25 years old, and were more likely to report that their attendance was alcohol related. Screening in A&E departments would identify considerable numbers of young people who might benefit from brief intervention, but the problems of doing so are acknowledged.

INTRODUCTION

There is ample evidence that a large number of attendances at Accident and Emergency (A&E) departments are associated both with dependent drinking and with single episodes of intoxication, which can result in accidents, fights, facial injuries, and other traumatic events requiring hospital care (Green et al., 1993; Department of Health, 1993; Waller et al., 1998). In an attempt to reduce alcohol-related harm, A&E departments have been singled out as a possible base for screening and for the delivery of brief interventions (Peters et al., 1998; Wright et al., 1998). A number of screening questionnaires have been developed and used in some hospital A&E departments. These studies have indicated the importance of using a screening instrument which can be administered quickly and which can be easily incorporated into routine hospital procedures (Rowland and Maynard, 1987; Barrett et al., 1989; Smith et al., 1996). The potential for intervention in problem drinking has also been demonstrated in studies describing the use of a specialist A&E nurse (Wright et al., 1998). However, the structural and attitudinal barriers to using A&E departments for screening and intervention have been recognized and opinion is still divided regarding the potential to strengthen the preventive role of A&E departments and reduce the costs of alcohol-related attendances (Herring and Thom, 1999).

To date, A&E departments which have become involved in responding to alcohol-related attendances have concentrated on intervening in heavy or dependent drinking (Green et al., 1993; Smith et al., 1996; Peters et al., 1998; Wright et al., 1998); opportunistic intervention in attendances associated with intoxication or heavy drinking has received much less attention. This means that young people are unlikely to be questioned about their alcohol consumption or offered advice, although studies of younger age groups (under 25 years old) indicate that they are likely to be involved in drinking contests and practices which incur a risk of accidental injury leading to hospital attendance (Royal College of Physicians and British Paediatric Association, 1995; Murgraff et al., 1999). Research on alcohol-related attendances at A&E departments has not examined young people as a distinct group, and the extent to which A&E attendance might afford an opportunity to identify problematic drinking or alcohol-related risk in young people has not been addressed in the literature (Hayden, 1995).

This paper describes the extent to which ambulant attendances by young people at two London hospitals were alcohol related, and considers the potential for screening and intervention with non-dependent young drinkers.

METHODS

The two A&E departments (one in central London, referred to here as ‘Central’ and one in a London suburban area, ‘Suburban’) were selected to provide some contrast in the type of local community served by the hospital, because access was easy to negotiate, and because they were accessible to the researchers. They also provided ‘best case scenario’ examples, since both departments were managed by consultants concerned about alcohol-related attendances and both had procedures for identifying and responding to dependent drinking. The departments offered, therefore, an opportunity to assess screening and prevention approaches within facilitating settings, although neither department had tackled the specific problem of alcohol-related attendances by young people. Ethical permissions were obtained from the relevant medical committees.

At each site, the sample comprised all ambulant patients attending over the course of one sample week, between the hours of 08:00 and 24:00 (midnight) from Sunday to Thursday and between 08:00 and 03:00 on Friday and Saturday respectively. The field work took place in March 1996 at ‘Central’, where the week comprised 7 days spread throughout 1 month and in May 1996 at ‘Suburban’ where data were collected on 7 consecutive days. The difference in procedure occurred at the request of A&E staff, who had been consulted on ways to minimize disruption in the departments.

Researchers, working in shifts of two in the A&E waiting room, handed patients a written explanation about the study, provided further verbal explanation if necessary, and asked all patients aged 16 years or over to complete a short, anonymous, self-completion questionnaire. On completion, the questionnaire was put in an envelope and the respondent posted it in a box in the waiting room.

The questions covered socio-demographic details, the reason for attendance, the location of the accident, injury or illness, whether alcohol had been consumed in the 6 h prior to attendance, and perceptions of the extent to which alcohol had contributed to hospital attendance. The questionnaire included the Alcohol-Use Disorders Identification Test (AUDIT), which explores levels of alcohol intake, degrees of dependence, adverse reactions, and alcohol-related problems. It has been suggested that the AUDIT is a more sensitive screening instrument than other questionnaires (Bohn et al., 1995), and Conigrave et al. (1995) concluded that a cut-off point of 8 or above was able to ‘detect those experiencing current alcohol problems as well as those at risk of future harm’. This ability to detect ‘risky’ drinking made the questionnaire a particularly suitable choice for screening younger people who are less likely to manifest symptoms of dependent drinking.

Initially univariate frequency tables were generated, to describe the data by respondent characteristics. Multiple logistic regression analysis was performed in a hierarchical manner to determine the independent contribution of each factor to the overall odds of the outcome of interest. All independent factors were subsequently controlled for when any factor of interest was considered. Statistical significance was assessed using the likelihood ratio statistic (Clayton and Hills, 1996). The statistical software package Stata 5.0 (Stata Corp, College Station, TX, USA) was used for all analyses.

RESULTS

At both hospitals, 78% of ambulant patients asked agreed to participate. Reasons given for refusal to participate were: feeling too ill or distressed; language; perceived research as not personally relevant; suspicious of the research. Of the questionnaires returned, 4% of ‘Central’ and 5% of ‘Suburban’ were incomplete. Because of the nature of the injury or because of feeling unwell, one-fifth of all respondents (20.7%) needed assistance either from a companion or from the researcher to complete the questionnaire. A total of 416 complete questionnaires were collected from ‘Central’ and 263 from ‘Suburban’.

Sample characteristics are given in Table 1. There were no differences between the two hospital samples in terms of age, sex, employment, marital status, and trauma. A higher proportion of ‘Suburban’ respondents were Asian, compared to the ‘Central’ sample. Within each age group, there was no statistical evidence of differences between hospital attended and sex, employment, marital status, or trauma (all P-values > 0.07). Subsequent analyses grouped departments of both together.

View this table:
Table 1.

Sample characteristics

Parameter‘Central’ (%) n = 416‘Suburban’ (%) n = 263Significance and degrees of freedom (d.f.)
aIncludes home-makers, retired and semi-retired individuals, and those who are sick or disabled; breasons for attendance reported by patients were categorized as trauma, where an incident had resulted in injury (e.g. falls, traffic accidents, injuries from fights) and non-trauma, where the respondent was suffering from an illness or a condition (e.g. gastric problems, unspecified abdominal pain).
Age and sex
16–24 years24.324.0P = 0.923 (1d.f.)
Male55.050.2P = 0.217 (1d.f.)
EthnicityP < 0.001 (3d.f.)
White77.170.6
Black10.09.9
Asian5.615.6
Other7.33.8
EmploymentP = 0.716 (3d.f.)
Employed54.458.4
Unemployed14.214.1
Student13.212.2
Othera18.115.3
Marital statusP = 0.100 (3d.f.)
Single51.242.0
Married/cohabiting36.945.8
Divorced/separated8.78.4
Widowed3.23.8
Reason for attendanceP = 0.555 (2d.f.)
Traumab59.963.7
Non-trauma35.831.7
Unclear4.34.6

There were 164 patients in the age group 16–24 years and 515 patients aged 25 years and over. Young people were more likely to score highly on the AUDIT, and more likely to report that their attendance was related to their own or another's use of alcohol (Table 2). Among those drinking alcohol in the 6 h prior to attendance, 78.6% (22/28) of young people, compared to 63.2% (43/68) of those over 25 years, scored 8 or more on the AUDIT (P = 0.144). Similarly, among those not drinking before attendance, 28.4% (38/134) of young people, compared to 17.1% (75/439) of those over 25 years, scored 8 or more on the AUDIT (P = 0.004).

View this table:
Table 2.

Respondents' use of alcohol by age group

Age (years)
Alcohol-use parameter16–24 (n = 164)25+ (n = 515)Significance
Respondents with high AUDIT scores (8+) (%)37.223.3P < 0.001
Respondents drinking in 6 h before attendance (%)17.313.4P = 0.221
Respondents reporting incident as alcohol-related (%)14.67.1P = 0.004

The risk of scoring 8 or more on the AUDIT varied by age group, sex, ethnicity, employment status, marital status, alcohol consumption prior to attendance, and perceived alcohol-related attendance (P < 0.001 for each variable; Table 3). Hospital location was not associated with the higher risk score (P = 0.578). Two variables, alcohol consumption in the 6 h prior to attendance and perceived alcohol-related attendance, were correlated (r = 0.569, P < 0.001), so alcohol consumption before attendance was selected for the model.

View this table:
Table 3.

Risk factors for scoring 8 or more on the AUDIT

ParameterNo./total scoring 8+% scoring 8+Crude odds ratioAdjusted odds ratioa
aAdjusted for age group, sex, ethnicity, employment status, marital status, and alcohol prior to attendance; bincludes home-makers, retired and semi-retired individuals, and those who are sick or disabled; cin the preceding 6 h; dpatient reported that accident/injury was alcohol related.
Age group
16–24 years61/16437.21.9491.739
25+ years120/51523.31.0001.000
χ2 1d.f. = 11.74 P < 0.001χ2 1d.f. = 4.61 P = 0.032
Sex
Female59/31818.61.0001.000
Male122/36133.82.2411.904
χ2 1d.f. = 20.47 P < 0.001χ2 1d.f. = 9.33 P = 0.002
Ethnicity
White155/50230.881.0001.000
Black7/6710.450.2610.241
Asian11/6417.190.4650.551
Other7/4017.500.4750.577
χ2 3d.f. = 20.37 P < 0.001χ2 3d.f. = 14.44 P = 0.002
Employment
Employed110/37529.331.0001.000
Unemployed37/9538.951.5371.594
Student21/8624.420.7780.624
Otherb11/1149.650.2570.351
χ2 3d.f. = 28.96 P < 0.001χ2 3d.f. = 14.98 P = 0.002
Marital status
Single112/32134.892.7772.298
Married/cohabiting44/27216.181.0001.000
Divorced/separated23/5839.663.4053.327
Widowed1/234.350.2360.722
χ2 3d.f. = 40.14 P < 0.001χ2 3d.f. = 17.73 P < 0.001
Alcohol prior to attendancec
Yes65/9667.718.5366.912
No113/57319.721.0001.000
χ2 1d.f. = 85.34 P < 0.001χ2 1d.f. = 57.62 P < 0.001
Alcohol related accident/injuryd
Yes38/5865.526.390
No135/58922.921.000
χ2 1d.f. = 42.50 P < 0.001

Adjusted odds ratios did not vary greatly from unadjusted odds ratios. Adjusted results suggested that young people had nearly twice the odds of scoring highly on the AUDIT, compared to those over 25 years. Non-white ethnic groups had lower odds of scoring 8 or more, and the unemployed, divorced, separated, or single individuals had higher odds of scoring 8 or more. Those drinking in the 6 h prior to attendance at A&E had seven times the odds of scoring highly, compared to those who had not been drinking.

Strong evidence of interaction was detected between age and sex (P = 0.007). Among 16- to 24-year-olds, there was no difference in the odds of males and females scoring 8 or more on the AUDIT (P = 0.792 after adjustment), although among older respondents, males were nearly three times more likely to score 8 or above, compared to females (OR = 2.845, P < 0.001 after adjustment).

DISCUSSION

This study confirms the potential to identify considerable numbers of young people whose attendance at A&E departments is related to alcohol use and problem drinking. As expected, a high proportion of A&E attendances by young people were related to alcohol use and it is notable that, among the under 25-year-olds, young women were as likely as young men to present with alcohol-related injuries or conditions. The recognition by some patients, especially in the younger age group, that alcohol was a factor in their attendance, is an indication that brief interventions, if appropriately developed and targeted, may prove fruitful.

Even among those reporting that they had not consumed alcohol in the 6 h prior to attendance, almost 30% of young people scored 8 or more on the AUDIT. Whether or not drinking prior to attendance was accurately reported by this group, the figure emphasizes the usefulness of using a screening instrument sensitive enough to detect hazardous drinking in young people, rather than relying entirely on self-report or on detection methods, such as ‘alcohol on the breath’. It also indicates the need to acknowledge the heterogeneity of drinking patterns and attitudes to drinking among young people when developing future preventive and intervention approaches in A&E departments.

Earlier studies (Green et al., 1993; Smith et al., 1996; Wright et al., 1998) have already demonstrated that it is possible to screen and respond positively within A&E settings to problem (hazardous and dependent) drinking. Currently, there is interest in developing the role of A&E departments to screen and intervene in a broader range of alcohol-related attendances, including attendances related to intoxication, binge drinking, and hazardous, but non-dependent, drinking patterns. At the same time, other data from this study (Herring and Thom, 1999) and from elsewhere (Peters et al., 1998; Waller et al., 1998) reveal considerable barriers to developing such a role.

The nature of A&E care and the structure and organization of A&E departments present difficulties for staff expected to respond to an increasing range of preventive activities (Herring and Thom, 1999). One major factor is the time required to screen. The AUDIT takes approximately 2 min to complete and score (Conigrave et al., 1995). Other instruments, such as the Paddington Alcohol Test take only 1 min (Smith et al., 1996). Identification of an effective screening instrument which can be applied speedily within A&E procedures, which will identify non-dependent (hazardous) as well as dependent drinkers and be effective in screening younger patients, and which is acceptable to staff, is a prerequisite for encouraging routine screening beyond a few committed A&E departments.

Barriers also arise from attitudes towards alcohol use, perceptions of the role of A&E departments in responding to alcohol-related attendances and the limited training of staff in alcohol issues. As Peters et al. (1998) commented, the attitudes of nursing staff are crucial. In their study, the majority of the nursing staff interviewed claimed a holistic approach to health care, but did not equate this with the incorporation of screening and health promotion activity into the routine triage examination. Interviews with nurses conducted in the course of the current study found that attendances related to intoxication tended to be accepted as ‘normal’, and intervention was seen as inappropriate in the case of injured patients who had been drinking (Herring and Thom, 1999).

Such barriers are particularly pertinent in considering responses to young people. It is easier to argue for screening for dependent drinking where referral to specialist services or (in rare circumstances) to a specialist A&E nurse is a possibility. But it is more difficult to encourage screening for harmful, non-dependent drinking among young people if there are insufficient support services either within the hospital or the community. Clearly, A&E departments have a role to play in responding to harms related to youthful drinking. Such a role is unlikely to flourish, unless it is part of an integrated programme of activities involving partnership between local schools and colleges, the youth service, criminal justice workers, and health promotion specialists.

Questions remain, therefore, as to how best to encourage A&E departments to extend their role in screening for alcohol-related attendances, especially those of a non-dependent nature; which screening procedures and screening instruments are best suited for routine application in A&E departments; and whether intervention with young people — possibly in the form of ‘brief interventions' — is a viable option in this setting. There is no doubt that A&E departments could play an important community role in monitoring and responding to alcohol-related harm. But if policy is to drive A&E departments in that direction, the above issues and questions must be addressed and the cost effectiveness of routine screening and intervention in A&E departments demonstrated. Equally, however, the need for appropriate resources and support in A&E departments must be acknowledged and steps taken to put supportive structures in place before negative attitudes and organizational difficulties hinder the implementation of screening and intervention initiatives and reinforce current reluctance to engage in alcohol work. Existing models of good practice merit extension and trial in a wider range of A&E settings and alternative forms of response, including brief interventions, require pilot studies to determine an appropriate range of effective interventions suitable for targeting different patient groups and different types of alcohol-related A&E attendances.

Acknowledgments

We would like to thank Daisy Hayden and Debbie Crisp for their assistance in the execution of this study and members of staff of the two hospitals for their collaboration. Mr Robin Touquet and Ms Seonaid Wright provided valuable comments and assistance. The study was funded by the North Thames Regional Health Authority. The Centre for Research on Drugs and Health Behaviour acknowledges the financial support of the North Thames Office of the NHS Executive.

Footnotes

  • * Author to whom correspondence should be addressed.

REFERENCES

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