Accident and Emergency

The mixture of alcohol and young people is putting a huge strain on the National Health Service and action needs to be taken now.

Dr Chris Luke, Accident and Emergency consultant at the Royal Liverpool University Hospital, painted an alarming picture when he spoke at the Alcohol and the Young conference, hosted by the Royal College of Physicians. Dr Luke outlined the burden which alcohol placed on the NHS:

  • 1 in 4 acute male admissions

  • Over 28,000 hospital admissions (figures for 1994-5) due to alcohol dependence or the toxic effects

  • Over 4,000 deaths directly attributable to alcohol in England and Wales (1995) compared with 1,620 deaths associated with other substance misuse

  • Over 33 per cent rise in alcohol-related deaths since 1984 (higher for those aged under 45)

  • Alcohol implicated in 28,000 - 50,000 deaths

  • £164 million on care of related problems (in-patient and general practice)

Accident and Emergency departments are particularly hard hit. Dr Luke gave some stark figures on the relationship of alcohol with emergency medicine, pointing out that in the typical A&E departments of one major city, Manchester, around three quarters of patients attending after midnight are drunk. In addition the following are alcohol related:

  • 50-73 per cent of assault victims' injuries:

  • Around 50 per cent of all serious road crashes

  • Nearly 50 per cent of domestic violence against females

  • 47 per cent of serious injuries

  • 40 per cent of self-poisonings

  • 30 per cent of injuries to pedestrian victims of road traffic accidents (and 53 per cent of serious injuries to drivers)

  • Just under 22 per cent of serious acute orthopaedic admissions (in his own hospital in Liverpool)

  • 20 per cent of inappropriate ambulance calls

As far as young people are concerned, Dr Luke said that alcohol, our society's most problematic drug, is consumed by the vast majority. Although cider and beer are the most popular drinks rather than alcopops, the industry has increasingly targeted young people in the last decade. The '90s have seen alcohol featuring more and more as a gateway to illicit drugs. He emphasised the scale of consumption among young people, stating that:

  • 29 per cent of boys and 26 per cent of girls aged 10 to 13 consume alcohol, three quarters of whom reported being drunk

  • 1,000 children under 14 and over are hospitalised every year with alcohol-related presentations

  • "Virtually all" 15-16 year olds have consumed alcohol

  • 89 per cent of undergraduates drink (28 per cent binge)

  • Binge drinking is a common and hazardous pattern of drinking in 16-24 year olds.

Young women have particular problems caused by alcohol. Among them, professionals in the 18-24 age group drink most and have the highest level of dependence. In the medical world it has been estimated that 10 per cent of nurses have a problem with alcohol or other drug misuse (see Don't Carry On, Doctor, page 8).

Surveys in Liverpool, the city in which Dr Luke works, also indicated that 1.6 per cent of the population had major overt medical problems due to alcohol dependence. This figure was reached from a study of GPs records, for example incidence of alcoholic liver disease or rate of prescribing of librium, heminevrin, and thiamine. Liverpool also shows 29 per cent of drink-driving convictions and 39 per cent of arrests for drunk-disorderly among those aged 18 to 25. In one two month period, 169 patients under 18 years old were admitted to the Royal Liverpool University Hospitals with alcohol-related presentations.

Dr Luke presented evidence from the Royal Liverpool Children's Hospital, better known as Alder Hey. The figures are extremely alarming:

  • 17 per cent of 11-15 year olds drink regularly (at an average of 3.5 pints of beer a week)

  • 10 per cent of boys and 8 per cent of girls aged 15-16 are drinking in excess of the recommended adult limits

  • 30 per cent of boys and 20 per cent of girls have drunk around 6 pints on one occasion

  • There has been a ten-fold increase in alcohol-related paediatric attendances during the past decade.

Dr Luke concluded by saying that "alcohol is a major threat to an over-loaded UK healthcare system". What was needed was "a national co-ordinated alcohol strategy [involving] legislation, licensing, education, enforcement, monitoring, advertising, and research." He said that A&E departments' role was central.

They were the "natural starting points", they constituted a national network, and were a logical place for intervention by way of rescue and rehabilitation. He stressed the importance of training the people who worked there and suggested the establishment of a system of alcohol specialist nurses.

Chris Luke is far from alone in drawing attention to the increasing burden which alcohol is placing on the NHS and Accident and Emergency departments in particular. In an important article in the journal, Alcohol and Alcoholism, *researchers from the Health Education Authority and the Centre for Research on Drugs and Health Behaviour report the findings of a questionnaire sent to 224 A&E departments in England. They looked for information on all attendances related to alcohol, "including acute alcohol poisoning, alcohol withdrawal, alcohol-related accidents in the home and workplace, road traffic accidents, self-injury and assault." There was a 96 per cent response rate and so, it must be assumed, we have an accurate picture of the national problem.

It emerges that there is little systematic recording or enquiry about the involvement of alcohol in any patient's attendance. "Few departments routinely enquire about and record alcohol consumption even where patient records are computerised. The most common screening procedures reported were to note if an attendance was observed to be alcohol-related, judging by smell of alcohol on the patient's breath, or by the patient's behaviour." Enquiries of the patient as to level of consumption were only made "if alcohol dependence/problem was suspected."

Respondents were asked about what interventions hospitals made in cases of alcohol-related attendance. Referral to outside specialist services was the most frequent course taken. It was more often nurses than doctors who gave patients verbal or written advice on services or on alcohol generally. Such advice as was given "was mostly described as information on sensible drinking levels and on units of alcohol." It was not apparent whether any assessment of dependence was made prior to discussing "sensible" levels.

The question as to the proportion of attendances in A&E which were alcohol-related was difficult because of the "lack of procedures and guidelines for consistent record keeping even in departments where patient records were computerised." The estimates provided (from 53 per cent of nurse and 62 per cent of doctor respondents) were based on their own perception, more or less subjective as these might be. The doctors said that, of all attendances, 16.3 per cent were alcohol-related, the nurses 19.3 per cent. This provides a figure of about one in six A&E attendances as alcohol-related. In the case of one particular average-sized hospital in a largely rural area, there were 30,208 attendances in the A&E department in the year 1997/98. This would mean, according to the research, that about 5,000 were alcohol-related. This in turn gives a rough figure for all 224 hospitals of 1.1 million alcohol related attendances in one year.

More than 50 per cent of respondents could not estimate the proportions of the different types of alcohol-related attendances, although all respondents said that assault was the most prevalent. (30-35 per cent).

Nurses were more positive than doctors when asked about any preventative role which A&E departments might play: "Only about one in five nurses thought that there was nothing A&E departments could do to help patients change their drinking behaviour compared with one third of doctors. Equally, attitudes towards intervention in the form of brief advice were favourable." A real need for staff training emerged. 80 per cent of nurses and 65 per cent of doctors said that this was necessary, although it might be seen as worrying that almost a quarter of doctors felt otherwise. It is interesting to note that a third of nurses and doctors disagreed with the statement, "Responding to alcohol-related attendances in A&E requires the presence of a staff member trained in alcohol-related issues." It is often argued that alcohol and other drugs are inadequately dealt with in medical schools.

The authors of the report make the point that "current interest in finding ways to prevent or minimise the harms resulting from intoxication, heavy episodic or binge drinking, or dependent drinking...invites scrutiny of potential for A&E departments to develop a prevention and intervention role in detecting and responding to alcohol-related attendances... The results from the survey of A&E departments in England have established that few departments have detection procedures or intervention practices, and that staff perceive considerable barriers to the adoption of a preventative role." Nurses in particular, however, are positive about improving the way in which alcohol-related attendances are handled. It may well be sensible to utilise the expertise of the specialist agencies in training medical staff at least in skills of identification and the delicate matter of questioning patients - an area in which most respondents found considerable difficulty. Certainly, it is evident that the present methods of ascertaining whether alcohol is involved in any A&E attendance are totally inadequate. They are also more than likely to result in underestimates of the problem. Hard worked casualty nurses may well notice patients who are roaring drunk or who smell highly of alcohol, but those who have sustained injuries as a result of dependent drinking might often not be so easy to spot, given the skills in concealment and high levels of tolerance which accompany the condition.

The report concludes: "Clearly there is potential for A&E departments to play a major role in the response to alcohol related problems. Mobilising and sustaining support for the development of preventive approaches in A&E departments presents a challenge which can only be addressed by the development of clear guidelines for good practice".

More generally, the research highlights once again the need for alcohol problems to be treated in greater depth when training both doctors and nurses. The scale of the cost to the NHS is also implicit in the findings.

*Alcohol and Alcoholism (Vol.33 No4 July/August 1998)

IAS Comment

Alcohol is overwhelming the National Health Service. The problems facing Accident and Emergency staff are increasing as their departments fill with the casualties of booze, often under-age drinkers. As a contribution to the mounting mayhem, the Government is prosposing a thirty-six hours drinking spree to mark the turn of the millennium. One A&Econsultant spoke of Armageddon for the NHS. The language may have been colourful but it reflects a real alarm at the prospect of break-down under the strain of alcohol-related injuries. It is a rich irony that Alan Milburn, the junior health minister, should choose this moment to focus on assaults on NHS staff: "This Government values NHS staff. We are determined that the NHS should provide an environment in which staff can go about their business without fear of violence."

In this edition of Alert the problems facing A&E departments are discussed, as are the plans for the millennium. In contrast, we also report the statement recently issued by the Ministerial Group on Alcopops. In this the Portman Groups comes in for considerable praise and clearly the Government is looking to this drink-industry-funded organisation for a lead in combatting the problem of under-age drinking. It is good that proof of age schemes and other measures are having some success, but essentially this is tinkering with the question. Ask doctors and nurses working in Accident and Emergency departments whether they think that much progress is being made and they would laugh in your face. Teenagers attempting to buy alcohol in an off-licence is a symptom. The real problem lies in a society which implants the desire to drink in the first place. Advertising codes are all very well, but again they deal only with a tiny area. Of course it is wrong deliberately to target the young with images designed to appeal specifically to them. But what about the vast majority of alcohol advertising? The young are susceptible to appeals to sophistication, or to masculine bravado, or fashionabilty, or to their sense of humour as much as they are to cartoon characters or amusing frogs. They are impressed by sporting heroes emblazoned with the emblems of breweries.

The Ministerial Group needs to look further and deeper. And it should listen to the public health lobby rather than the industry.