Alcohol: impact in the emergency department.

Ask an emergency department nurse in Australia to describe the biggest clinical challenge  they face during a typical working week and many, if not most, will say one word: Alcohol.

“The seemingly endless racist, sexist and otherwise bigoted abuse and profanities liberated by alcohol, along with threats or actual violence, and streams of intoxicated patients vomiting and soiling themselves with urine and stool are scenes unacceptably common in any Australasian ED. It is no surprise that staff often do not feel safe around alcohol-affected patients.
Clearly there is a problem and a meaningful intervention long overdue.
Despite highlighting violence as a significant hazard for ED staff nearly two decades ago, there has been little progress in reducing its incidence. This is a multifactorial issue that needs greater attention. Strategies such as tailored department design, communication techniques, increasing security presence or issuing fines for behaviour partially address staff safety and violence in the ED, but do not address the significant contribution of alcohol.
It is the imperative of emergency clinicians to champion a new, more responsible era in alcohol culture.” –(Tran 2016)

A single intoxicated and aggressive person requiring physical and/or chemical restraint can tie up the resources of multiple staff for prolonged periods of time detracting care delivery to other patients in the department.

Even caring for the ‘happy-drunk’ patient (which might be amusingly entertaining) will often require allocating time and resources that are not justified by their clinical need.
And time & resources are a precious commodity in the ED.

Complicating the problem is the confounding of acutely intoxicated patients with other medical issues.

  • Intoxicated and drug effected.
  • Intoxicated with a head or other significant injury.
  • Intoxicated with acute medical crisis.
  • Intoxicated and in a situational crisis.
  • Intoxicated with acute mental health problems.

Intoxicated people under our duty of care are often (even when not violent) challenging to assess properly, complex to care for, difficult to manage, and often pose a risk to themselves, staff, and others within the ED environment.

In order to for fill that duty of care we must often tolerate verbal insults and rough physical interactions. We must sometimes endure assault.

Here is a summary of some more issues raised by Dr Viet Tran in the journal of Emergency Medicine Australasia:

  • Australia is 7th highest consumer of alcohol per capita.
  • Alcohol use has been associated with up to 40% of ED presentations including: acute intoxication, trauma sustained whilst intoxicated and injury resultant from assault by an intoxicated person.
  • Alcohol is involved in up to 50% of episodes of violence or aggression in the ED.
  • One study relieved that in a 12 month period nearly 98% of staff had experienced alcohol-related verbal abuse and 92% physical abuse.
  • Aggressive, intoxicated persons in the ED can provoke direct distress to other patients, leading to early self-discharge.
  • Intoxicated patients often require substantive reallocation of resources from those not intoxicated.

Acute alcohol intoxication aside, we still see many other presentations that are indirectly attributable to alcohol including domestic violence, motor vehicle accidents, depression, attempted self harm and the long list of medical conditions resultant from long term excessive alcohol consumption.

So as Dr Tran urges, it is also up to us as nurses to raise awareness of our reality with respect to the impact on public health of alcohol related injury and violence, and to champion a more responsible and more accountable culture of alcohol consumption in Australia.


Reference

Tran, V., Mackenzie, S., Hamilton, S., Edmonds, M. J. and Brichko, L. (2016), Emergency departments and alcohol: The perpetual hangover. Emergency Medicine Australasia, 28: 735–738. doi:10.1111/1742–6723.12699

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