1. CNMHP Judith Morgan RN MA BSC CMS ONC Consultant Nurse in Emergency Care ABM University NHS Trust Alcohol Misuse & ED Screening Alcohol Misuse & ED Screening

2. CNMHP Objectives 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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4. Facts & 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

5. CNMHP 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

6. CNMHP 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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8. Calculating 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.

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

10. CNMHP 1 unit = 8g

11. CNMHP Effects of Alcohol on the Body (8g = ½ 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

12. CNMHP Effects of Alcohol on the Body (8g = ½ lager) Moderate intoxication: 150 - 300 mg/ 100mls:. Visual impairment; Sensory loss; Impairment of motor skills and slurred speech.

13. CNMHP Effects of Alcohol on the Body (8mg = ½ lager) Severe intoxication/ coma. 300 - 500 mg/ 100 mls. Hypothermia Motor skills markedly impaired Blurred vision Occasional hypoglycaemia & convulsions

14. CNMHP Effects of Alcohol on the Body (8mg = ½ 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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16. 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

17. CNMHP Alcohol & Falls J J E Johnston, S J McGovern Emerg Med J 2004; 21:185-188] 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

18. CNMHP What ED Presenting Complaints Relate Directly to Alcohol Assault – 50 to 73% alcohol related (Luke 1998)

19. CNMHP 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).

20. CNMHP Paediatric ED Attendances Attendance ED summer 2004: 60 children (0.4% of new attendees) 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.

21. CNMHP Alcohol & 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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23. Government screening: April 2008: Mandatory WAG data capture 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

24. CNMHP Government screening: 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

25. CNMHP Screening Tool in ED Use Paddington Alcohol Test (PAT)

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27. Paddington Alcohol Test (PAT) 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

28. CNMHP Paddington Alcohol Test (PAT) 1.Do you drink AlcoholYes No: (end) 2.What is the most you will drink in any one day Standard alcohol units see next slide for details of alcohol units

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

30. CNMHP How often do you drink more than twice the recommended amount? Every day = dependent drinker (PAT +ve) X times per week = Hazardous drinker (PAT +ve) Never / less than weekly

31. CNMHP Further 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)

32. CNMHP Effects 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).Freemantle et al. 1993Kahan et al. 1995Wilk et al. 1997Moyer et al. 2002Ballesteros et al. 2004 64% (n=281) of adult hazardous drinkers identified by PAT accepted brief advice (Patton et al 2003)