The effect of referral for brief intervention for alcohol misuse on repetition of deliberate self-harm: an exploratory randomized controlled trial.

BACKGROUND: Referral for brief intervention among people who misuse alcohol is reported to be effective but its impact among those who present to services following deliberate self-harm (DSH) has not been examined. METHOD: Consecutive patients who presented to an Emergency Department (ED) following an episode of DSH were screened for alcohol misuse. Those found to be misusing alcohol were randomly assigned to brief intervention plus a health information leaflet or to a health information leaflet alone. The primary outcome was whether the patient reattended an ED following a further episode of DSH during the subsequent 6 months. Secondary outcomes were alcohol consumption, mental health and satisfaction with care measured 3 and 6 months after randomization. RESULTS: One hundred and three people took part in the study. Follow-up data on our primary outcome were obtained for all subjects and on 63% for secondary outcomes. Half those referred for brief intervention received it. Repetition of DSH was strongly associated with baseline alcohol consumption, but not influenced by treatment allocation. There was a non-significant trend towards the number of units of alcohol consumed per drinking day being lower among those randomized to brief intervention. CONCLUSIONS: Referral for brief intervention for alcohol misuse following an episode of DSH may not influence the likelihood of repetition of self-harm. Longer-term interventions may be needed to help people who deliberately harm themselves and have evidence of concurrent alcohol misuse.

Resuscitation room blood alcohol concentrations: one-year cohort study.

OBJECTIVE: To clarify the relationship between presenting clinical condition and blood alcohol concentration (BAC) among adult patients admitted to a resuscitation room (RR) of an emergency department (ED) in order to help guide clinical practice. METHOD: Single-site prospective cohort study of all patients admitted to the RR of an inner-city hospital over a one-year period. The study sample comprised all those aged 16 years and over from whom a blood sample was taken, with BAC (results not known to ED staff), pathology by International Classification of Diseases (ICD) version 10 coding, injury severity score for trauma, return visit to hospital and mortality during the subsequent 6-month period, being recorded. RESULTS: 291 (15%) of 1908 presentations had a positive BAC (ie, BAC >10 mg/100 ml) ranging from 11 to 574 mg/100 ml, of which almost 40% were over 240 mg/100 ml (ICD-10 code Y90.8). In addition to collapse from alcohol/drugs, almost half of those presenting following self-harm or assault had a positive BAC. Those with a positive BAC had a higher rate of ED re-attendance in the following 6 months. 10% of all presentations were due to trauma. CONCLUSION: The following five presentations to the RR are associated with a positive BAC: collapse from alcohol/drugs, self-harm, trauma, gastrointestinal bleeding (ICD-10 code K92.2) and non-cardiac chest pain (ICD-10 code R07). Patients with a positive BAC demonstrate a very wide range of pathology, some with severe levels of misuse. This highlights the opportunity for prompt feedback when sober, to ensure all is done to encourage patients to contemplate change in order to reduce re-attendance.

Hazardous drinkers in the accident and emergency department--who attends an appointment with the alcohol health worker?

AIMS: To identify factors that predict attendance at a brief assessment and referral session among patients identified as hazardous drinkers while being treated in an accident and emergency department. METHODS: Patients presenting to an accident and emergency department (AED) were screened using the Paddington Alcohol Test (PAT). All patients identified as hazardous drinkers were given written information and offered an appointment with an alcohol health worker (AHW) to discuss their drinking. Data was collected on patients' age, gender, presenting condition, and alcohol consumption. Binary logistic regression was used to identify variables that predicted attendance at the appointment with the AHW among those who accepted advice. RESULTS: Patients who attended the appointment were older than those who did not. Those who believed their attendance in the AED was related to alcohol were also more likely to receive brief intervention. CONCLUSIONS: Clinicians should explore patients' perceptions of the link between their alcohol consumption and AED attendance, and where appropriate emphasise the potential association.

Hazardous drinkers in the accident and emergency department--who accepts advice?

AIMS: To identify factors that predict acceptance of brief advice among people consuming excessive alcohol in an accident and emergency (A&E) department. METHODS: Patients presenting to an A&E department were screened using the Paddington Alcohol Test. All patients identified as hazardous drinkers were offered advice about their drinking. Data were collected on patients' age, sex, presenting condition, and alcohol consumption. Binary logistic regression was used to identify variables that predicted acceptance of the offer of advice. RESULTS: The presenting condition, together with the total number of units consumed on a single occasion, predict the uptake of an offer of help. CONCLUSIONS: Patients identified as hazardous drinkers who present after a fall, head injury, or other accident are less likely to accept help. Clinicians should emphasise the potential relation between alcohol consumption and health related consequences to encourage the uptake of advice for these patients.

Impact of health consequences feedback on patients acceptance of advice about alcohol consumption.

OBJECTIVES: To demonstrate the impact of health consequences feedback on patients willingness to accept advice about drinking. METHODS: 281 patients identified as hazardous drinkers were offered advice about alcohol consumption. During the experimental period patients' were given feedback as to the health consequences. RESULTS: Introduction of feedback led to a 23% increase in the proportion of patients who were willing to accept brief advice. CONCLUSIONS: Feedback provision should be included as part of Screening and Brief intervention programmes to increase the number of patients that may benefit from an intervention.

Improving detection of alcohol misuse in patients presenting to an accident and emergency department.

OBJECTIVES: To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT). Design-Prospective study of the effects of audit feedback. SETTING: An urban accident and emergency department. SUBJECTS: Senior house officers (SHO) (n = 13). OUTCOME MEASUREMENTS: PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT. RESULTS: 1062 of 1737 patients (61.1%) were defined as PAT possible-that is, presented with > or = one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p<0.0001). The response to audit and feedback showed marked inter-SHO variation. When feedback was withdrawn (month 4), there was a significant reduction in PAT use (p=0.003). Three other indices of detection followed this trend: (a) number of PAT positive patients identified, (b) proportion of PAT possible patients identified as PAT positive, and (c) number of PAT positive patients referred to the alcoholic health worker. The 10 most common PAT positive categories, accounting for 77% of all PAT positive complaints were: fall > collapse (including "fit", "blackout") > head injury (including "facial injury") > assault (including "domestic violence" and 'other') > nonspecific gastrointestinal problem > "unwell" > psychiatric (including "depression", "overdose", "confusion") > cardiac (including "chest pain" and "palpitations") > self neglect > repeat attendance. CONCLUSIONS: Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.

Intervention by an alcohol health worker in an accident and emergency department.

We have evaluated the effect of brief intervention by an alcohol health worker on alcohol consumption by 202 alcohol misusing patients. For 71 patients where questionnaires were successfully completed, 46 (65%) reported drinking less alcohol at 6 months as opposed to six (8.5%) who reported drinking more. The overall reduction was statistically significant (P < 0.001), with a mean reduction of 43%.

Patients unaware of their HIV status present to inner city accident and emergency department with respiratory complications.

OBJECTIVE: To examine the clinical presentations and management of patients presenting to an accident and emergency (A&E) department with an AIDS defining illness (ADI). METHODS: Presentations of patients in the A&E department with ADI were reviewed retrospectively. The age, sex, ethnic origin, risk factor for HIV infection, route of referral to hospital, presenting complaint, triage category, referral from A&E, admission under medical specialists, diagnosis, and survival from ADI were noted for each patient. RESULTS: 133 patients were registered at St Mary's Hospital in London with ADI during 1994. A significant minority of these patients (25/133) presented to the hospital without prior knowledge of their HIV positive status. Thirty two patients presented to the A&E department with their ADI. Of these, 13/32 (41%) were unaware of the HIV serostatus. All 13 patients had an acute respiratory disease (Pneumocystis carinii pneumonia or pulmonary tuberculosis). In contrast, patients aware of their HIV positive status (19/32) presented to the A&E department with a wide range of non-pulmonary ADI. CONCLUSIONS: The study emphasises the importance of respiratory complications in patients who present with a ADI to emergency departments but are unaware of their HIV positivity. These patients presented solely with Pneumocystis carinii pneumonia or pulmonary tuberculosis, conditions in which early diagnosis and treatment significantly reduce morbidity and mortality.

Detection of alcohol misusing patients in accident and emergency departments: the Paddington alcohol test (PAT)

OBJECTIVE: To develop an effective but practical screening questionnaire for use by accident and emergency (A&E) staff to detect alcohol misuse early on in its natural history, without unreasonably prolonging patient waiting times; and to integrate an alcohol health worker (AHW) into A&E to provide counselling for referred patients. METHODS: Two pilot studies for adult patients were undertaken to develop the 1 min Paddington alcohol test (PAT), which has only three compulsory questions for detecting alcohol misuse: two cover peak consumption and frequency of possible binge drinking, and the third asks whether in the patients' view their attendance at A&E was alcohol related. The use of the PAT was validated in "appropriate" adult patients over a one year period. Patients found to be positive were invited to attend the A&E review clinic for counselling by the AHW. RESULTS: The development of the PAT resulted in a referral rate of one patient per 158 A&E adult attenders, facilitating a counselling rate of one patient per 263 A&E adult attenders by the AHW. This counselling rate is a 10-fold increase on the rate of one patient per 2610 adult attenders found in a study undertaken during 1988-90. CONCLUSIONS: The use of the PAT is one practical method for A&E staff to detect the alcohol misusing patient for referral to a departmental alcohol health worker.

The cost of overseas visitors to an inner city accident and emergency department.

OBJECTIVE: To estimate, in a metropolitan accident and emergency (A&E) department, the annual cost of treating overseas visitors whose countries of origin do not have reciprocal arrangements with Britain. METHODS: The study was retrospective. A 24 h period (00.01 h to 24.00 h inclusive) on consecutive days in consecutive weeks (that is, Monday in week 1, Tuesday in week 2, etc) was costed over 52 weeks (1.8.92-31.7.93 inclusive) and extrapolated to 365 days. All visitors between those dates were divided into eligible (from countries with a reciprocal agreement) or non-eligible (from countries without a reciprocal agreement). Costs were calculated for medical and nursing care, investigation and treatment, and fixed costs. RESULTS: The annual St Mary's Hospital A&E budget for the study period (01/08/92 to 31/07/93) was 2,612,200 pounds; the average medical and nursing cost per major or minor case was 66.88 pounds and 20.08 pounds respectively. Investigation, treatment, and fixed costs were 16.31 pounds per patient. In total 2704 non-eligible patients (498 major and 2206 minor cases) were treated at a cost of 121,705 pounds (95% confidence interval 114,234 pounds to 129,176 pounds), which was 4.7% of the total annual budget. CONCLUSIONS: The cost of non-eligible patients to the NHS is substantial. One possible solution would be for visitors from countries which do not offer subsidised emergency treatment to British nationals to purchase health insurance compulsorily on or before entry to Britain. The revenue could be used to improve standards of care for all A&E patients.

Primary care in London: an evaluation of general practitioners working in an inner city accident and emergency department.

OBJECTIVE: To determine the characteristics of primary care attenders to St Mary's Hospital accident and emergency (A&E) department, evaluate the effects of the introduction of general practitioners (GPs) on patient care in A&E, and make recommendations for the provision of GPs in appropriate A&E departments. DESIGN: Prospective survey over a six week period. METHODS: Data collected from the attendances of 970 consecutive patients triaged with "minor" primary care problems, whether seen by A&E doctors or by GPs working in A&E, were analysed. RESULTS: During the study period 1078 patients (16.6%) were triaged as suitable for primary care. The A&E GPs saw 58.4% of these patients. The majority of primary care patients were young British residents, 71.1% of whom were registered with a GP. Sixty per cent of patients lived within St Mary's catchment area. Of those registered patients asked why they attended A&E, 27.1% thought their problem inappropriate for their GP. A&E doctors were more likely to investigate patients and arrange hospital follow up than GPs, who arranged community follow up in 80% of patients needing further care. CONCLUSIONS: The demand for primary care at St Mary's necessitates the provision of a primary care service, albeit for the first visit only. This can be provided by GPs in A&E. The features of the patients using the service suggests that discouraging first attendance is unrealistic, but using the visit to educate patients and return them to the care of the community is not.