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The burden of alcohol misuse on an inner‐city general hospital

M. Pirmohamed, C. Brown, L. Owens, C. Luke, I.T. Gilmore, A.M. Breckenridge, B.K. Park
DOI: http://dx.doi.org/10.1093/qjmed/93.5.291 291-295 First published online: 1 May 2000

Abstract

Alcohol consumption in the UK has been increasing steadily. We prospectively studied the burden on hospital services caused by overt alcohol misuse, in an inner‐city hospital in north‐west England. All Accident & Emergency (A&E) patients were assessed to determine whether their hospital attendance was alcohol‐related, and whether this resulted in admission and/or generated new out‐patient appointments. Over 2 months, 1915 patients attended A&E with alcohol‐related problems, accounting for 12% of attendances; 50% were aged 18–39 years, and acute alcohol intoxication was the commonest presenting complaint. Overall, 6.2% of all hospital admissions were due to alcohol‐related problems. Over 2800 new out‐patient visits were likely to have been generated over an 18‐month period from initial attendance with an alcohol‐related problem, mostly for orthopaedic clinics. The burden placed by overt alcohol‐related problems on hospitals is enormous, both in terms of the emergency and out‐patient services. The implementation of education, screening and intervention strategies in A&E departments, and employment of key trained personnel, should be considered, to optimize the clinical management of these patients.

Introduction

The harmful effects of alcohol on the individual and society have received a great deal of media attention recently. This underlies the fact that alcohol consumption in the population as whole is increasing steadily; for example, between 1970 and 1995, annual alcohol consumption rose by between 2 and 3 litres of pure alcohol per person, and the steady increase in consumption has continued to the present day.1 Currently 1 : 4 men and 1 : 10 women are believed to be drinking above 21 and 14 units a week, respectively.2 Alcohol consumption in the young and in school children also seems to be increasing.3 This is likely to lead to the development of alcohol dependence at an earlier age in a proportion of young drinkers, and the subsequent development of physical complications, increasing the potential burden of alcohol‐related illnesses on the health‐care system.

Reduction of alcohol consumption is one of the health priorities of the NHS1 and WHO.4 To determine whether the targets have been achieved, it is important to have relevant data on the size of the current problem and its burden on the health‐care system. Several studies over the last 20 years or so have examined the size of the problem, and its effect on the use of emergency hospital services.5–11 However, most have been relatively small, were done at least a decade ago, or have concentrated only on single specialties without taking into account the overall burden. For example, with any acute condition, the initial use of emergency services forms only part of the burden placed on a hospital, since many of the patients may need admission for variable periods, and following discharge, many of these patients need to be followed up in the out‐patients department.

To address these issues, we undertook a 2‐month prospective survey in the Royal Liverpool University Hospital, which has the largest Accident & Emergency Department in Europe.

Methods

The hospital serves a population of approximately 300 000 individuals over the age of 16 years. Although near the city centre, it serves a wide area of Liverpool, ranging from highly prosperous to grossly underprivileged areas (the underprivileged area scores based on the 1991 census range from −9 for the former areas to +57 for the latter; data provided by Liverpool Health Authority). The Jarman index for Liverpool, a marker of deprivation, is 82.12 Patients under 16 years of age are served by a separate children's hospital in the city which has its own A&E department.

The majority of admissions to the hospital are through the A&E department (either self‐presentations or after referral by the general practitioner) and the acute medical assessment unit (AMAU; after referral from either the A&E department or GP). A minority are admitted electively for procedures or investigations.

The survey was performed between 7 August 1996 and 7 October 1996, and covered 61 days. In order to identify every patient attending the A&E department, a brightly coloured sticker was placed on each A&E card before the patient was seen by medical staff. The sticker was removed within 12 h as soon as the relevant patient details had been obtained. Based on their clinical assessment, the attending doctor who completed the label had to state whether in their opinion the attendance was alcohol‐related, i.e. whether attendance at the hospital was a direct result of alcohol misuse by the patient or another person. The patients were then categorized into one or more of the following four categories: (i) under the influence of alcohol at the time of attendance; (ii) suffering from an health problem for which there is good evidence to implicate alcohol in its aetiology13 (these will be termed ‘medical illnesses’ hereafter, and included patients with surgical problems such as pancreatitis and medical problems such as hepatic encephalopathy); (iii) the patient had suffered trauma (of variable severity) as a result of excess alcohol consumption; and (iv) the patient was an innocent third party who had sustained trauma as a result of excess alcohol consumption by another individual.

When no sticker had been applied by the receptionist (5%) or had not been completed by the assessing doctor (20%), one investigator (CB) went through all the notes and determined whether the attendance was alcohol‐related. Where a completed label indicated that the attendance was alcohol‐related, the notes were examined to obtain relevant details and categorize the patients as indicated above. Admissions which had bypassed the A&E department were assessed daily to determine whether they were deemed to be alcohol‐related.

After the survey was completed, a random sample of 100 case notes which had originally been designated as not being a result of alcohol were assessed to ascertain what proportion of patients might have been wrongly categorized.

Patients attending during one week of the survey period which was chosen at random (1–7 September 1996) were followed up for the next 18 months to determine the number of new and follow‐up out‐patient visits generated.

Due to the nature of the study, most of the results are presented as descriptive statistics. Associations between variables were analysed by χ2 tests.

Results

During the 2‐month period of the survey, the total number of patients seen in A&E was 15 931. An alcohol‐related problem was thought to be responsible for A&E attendance in 1915 of these patients (median age 36 years, range 11–90 years; 73% males). The proportion of patients with alcohol‐related problems attending varied on different days over the survey period, but were generally greater during weekends and at nights (Figure 1). Overall, alcohol‐related problems accounted for 12% of all A&E attendances. The reasons for attendance were categorized as shown in Table 1. A total of 130 patients (6.8%) attended more than once (range 2–11), resulting in 329 re‐attendances altogether. A small number (n=37) of patients with alcohol‐related problems bypassed the A&E department, and were admitted directly to the wards either via clinics or for pre‐booked investigations.

Of all the patients attending the hospital with alcohol‐related problems (n=1952), 546 patients (28%; median age 45 years, age range 16–90) were admitted, the majority for just 1 day (range 1–47 days). This represented 6.2% of all admissions to the hospital during the period of the survey. Patients with medical problems as a result of alcohol misuse (n=427; 50% admitted) were more likely to be admitted than those in other groups (n=1525; 22% admitted; χ2 132, p<0.0001). The medical problems included patients with gastro‐intestinal bleeding, pancreatitis, ascites, liver failure and alcohol withdrawal.

The age ranges of patients attending are shown in Figure 2. All ages were represented, with those between 18–39 years of age accounting for 50% of attendances. The number of patients under the age of 18 years was 89 (4.6%). The youngest patient was 11 years old, and had been knocked off her bicycle by a drunk driver. The commonest reasons for attendance in this age group included minor injuries (usually sustained from falls), assault and head injuries. Twenty‐three (25.8%) of the patients under 18 years of age were intoxicated on arrival to the hospital. Another 23 patients (25.8%) were innocent third parties. At the other extreme, 154 (7.9%) of the patients were over the age of 65 years, the commonest reason for attendance being falls while intoxicated (n=45, 29%). The elderly were more likely to be admitted when compared with those under the age of 18 years (admission rates of 46% vs. 12%; χ2 27; p<0.0001).

To determine whether all patients attending for alcohol‐related problems had been detected in the A&E department, a set of 100 casenotes chosen at random were reviewed; one patient out of 100 had been misclassified by the attending staff. If this figure is extrapolated to all of the non‐alcohol‐related attendances during the same period, then it is likely that approximately 143 patients will not have been detected by the methodology used.

To determine how many patients needed an out‐patient appointment following an initial A&E attendance, we followed up the cohort (n=192) who attended during 1–7 September 1996. Fifty‐nine patients (30.7%) were given a new out‐patient appointment, mainly to orthopaedic clinics (n=35; 59%). The total number of new out‐patient visits generated was 277, with a mean of 4.6 per patient; 35% of these appointments were not kept by the patients. If this figure is extrapolated to the whole of our 2‐month study period, approximately 600 new patients would have been seen in out‐patients, with over 2800 out‐patient visits being generated. It is also important to note that 114 of the patients who attended A&E during the first week of September had attended out‐patients previously and were continuing to do so, and thus are not categorized as having generated a new out‐patient appointment.

Figure 1.

Alcohol‐related attendances at the A&E Department according to (a) day (defined as 0001 h to 2400 h) of attendance, and (b) time of attendance.

Figure 2.

Ages and sex of patients with alcohol‐related problems.

View this table:
Table 1

Categorization of patients attending with alcohol‐related problems

Reason for attendanceTotal number (%)Patients sent home (%)Patients admitted (%)
Under the influence of alcohol1734 (88.8%)6733
Alcohol‐induced medical illness427 (21.9%)5050
Trauma as a result of alcohol excess651 (33.4%)7426
Trauma to a third party 533 (27.3%)8119

Discussion

The main purpose of the survey was to elicit data on the burden placed on emergency services by alcohol‐related problems. Our results show that the burden of alcohol is high, accounting for 12% of all A&E attendances, and 6% of all admissions. Previous studies assessing the burden placed by alcohol have largely concentrated on admissions, with estimates ranging from 2% to 34%.5–11 Methodological differences are largely responsible for the differing estimates; many of the previous studies having surveyed smaller numbers of patients,5–11 restricted themselves to one specialty,5–7,10,,11 or used screening tools such as the MAST8 or CAGE7 questionnaires to detect alcohol misuse. In our study, in view of the large numbers of patients attending the A&E department (approximately 100 000 annually), we adopted a pragmatic study design, which was dependent on clinical assessment by the attending emergency room doctor. Thus, our study has been able to detect patients with overt alcohol‐related problems, but will have missed a large proportion of patients with covert problems, which require detection by alcohol screening tools7. Indeed, it has been shown that A&E departments often overlook drinking problems in their patients while attending to their presenting disorder,14,,15 although our methodology using a brightly coloured sticker on the case records probably prompted the doctor to consider alcohol. In support of this, our note review suggests that few overt problems were missed.

The burden placed on a hospital does not end in the A&E department, but continues with admissions of patients to the ward and out‐patient attendances. Our figures suggest that for every 100 patients attending the A&E department with an alcohol‐related problem, at least 31 new patients will be seen in out‐patients attending 144 appointments over an 18‐month period. Clearly, this represents a potentially avoidable use of resources, which, considering that over one‐third of the appointments were not kept, has knock‐on effects on waiting lists for other patients.

The figures obtained in this study indicate that alcohol places a large burden on the available resources within our hospital. A limitation of our study is that only one hospital in a city with a high Jarman index was surveyed; however, it is important to note that many of the larger cities in the UK have similar degrees of deprivation.12 Thus, the proportionate figures found in our survey will be readily applicable to other cities, not only in the UK, but possibly also in other industrialized countries such as the US, where surveys have shown that alcohol‐related problems are over‐represented in emergency room settings.16

A worrying aspect of the findings of our survey is the number of under‐age drinkers seen in the A&E department, despite the fact that the hospital largely serves an adult population. Most of these patients attended because of trauma suffered from excess drinking. This is likely to be an under‐estimate, since the majority of such patients will attend the nearby children's hospital, which has also reported a large increase in A&E attendances due to alcohol abuse.17 The problem of drinking in children is increasingly being recognized,3 and clearly requires the development of urgent intervention strategies before these children grow up to be alcohol‐dependent adults. The under‐40‐year‐olds represented half of all attendees; most of these patients will be hazardous drinkers (defined as 21–49 units weekly in men and 14–35 units in women18) and thus represent a group which may be amenable to intervention.

The Department of Health strategy document ‘Health of the Nation’ has set specific targets for reduction of alcohol in the general population.1 However, these targets are not being met.19 Although a large proportion of this health promotion needs to be performed in primary care,19 the A&E department may also be an appropriate and complementary setting to carry out screening using tools such as the 1‐minute Paddington Alcohol Test,20 or the WHO AUDIT questionnaire,21 and subsequently to deliver early interventions, as shown by Wright et al.22 Such interventions may be especially appropriate in hazardous drinkers, who may constitute 10% of the adult population of the UK.23 However, few departments currently offer an alcohol screening or intervention service, and although most A&E workers support developing a preventive role, the lack of time and staff represents a considerable barrier.24 Perhaps the employment of key personnel such as alcohol specialist nurses trained in alcohol‐related problems might be a positive step towards developing a hospital policy in coping with the burden posed by alcohol.

In conclusion, our results show that a considerable burden is placed on general hospitals by overt alcohol‐related problems. The figure obtained in the survey is likely to be an under‐estimate, but nevertheless suggests that education, screening and intervention strategies are all needed to reduce the avoidable burden posed by alcohol on the scarce resources of health services.

Acknowledgments

The authors wish to thank the staff of the Accident & Emergency Department at the Royal Liverpool and Broadgreen University Hospitals Trust for their co‐operation with the study. The support of the NHS Executive North West and Liverpool Health Authority is gratefully acknowledged. BKP is a Wellcome Principal Fellow.

Footnotes

  • Address correspondence to Dr M. Pirmohamed, Department of Pharmacology and Therapeutics, University of Liverpool, Ashton Street, Liverpool L69 3GE. e‐mail: munirpliv.ac.uk

References

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