Do you overlook patients with alcohol problems?

How many patients would you estimate come to your ED for alcohol-related diseases and injuries? According to a new report, the number may be much higher than you think.

There are three times as many alcohol-related ED visits than previous estimates, with an estimated 68.6 million ED visits attributed to alcohol each year, says a study based on the National Hospital Ambulatory Medical Care Survey’s data from 1992-2000.1

In addition, numbers of alcohol-related visits are increasing and currently account for almost 8% of all ED visits, says the nine-year study from Massachusetts General Hospital in Boston. "Any nurse who works in the ED, for even one shift, realizes the impact that alcohol has on our society," says Carlos Camargo, MD, DRPH, the study’s senior author and an ED physician at Massachusetts General. "But it’s very hard to detect alcohol-related problems because people deny them and providers don’t always ask."

More frequent ED screening can result in more referrals and interventions, and decrease repeat ED visits, argues Camargo. "This is a call to action for EDs," he says.

These patients are low priority

In the ED, alcohol and substance abuse often is put on the back burner, says Linda Redd, RN, BSN, an ED nurse at Massachusetts General. "These patients so easily fall through the cracks," she says. "Once they are medically stabilized, the goal is to keep the flow of patients going."

As a result, these patients keep coming back to the ED, says Redd. "If nobody is able to pick up that piece, then these patients are going to be passed over and will keep coming in time and again," she says.

To significantly improve screening for alcohol problems, consider these suggestions:

  • Make the next step easier for patients.

Patients who acknowledge an alcohol or substance abuse problem may find that getting help is a daunting challenge, says Redd. "If you leave it up to the patient to find a detox program, chances are they won’t be very successful," she says. "In the midst of calling, the patient will often throw their hands up and give up."

Redd facilitates this process by locating beds for both insured and uninsured patients. "By keeping up relationships with the different detox programs, they are more likely to find you a bed when you need it," she says. The ED currently is testing a pilot program by funding two beds for uninsured patients at a local detox center, she reports.

  • Share success stories with ED nurses.

This is a powerful incentive to screen patients, says Redd.

"I make a point of following up with detox centers about patients we have referred to them," she reports. "For example, I recently learned that one patient who we referred three times finally completed the program."

Another problem may bring them in

  • Ask all patients about alcohol use.

Patients may come in with a medical problem completely unrelated to alcohol abuse, emphasizes Redd. "They may not be able to directly ask for help," she says. "The goal is to tap into the whole group of patients that come in for something completely different."

Even if the patient is not yet ready to accept help, you still can offer information, says Redd. "I give patients brochures and a card with a hotline number for them to use when they are ready," she says.

At Boston Medical Center, an innovative Project Assert program screens all noncritical patients presenting for medical treatment in the ED. Even if your ED does not have extensive resources, you still can perform a quick screening by asking the following questions, recommends Edward Bernstein, MD, professor and vice chair for academic affairs for the department of emergency medicine at Boston University School of Medicine:

— Do you smoke, drink alcohol or use drugs?

— During a typical week, how many days do you drink alcohol beverages?

— When you drink, how many drinks do you usually consume?

— What is the most you drink in a two-hour period?

"I think these questions could be asked at triage with the understanding that all patients are asked and that we need to know because of alcohol’s effects on medication and various health problems," says Bernstein.

Recently, Bernstein screened a 35-year-old woman who came to the ED with a sprained ankle. She reported six drinks on a single occasion, with an additional 160 ounces of beer consumed in the same week. "I reviewed the National Institute on Alcohol Abuse and Alcoholism guidelines with her, which are no more than three drinks for a woman on one occasion, and no more than seven drinks in a week," he says.

The woman admitted concern about her drinking and was given a "readiness ruler" that uses a 1-10 scale to assess the patient’s readiness to make a change, with "one" being not at all ready and "10" being completely ready. (For information on how to access a readiness ruler, see resources, below.) The woman marked the scale a "10" and said she was willing to go to a specific program that afternoon. "I wrote her plan down on the screening form, which she signed as an agreement with herself to carry out this plan," says Bernstein.

Reference

1. McDonald AJ, Wang N, Camargo CA. U.S. emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Arch Intern Med 2004; 164:531-537.

Sources and Resources

For more information on alcohol-related visits in the ED, contact:

  • Edward Bernstein, MD, Professor and Vice Chair for Academic Affairs, Department of Emergency Medicine, Boston University School of Medicine, and Professor of Social and Behavioral Sciences, Boston University School of Public Health, 818 Harrison St., Boston, MA 02118. Telephone: (617) 414-3453. Fax: (617) 414-7759. E-mail: ebernste@bu.edu.
  • Carlos Camargo, MD, DRPH, Emergency Medicine Network, Massachusetts General Hospital, 326 Cambridge, Suite 410, Boston, MA 02114. Telephone: (617) 726-5276. Fax: (617) 724-4050. E-mail: ccamargo@partners.org.
  • Linda Redd, RN, BSN, Emergency Department, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Telephone: (617) 726-2994. E-mail: lredd@partners.org.

The National Institute on Alcohol Abuse and Alcoholism has developed a guide to assist health care professionals in screening patients for alcohol problems and conducting brief interventions. The guide can be downloaded free of charge on the web site (www.niaaa.nih.gov). Click on "Publications," "Reports/Manuals/Guides/Briefs," "Helping Patients with Alcohol Problems: A Health Practitioner’s Guide."

At press time, a readiness ruler was scheduled to be posted on the web site "Emergency Department Alcohol Education Project." Web: www.ed.bmc.org/sbirt.