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Universal electronic screening detects alcohol abuse in emergency patients

An electronic universal screening procedure implemented by admitting nurses in the emergency room identified alcohol misuse, associating it with higher liver disease risk and providing a “teachable moment” for possible interventions for the patients.

“The medical consequences of alcohol misuse are a significant burden on the workload of acute hospitals and yet patients with severe alcohol problems are often not recognized or referred to appropriate services, with the potential for life threatening complications to develop. This is particularly relevant for the early detection and management of [alcohol-related liver disease], given that patients may have few symptoms or signs until an advanced stage,” Greta Westwood PhD, MSc, from the Queen Alexandra Hospital, Portsmouth, U.K., and colleagues wrote. “Unselected screening for alcohol misuse is feasible and identifies distinct cohorts of patients with high levels of dependency, frequent ED attendance, multiple hospital admissions and an elevated risk of ARLD. These patients can be targeted with evidence-based treatments aimed at reducing the growing morbidity and mortality from alcohol related illness.”

Screening procedure

To test the screening procedure, the researchers retrospectively analyzed all patients admitted to the Acute Medical Unit of the Queen Alexandria Hospital between July 1, 2011, and Mar. 21, 2014.

The mePAT screening procedure, a modified electronic version of the Paddington Alcohol Test, would prompt the admitting nurse to record type of alcohol consumed, frequency and maximum daily amount using a standard definition of 10 mL of pure alcohol, whether the admission was considered alcohol related, and any signs of alcohol withdrawal.

The mePAT calculates a score of zero to two (low risk), three to five (increasing risk), or six or above (high risk) for risk of alcohol harm. Patients with an increasing risk receive a referral to an in-reach community alcohol intervention team for brief intervention and support, while patients with a high risk are automatically referred to an alcohol specialist nurse service who assess the patient with a full alcohol use disorders identification test. Patients with high risk also receive supervised alcohol detoxification and recovery-oriented support.

“In our study, alcohol screening was performed by the admitting nurses rather than doctors, using a simple screening tool as part of the routine admission process with data electronically recorded in real time,” the researchers wrote. “Completion of the mePAT alcohol questionnaire was mandatory and resulted in a high level of screening completion. This allowed us to identify a cohort with an elevated prevalence of alcohol dependency.”

Higher risks

Of the 53,165 patients admitted during the study period, 48,211 completed the screening. The researchers found 1,133 patients had a score representing increasing risk and 1,921 had a score representing a high risk for alcohol harm. Compared with those who completed the screening, those who did not had a higher mortality rate (8.3% vs. 6.17%; P < .001), were more likely not to be alert on admission (3.66% vs. 2.48%; P < .001), had shorter lengths of hospital stay (median 1.5 vs. 2.85 days; P < .001), had more same-day discharges (29.67% vs. 13.31%; P < .001) and were more likely to have self-discharged (3.37% vs. 1.81%; P < .001).

Patients who had a higher risk score had a median of 4.74 hospital admissions in the last 3 years, while the increasing risk group had a median of 2.92 hospital admissions and the lower risk group had a median of three (P < .001). The higher risk group also had more emergency department admissions (median 7.68) compared with the increasing risk group (2.64) and those in the lower group (3.81; P < .001). Among the patients in the higher risk group, 65.8% were referred to the Alcohol Specialist Nurse Service to undergo detoxification, all of whom completed the course.

After a review of diagnoses, patients in the higher risk group were most often admitted for alcohol-related mental health disorders, gastrointestinal bleeding, acute poisoning and alcohol related liver disease, whereas those in the low-risk group more often had general medical acute intakes such as pneumonia, chest pain and urinary tract infections.

“Collectively, liver, pancreatic and digestive disorders accounted for 22.1% of primary admission codes in the higher risk group compared to just 3.2% in the lower risk mePAT category,” the researchers wrote. “Individuals admitted to hospital may represent an opportunity not just to identify alcohol problems or chronic liver disease but also to start effective therapies for alcohol misuse, a ‘teachable moment’ when patients may be more receptive to interventions.” – by Talitha Bennett

Disclosure: Westwood reports no relevant financial disclosures. Please see the full study for the other researchers’ relevant financial disclosures.