Alcohol use in the UK is associated with a high level of morbidity and mortality. The latest figures from the Office for National Statistics indicate that alcohol-related deaths have more than doubled over the last 15 years,¹ with 23% of all males and 9% of all females consuming at least double the Department of Health-recommended units on one or more occasion per week.² The Prime Minister’s Strategy Unit³ has estimated that alcohol misuse costs the National Health Service £1.6 billion/year, with attendances at accident and emergency departments (AEDs) accounting for one-third of the total. Considering that up to 70% of all AED admissions at peak times⁴ are associated with alcohol misuse, it is apparent that this is an ideal location to both detect hazardous drinkers, and to offer help and advice to reduce their consumption.^5–7

It is now 2 years since the publication of the first UK alcohol harm reduction strategy. A survey by Owens et al⁸ examined the impact of the strategy in general hospital settings, concluding that most did not have appropriate services to deal with patients presenting with alcohol-related problems. To determine the extent to which the recommendations for the provision of alcohol screening and brief interventions have been adopted by AEDs, we have undertaken a survey of departments in England.

METHODS

As part of a larger study investigating the impact of the changes in the licensing act (2004)⁹ on alcohol-related attendances to AEDs,¹⁰ the researchers made contact with the lead consultants of all 191 type 1 AEDs in England.

Survey design

The questionnaire consisted of the following five items:

• Do you ask patients about their drinking or screen for hazardous drinking?

• Do you measure blood/alcohol level (routinely/as necessary/never)?

• Do you record alcohol-related attendances in the notes?

• Do you offer advice or treatment to people with alcohol problems?

• Do you have access to an alcohol health worker or nurse specialist?

Procedure

This study was endorsed by both the British Association of Emergency Medicine and the College of Emergency Medicine. During March 2006, the brief questionnaire was posted to each lead consultant. A second wave of questionnaires was sent during April 2006. After 1 month, all remaining non-respondents were contacted by telephone.

Data analysis

The data from the survey are presented descriptively.

RESULTS

Responses were received from 189 departments (98.9% response rate). For the assessment of regional variation, departments were determined to be located in northern (31.6%), midlands (15.3%), south west (11.1%) or south east (42%) areas.

Table 1 summarises the results of the survey. Only 4 (2.1%) departments admitted to using a formal screening tool to identify hazardous drinkers; however, 24 (12.7%) departments did ask general questions about consumption. Blood alcohol levels were measured as required by 100 (52.7%) departments. No departments routinely measure blood alcohol, and 84 (44.4%) departments never assess blood alcohol levels. Alcohol-related attendances were formally recorded by 131 (69.7%) departments, with 21 (10.1%) actually annotating the patients’ electronic record. Most departments (73.9%) offered advice on alcohol problems; however, less than half of all departments offered treatment (44.4%). Access to an alcohol health worker or a clinical nurse specialist was reported by 32 (16.9%) departments.

Table 2 shows a breakdown of departmental responses by geographic region (south east, south west, midlands and northern). There was a significant difference in the proportions of departments in each area that were asking general questions about alcohol consumption (χ² = 15.2, df = 6, p<0.05); however, no other significant differences were identified.

DISCUSSION

This study has a response rate of almost 99%, the largest response rate of any survey of English AEDs. To achieve this rate, survey questions were kept to a minimum. This meant that detailed data on the management of alcohol problems in the departments were not collected; nonetheless, this study provides an important snapshot of current practice.

The number of departments requesting blood alcohol levels, recording alcohol-related attendances and offering advice on alcohol-related problems is encouraging. However, these data must be critically reviewed in the context of an AED culture, where very few departments actually employ formal screening procedures to identify hazardous and harmful drinkers. It is likely that, in the absence of such formal procedures, AED staff will rely on their judgement or intuition to identify those patients who they believe may benefit from advice or treatment, which we know to be less reliable than formal screening.¹¹

The measurement of blood alcohol levels occurs in about half of all departments as required. Such measures may be useful in the detection of hazardous or harmful levels of alcohol consumption among those patients who are either unable or unwilling to complete a verbal assessment.^12–14 The substantial minority of departments that do not assess blood alcohol levels further reduce their likelihood of identifying alcohol-misusing patients.

The Alcohol Needs Assessment Research Project survey¹⁵ identified the northern region of England (north east, north west and Yorkshire) as having the largest proportion of hazardous and harmful drinkers. Despite this, only 11% of departments in the northern region ask questions about alcohol consumption. Clearly, there are regional inconsistencies in the way departments identify and address alcohol-related problems; however, reasons for this remain uncertain.

The results of this survey suggest that English AEDs are aware of the role that alcohol plays in the aetiology of admissions and that they are willing to address alcohol issues as part of their package of clinical care. The low numbers of departments asking specific questions about alcohol consumption and its relationship to a patient’s reason for attendance, and those who do not undertake assessment of blood alcohol levels as required are of concern. Presentation to the AED is a teachable moment.¹⁶ Simply asking questions about consumption can act as an intervention and reduce levels of alcohol consumption.¹⁷ Why do AEDs continue to treat the consequences of alcohol misuse without addressing the underlying cause? Clinicians may be unwilling to identify hazardous drinkers as they do not believe that they are able to offer an effective intervention themselves, or offer access to appropriate local services (such as an alcohol health worker or clinical nurse specialist).^18,19 There is some evidence to suggest that clinicians’ own patterns of alcohol consumption may encourage a state of clinical inertia.^20,21

The current Department of Health trailblazer projects²² should provide definitive recommendations as to the most appropriate methods of screening and intervention. Before the dissemination of the results in 2009, we recommended that all AEDs consider formal methods of identifying hazardous drinkers such as the Single Alcohol Screening Question²³ or Paddington Alcohol Test.²⁴