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L’orientation du patient alcoolisé aux urgences : état des lieux et perspectives
Abstract
Résumé
La consommation d’alcool apparaît comme un facteur de risque de consultation aux urgences comme l’atteste la prévalence importante de patients alcoolisés ou présentant un trouble lié à l’usage d’alcool dans les services d’accueil et d’urgence (SAU). Malgré l’existence de recommandations, depuis 2001, précisant la prise en charge et l’orientation de l’intoxication éthylique aiguë admise au SAU, et bien que la clinique soit bien définie, les patients en difficulté avec l’alcool sont peu captés en raison de la grande variabilité des modes de présentation et l’absence de filière spécifique d’orientation facilement identifiable. Un groupe réunissant urgentistes, addictologues et psychiatres s’est constitué afin de discuter et de proposer des stratégies pratiques pour guider la création de filières de soins addictologiques dont la porte d’entrée serait le SAU. Trois axes principaux ont été identifiés : la proximité entre équipes des services d’urgence et équipes de liaisons et de soins en addictologie (ELSA) favorise les échanges cliniques et stimule les actions de formation ; la pertinence de lits dédiés d’addictologie aiguë ou de crise addictologique ; l’intérêt de consultations d’addictologie ambulatoire de post-urgence. Pour être pertinent, la constitution d’un réseau structuré autour des ressources locorégionales articulera urgentistes, addictologues, services de médecine et de psychiatrie et s’appuiera sur des procédures décisionnelles simples et partagées. La construction d’une filière d’addictologie aiguë réactive, au-delà des enjeux de santé publique auxquels elle répond, pourrait avoir un grand intérêt médico-économique.
... « La prise en charge idéale du patient alcoolisé repose sur une surveillance médicale pendant quelques heures » [11], le plus habituellement en unité d'hébergement de courte durée (UHCD) au service des urgences [4,9]. Ce n'est dans la réalité proposé qu'aux formes compliquées, pathologiques ou les plus sévères avec altérations comportementales. ...
... Une IEA motivant le recours aux urgences constitue en elle-même un mésusage d'alcool (ANAES grade B), et témoigne d'une situation à problème [8,9]. C'est une occasion d'échanger, d'évaluer les consommations d'alcool ou d'autres substances, dans un discours du lendemain de l'IEA [4,5,17]. Plutôt qu'un aléa dans un parcours de consommations, une IEA amenant à rencontrer des soignants est une opportunité de soin, d'écoute de la souffrance associée au mésusage d'alcool, qui est identifiée dans plus de 90 % des IEA hospitalisées [5,10,12], initialement à l'hôpital, avec l'appui des équipes de liaison et de soins en addictologie (ELSA) [18], puis secondairement avec les soignants de proximité, parmi lesquels le médecin traitant à un rôle central. ...
L’intoxication éthylique aiguë (IEA) est fréquente en médecine générale, d’urgence et parfois en addictologie. L’IEA est modélisée entre des formes simples où se succèdent l’excitation psychomotrice, l’ébriété puis le coma, et des formes pathologiques. D’évolution le plus souvent spontanément favorable, l’IEA peut être émaillée de complications qu’il faut connaître pour les traiter précocement. Les soins de l’IEA sont d’abord symptomatiques, parfois hospitaliers et se prolongent par la proposition d’une rencontre au lendemain, utile et recommandée. La place de tout soignant est alors possible, parmi lesquels les médecins traitants, pour évaluer la situation avec l’alcool, d’éventuelles addictions associées et soutenir l’orientation vers des soins spécialisés lorsqu’ils sont requis.
Acute Alcoholic Intoxications in Hospital: Trends for 26 years at Mâcon Hospital (France)
Hospital is a privileged place to observe alcohol induced damage and acute alcohol intoxications (AAI), which are there one of the main grounds for recourse. Faced with this, hospital addictology has developed ways of meeting upstream of a care request, in a linkage and outreach activity, which finds its entire place there. This survey observed the positive blood alcohol concentration assay, carried out in a hospital between 1992 and 2017. It considered the evolution of this population: stability of the number of AAIs, growing part of the younger ones, associated with an overall ageing of this population, as well as its increasing feminisation, for average values of inversely decreasing alcohol blood level. These data can help to adapt an offer of speech from the day after the drunkenness, the most congruent to concerned people, in order to promote their access to care and to improve their quality of life.
Les intoxications éthyliques aiguës (IEA) représentent une part non négligeable de l’activité globale des services d’accueil des Urgences. Afin d’améliorer la prise en charge de ces patients, nous avons élaboré un protocole de prise en charge, regroupant à la fois la démarche clinique, diagnostique et thérapeutique de l’IEA et de ses complications, mais également les éléments nécessaires à la réalisation de l’intervention brève qui a démontré son utilité dans la réduction de la consommation d’alcool. Dans une première partie nous nous sommes efforcés de faire un rappel le plus exhaustif possible de l’épidémiologie, des différentes classifications, et des complications de l’IEA, ainsi que des examens biologiques ou radiologiques nécessaires au diagnostic de l’IEA, de ses complications ou de ses diagnostics différentiels. Ces différents éléments ont servi d’éléments fondamentaux à la rédaction d’un protocole de prise en charge de l’IEA. Dans une seconde partie, afin de déterminer si la création et l’utilisation de ce protocole avait un intérêt, nous nous sommes intéressés à l’avis des soignants de notre service. Sous forme d’un questionnaire nous avons sollicité l’ensemble de l’équipe médicale et paramédicale de notre service d’Urgences. Pour 94.7% la création et l’utilisation d’un protocole présente un intérêt, et pour un tiers des répondants ce protocole a déjà apporté une amélioration concernant la prise en charge de ces patients. Près de 40% des membres de notre équipe ne réalisent pas d’intervention brève, parce qu’ils ne se sentent pas formés à son utilisation. Ces résultats ouvrent des perspectives intéressantes quant à l’utilité d’un protocole de soins standardisé. Des efforts restent à fournir afin d’améliorer les compétences de chacun, mais les premiers résultats semblent encourageant
Le développement des soins aux sujets relevant de troubles de l’usage de substance a, en France, un versant hospitalier, dont l’activité de liaison est un pilier. Développée sur le modèle de la psychiatrie de liaison, l’alcoologie de liaison est une des premières modalités du développement de l’addictologie à l’Hôpital.
Si les références organisationnelles sont nombreuses pour développer une équipe de liaison et de soin en addictologie (ELSA), les repères cliniques sont rares pour aider les agents dans une relation de soin atypique, par les conditions de brièveté et d’unicité de la rencontre et la nécessité d’établir un lien pour rapidement le défaire en relayant vers d’autres professionnels.
Nous proposons d’aborder en dix points l’essentiel des éléments structurant l’activité clinique en alcoologie de liaison, considérant tour à tour les conditions pour pouvoir : parler d’alcool à quelqu’un qui ne demande rien, oser parler d’alcool et d’autres substances, travailler avec l’urgence, composer avec les pressions ou contraintes aux soins, travailler avec la répétition et l’échec, repérer puis prendre en compte les conduites addictives, éviter le piège de la causalité, intervenir dans un temps limité, renoncer à mesurer les effets de ses interventions, et enfin travailler avec tous les soignants.
Background:
Alcohol consumption is high in France.
Aim:
Estimation of alcohol-attributable mortality in France by sex, age and dose, for year 2009.
Method:
We combined survey and sales data to estimate the prevalence of alcohol consumption by age, sex and dose category. For each cause of death, the relative risk of death as a function of dose was obtained from a meta-analysis and combined with prevalence data to obtain the attributable fraction; this fraction multiplied by the number of deaths gave the alcohol-attributable mortality.
Results:
A total of 36,500 deaths in men are attributable to alcohol in France in 2009 (13% of total mortality) versus 12,500 in women (5% of total mortality). Overall, this includes 15,000 deaths from cancer, 12,000 from circulatory disease, 8000 from digestive system disease, 8000 from external causes and 3000 from mental and behavioural disorder. The alcohol-attributable fractions are 22% and 18% in the population aged 15 to 34 and 35 to 64, respectively, versus 7% among individuals aged 65 or more. Alcohol is detrimental even at a low dose of 13 g per day, causing 1100 deaths.
Conclusion:
With 49 000 deaths in France for the year 2009, the alcohol toll is high, and the effect of alcohol is detrimental even at low dose. Alcohol consumption is responsible for a large proportion of premature deaths. These results stress the importance of public health policies aimed at reducing alcohol consumption in France.
Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time.
METHODS We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden.
FINDINGS In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania.
INTERPRETATION Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children.
FUNDING Bill & Melinda Gates Foundation.
This study aims to identify the prevalence and at-risk situations of alcohol use disorders among patients examined in the emergency department and to compare the scales commonly used to identify alcohol use disorders.
We used the CAGE and AUDIT questionnaires and a structured interview, the MINI.
Of the presenting patients, 9.5% met the DSM-IV criteria for alcohol use disorders. The CAGE questionnaire was less sensitive (75%) and more specific (92%) than the AUDIT (87 and 80%, respectively). The typical alcohol-dependent patient is a young man who is unemployed and brought to the emergency department by the police. During the past 24 h, he has consumed alcohol, nicotine, cocaine, sedatives or cannabis.
Of the patients, 9.5% examined in the emergency department present with alcohol abuse or dependence without asking spontaneously for treatment for their addiction. These results support the importance of systematically identifying alcohol use disorders with a simple and rapid questionnaire such as the CAGE questionnaire.
To obtain baseline data on the incidence of acute alcohol intoxication, chronic alcoholism and illicit drug usage among a cohort of injured patients.
A prospective, descriptive study of 254 injured patients presenting at the trauma unit of Groote Schuur Hospital over an idealized week in 1997. Alcohol consumption was assessed by means of the Lion SD2 alcolmeter. Chronic alcoholism was assessed using the CAGE questionnaire. Each patient's urine was analysed for four drugs (cannabis, morphine, opiates and methaqualone) using conventional 'wet' analysis. Sweat was tested for cannabis using a Drugwipe.
Socio-demographics, cause of injury, injury severity, acute alcohol intoxication, chronic alcohol usage and illicit drug involvement.
Patients were predominantly male, coloured and an average of 31.3 years old. The majority had been injured as a result of interpersonal violence. Self-reported alcohol consumption was reliable but this was not so for self-reported drug usage. Sixty per cent of patients had positive alcohol levels on breath analysis. More than one-quarter of all the patients could be classified as chronic alcoholics on the CAGE questionnaire. On urine analysis, 40% of patients were found to have used at least one illicit drug in the recent past. The most commonly abused drugs were cannabis or a combination of cannabis and Mandrax, locally called a 'white pipe'. Use of the white pipe was confined almost exclusively to patients injured as a result of interpersonal violence.
Alcohol remains the most commonly abused substance among trauma patients, but there are growing numbers of patients who simultaneously abuse illicit drugs. This study will be conducted annually to detect trends and identify emerging problems.
The abuse of alcohol and drugs is a major public health problem and intoxication is one of the most important risk factors for violence and other causes of injury. The aim of the current study was to evaluate the prevalence of drug and alcohol use associated with injury in adult trauma patients in an inner city trauma unit in Johannesburg.
A cohort of 105 adult trauma patients admitted to our university trauma unit and its allied medicolegal laboratory were studied in order to provide prospective data and enable us to correlate the prevalence and type of substance abuse with the demographics and injury patterns after major trauma.
Forty-five patients required resuscitation at the Johannesburg Hospital Trauma Unit (JHTU) and 60 patients were examined at the Johannesburg Medicolegal Laboratory (JMLL), giving a total of 105 patients. Blood alcohol concentration (BAC) was positive in 59% of the patients. The average BAC in the trauma unit patients was 37 mmol/l (0.17 g/dl), more than three times the legal limit for driving. Of the patients 43.7% were positive for urinary cannabis; women were statistically significantly more likely to have taken cannabis than men (p = 0.039). There was no difference in rates of exposure to cannabis or alcohol in patients who were the victims of interpersonal violence compared with the victims of accidents (p = 0.17). Only 3 patients had taken other drugs of abuse; 2 had taken Mandrax (methaqualone) and 1 amphetamine.
Alcohol and cannabis are commonly misused by trauma patients in Johannesburg; the degree of misuse of other drugs appears to be low. Intoxication is a significant risk factor for violence and accidents and the resultant injuries are a massive burden on our society. Doctors have a responsibility to highlight the association between substance misuse and trauma and should also attempt to persuade individual trauma patients to reduce future alcohol consumption.
Alcohol-related diseases and injuries pose a significant burden on hospital emergency departments (EDs). Recognized limitations of self-reported data suggest that previous single-year national studies may have underestimated the magnitude of this burden.
Data were obtained from the National Hospital Ambulatory Medical Care Survey for 1992 through 2000. Thirty-seven alcohol-related diagnoses and their corresponding alcohol-attributable fractions (AAFs) were used to estimate the number of ED visits attributable to alcohol. Diagnoses with an AAF of 1 were analyzed by age, sex, and race. Disposition to inpatient settings and alcohol screening also were examined.
During these 9 years, there were an estimated 68.6 million (95% confidence interval [CI], 65.6 million to 71.7 million) ED visits attributable to alcohol, a rate of 28.7 (95% CI, 27.1-30.3) per 1000 US population. The number of alcohol-related visits increased 18% during this period. Visit rates for diagnoses with AAFs of 1 were highest for those who were aged 30 through 49 years, male, and black. From 1992 to 2000, these disparities remained stable for age group but significantly changed for sex (+22%) and race (-76%). Most patients with diagnoses with AAFs of 1 were not admitted to an inpatient unit, and the percentage of patients who underwent blood alcohol concentration testing was substantially lower than corresponding AAFs.
Alcohol-related ED visits are approximately 3 times higher than previous estimates determined by physician documentation or patient disclosure of alcohol involvement. Rising trends, changing disparities, and suboptimal ED management of such visits are a call to action.
The aim of the study was to estimate the prevalence of alcohol abuse and dependence in a general hospital emergency room and to propose an appropriate screening procedure. For that purpose, 234 patients between 14 and 70 years were interviewed using the screening questionnaires CAGE and Short MAST. In addition, clinical signs of alcoholism, drinking habits and physicians' diagnoses were assessed. The prevalence based on physicians' diagnoses was 9.8%, a screening algorithm based on clinical signs and drinking habits resulted in 23.9%, and a combination of the screening questionnaires in 25.6%. These results are close to the international average given by literature. The most appropriate screening procedure seems to be a combination of questionnaires and systematic clinical examination. It is recommended to implement such secondary prevention measures into general hospital emergency rooms.
To evaluate the effectiveness of a brief intervention in hospitalized Taiwanese men to reduce unhealthy alcohol consumption.
Randomized controlled trial.
Medical/surgical wards of a medical centre in Taipei, Taiwan.
Of 3669 consecutive adult male in-patients, 616 were identified as unhealthy alcohol users (>14 drinks/week) and assigned randomly to either usual care (n = 308) or a brief intervention (n = 308).
Primary outcomes were changes in alcohol consumption at 4, 9 and 12 months, including self-reported weekly alcohol consumption, drinking days and heavy drinking episodes assessed by 7-day time-line follow-back. Secondary outcomes were (i) self-reported alcohol problems, (ii) health-care utilization (hospital days and emergency department visits), (iii) self-reported seeking of speciality treatment for alcohol problems and (iv) 3-month Quick Drinking Screen.
Based on intention-to-treat analyses, the intervention group consumed significantly less alcohol than the control group among both unhealthy drinkers and the subgroup of alcohol-dependent participants over 12 months, on both 7-day and 3-month assessments. Adjunctive analyses of only those who completed all assessments found that total drinks consumed did not remain significant. Significantly more participants with alcohol use disorders in the intervention than in the control group (8.3%, 19 of 230 versus 2.1%, four of 189) consulted specialists by 12 months (P = 0.01). However, alcohol-related problems and health-care utilization did not differ significantly in the two groups during follow-up.
Data from Taiwan confirm that brief in-hospital intervention can result in a reduction in alcohol intake by men who drink heavily or are diagnosed with an alcohol use disorder.
The relationship between alcohol and injury is complex and the evidence level varies depending on the type of injury. The role of alcohol as a causal factor of traffic accidents is clear. There is less evidence concerning home and leisure injuries which include a wide range of accident causes and mechanisms. However, several studies dealing with specific injuries, such as drowning and fracture injuries in seniors, suggest a correlation between alcohol and the occurrence of injuries. Intentional injuries (violence, suicide) are complex and multifactorial phenomena. It is therefore more complicated to find the link between alcohol consumption and these kind of injuries. However, several physiological, psychological and social mechanisms are suggested to clarify this relationship. In conclusion, further data are needed to improve knowledge regarding the link between alcohol and injuries and, consequently, to implement preventive interventions. The collection of data on alcohol consumption at the moment of admission in emergency wards should be particularly promoted.
This study examined emergency department (ED) staff attitudes and beliefs about alcohol-related ED presentations in order to recommend improved detection and brief intervention strategies.
The survey was conducted at two inner-Sydney hospital EDs in 2006 to explore ED clinical staff's attitudes, current practice and barriers for managing alcohol-related ED presentations. The sample included N=78 ED staff (54% nurses, 46% doctors), representing a 30% response rate.
Management of alcohol-related problems was not routine among ED staff, with only 5% usually formally screening for alcohol problems, only 16% usually conducting brief interventions, and only 27% usually providing a referral to specialist treatment services. Over 85% of ED staff indicated that lack of patient motivation made providing alcohol interventions very difficult. Significant predictors of good self-reported practice among ED staff for patients with alcohol problems included: being a doctor, being confident and having a sense of responsibility towards managing patients with alcohol-related problems.
This study reported that many staff lack the confidence or sense of clinical responsibility to fully and appropriately manage ED patients with alcohol-related problems. ED staff appear to require additional training, resources and support to enhance their management of patients with alcohol-related problems.
The CAGE questionnaire, a new brief alcoholism screening test, was administered to all patients (N = 366; 39% alcoholic) admitted to psychiatric service over a one year period. The authors indicate that the CAGE questionnaire is not a sensitive alcoholism detector if a four item positive response is the criterion; however, if a two or three item criterion is used, it becomes a viable rapid alcoholism screening technique for large groups.
Many patients received in emergency units (EU) of hospitals present alcohol-related problems. Most are alcohol dependent or abusers and enter for drunkenness, stay a few hours and return home. To assess the effectiveness of a letter referring these patients to an outpatient alcoholism treatment clinic, we performed a randomized study. For 6 months, all the patients who had been diagnosed as alcoholic, who had an address and who had not consulted a physician for alcoholism in the 6 previous months were selected from the records of the EU of a French university hospital. At least 2 days after their stay in the EU, we sent a letter to 181 patients of an experimental group (group E) suggesting they make an appointment with a physician specializing in alcoholism. No letter was sent to 181 patients in a control group (group C). Six months later, 21 patients (11.2%) of group E had called the outpatient alcoholism treatment clinic to make an appointment and came to a consultation. Two of the 181 patients of group C came to the consultation. The effectiveness of this method for referring alcoholics to a clinic had been controlled by another prospective study. We concluded that sending a letter 2 days after the passage of an alcoholic to an EU for drunkenness is a useful method of referral to an outpatient alcoholism treatment clinic.
The Alcohol Use Disorders Identification Test (AUDIT) has been developed from a six-country WHO collaborative project as a screening instrument for hazardous and harmful alcohol consumption. It is a 10-item questionnaire which covers the domains of alcohol consumption, drinking behaviour, and alcohol-related problems. Questions were selected from a 150-item assessment schedule (which was administered to 1888 persons attending representative primary health care facilities) on the basis of their representativeness for these conceptual domains and their perceived usefulness for intervention. Responses to each question are scored from 0 to 4, giving a maximum possible score of 40. Among those diagnosed as having hazardous or harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with non-hazardous consumption had a score of less than 8. AUDIT provides a simple method of early detection of hazardous and harmful alcohol use in primary health care settings and is the first instrument of its type to be derived on the basis of a cross-national study.
On the inpatient substance abuse service of the Philadelphia Veterans Administration Hospital, we found that patients who were admitted to the hospital "unscheduled" had a disproportionately higher incidence of subsequent AMA (against medical advice) discharge, particularly if they were alcoholic. This finding calls into question the cost-effectiveness of hospitalization as an initial treatment strategy for substance abusers who enter treatment impulsively and points out the need for additional study to determine the most cost-effective treatments for addicts whose primary motivation for treatment may be to obtain relief from precipitating stressors.
This study identifies patient characteristics associated with adherence to outpatient mental health treatment referrals from a VA psychiatric emergency department. Attendance of outpatient appointments was monitored for 12 weeks following emergency department visits (N = 241). Overall attendance of the first appointments was 53%, ranging from 34% of the homeless, to 82% of patients with alcoholism in remission. Characteristics associated with initial adherence included having a place to live and the diagnosis of depression. At twelve weeks, the diagnosis of substance abuse was associated with worse ongoing adherence. The results underscore the need to develop interventions targeting patients at highest risk of poor adherence.
The effectiveness of an overnight psychiatric observation program was evaluated. The program was designed to avoid unnecessary hospitalization of patients experiencing acute psychiatric crises.
Of 110 patients admitted to the observation unit at a Veterans Affairs medical center over a six-month period in 1996, the charts of 92 patients were retrospectively reviewed. Characteristics of patients referred to the program were documented, inpatient hospitalization rates and suicide rates in the six-month periods before and after admission to the observation unit were examined, and variables related to the need for hospitalization immediately after observation were explored.
Most of the 92 patients (98 percent) were referred from the medical center's emergency room. At the time of observation, 80 percent of the patients were unemployed, 55 percent expressed suicidal or homicidal ideation, 49 percent were intoxicated or at risk for alcohol withdrawal, and 41 percent were homeless. The most frequent psychiatric diagnosis was substance abuse or dependence (77 percent). The large majority of patients (88 percent) were referred the next day to other outpatient programs for follow-up and treatment, which avoided costly inpatient treatment. In the six months before admission to the observation program, the mean number of inpatient psychiatric bed days was 9.8, compared with 2.7 days in the six-month period after discharge from the observation program. No increase in suicide gestures or attempts was noted among the patients. No variables significantly predicted admission to inpatient care after the observation period.
Overnight observation programs may provide a cost-effective alternative to traditional inpatient treatment for some individuals with psychiatric disorders.
We assessed the prevalence of alcohol dependence among patients examined in the psychiatric emergency service of a general hospital. We compared socio-demographic data and psychiatric status of patients with and without alcohol dependence. One-hundred and four consecutive patients received by the psychiatric emergency service of Bichat-Claude Bernard Hospital (Paris, France) were assessed. Diagnosis of alcohol dependence, acute alcohol intoxication, and antisocial personality was determined according to DSM-IV criteria. Other psychiatric disorders were identified using a structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Prevalency rate of alcohol dependence was 37.5% among patients examined by the psychiatric emergency service. Alcohol-dependent patients were more often men than women and more often unemployed than non-alcohol-dependent psychiatric emergencies. They presented more dysthymia, acute alcohol intoxication, and antisocial personality than non-alcoholic patients followed by the psychiatric emergency service. Attempted suicide was as frequent in alcohol-dependent patients (23%) as in other patients (29%). Alcohol-dependent patients consumed alcohol more often when alone, and their alcohol consumption began more frequently in the morning. Patients seen in a psychiatric emergency service must be identified as a population at risk for alcohol dependence (37.5%). Alcohol-dependent patients are more often men and have a higher rate of unemployment. They present significantly more often dysthymia and acute alcohol intoxication associated to alcohol dependence.
Alcohol abuse is a risk factor for serious illnesses, and a history of chronic alcohol abuse adversely affects the outcome of critically ill patients. It is not known what proportion of intensive care unit (ICU) admissions is related to alcohol use. Therefore, we investigated the proportion of emergency admissions related to alcohol.
A prospective cohort study was conducted in a university hospital ICU. All adult patients (n = 893) who underwent emergency admission to our ICU during a period of 1 year were studied.
The admitting physician determined whether there was a relationship between alcohol use and admission. ICU and hospital mortality and ICU length of stay (LOS) were recorded. The Therapeutic Intervention Scoring System (TISS) was used for ICU resource use estimation. There was a relationship between alcohol use and admission in 24% (215/893) of admissions and, in 156/893 admissions (17.5%), this seemed to be definite. ICU LOS was 1.2 days (0.7; 2.3) (median; interquartile range) for alcohol-related and 1.8 days (0.9; 3.6) for other admissions (P < 0.001). Patients with alcohol-related admissions consumed 17.8% of ICU patient-days and 18.7% of all accumulated TISS scores. ICU (8.8 vs. 10.5%, P = 0.603) and hospital (19.1 vs. 20.2%, P = 0.769) mortalities were no different between alcohol-related and other admissions.
ICU admission is very often related to long-term chronic and/or occasional alcohol use.
Because 40% of motor vehicle fatalities in the United States are alcohol-related, interventions delivered by trauma clinicians targeted to reduce drinking are of particular importance to public health. The objective of this study was to test the effectiveness of hospital-based brief intervention strategies to reduce alcohol consumption and other health-related outcomes in the year after an alcohol-related vehicular injury. Brief interventions are clinically based strategies including assessment and direct feedback about drinking alcohol, goal setting, behavioral modification techniques, and the use of a self-help manual.
The study was a randomized controlled trial of two types of brief intervention with a 12-month follow-up. Participants with alcohol-related vehicular injury who were admitted to Level I trauma centers were eligible for enrollment. Enrolled participants were randomized to a control, simple advice, or brief counseling condition. Primary outcome variables were alcohol consumption (standard drinks/month, binges/month), adverse driving events (driving citations, traffic crashes), and changes in health status (hospital and emergency department admissions).
The study enrolled 187 participants at baseline and retained 100 across 12 months. Participants had a significant decrease in alcohol consumption and traffic citations at 12 months as compared with baseline. Mean standard drinks/month declined from 56.80 (SD 63.89) at baseline to 32.10 (SD 53.20) at 12 months. Mean binges/month declined from 5.79 (SD 6.98) at baseline to 3.21 (SD 6.17) at 12 months. There were no differences in alcohol consumption, adverse driving events, or health status by condition.
Whether the reductions in alcohol consumption and traffic citations were a result of the crash, hospitalization for injury, screening for alcohol use, or combination of these factors is difficult to determine. Further work is needed to understand the mechanisms involved in reductions of health-related outcomes and the role of brief intervention in this population.
Alcohol and illicit drug abuse are major health care problems frequently leading to emergency department admission. The aims of this survey were (1) to determine for the Ghent University Hospital how frequently substance abuse contributed to emergency department admissions, (2) to describe the most important clinical features of these patients and (3) to determine how frequently these patients were referred to appropriate psychiatric services. All 1,941 patients attending the emergency department during the month of September 2003 were registered by the attending emergency department personnel. After exclusion of 8 cases, 1,933 patients were included: 198 (10%) with substance abuse leading to the emergency department admission (= INTOX group) and 1,735 (90%) in the NON-INTOX group. Males and the 21-50 years age group were overrepresented in the INTOX group. Patients with substance abuse were also overrepresented during the night, but not during the weekend. Among the patients from the INTOX group the most frequent reason for the emergency department visit was a psychiatric problem (102/198; 51%). Traumatic lesions related to a fight (n= 19), to a traffic accident (n= 17) and to leisure time activities (n=30) were also frequent. In most patients, only alcohol was abused (144/198; 73%), most frequently chronically (102/144; 71%). In 13% (26/198), there was only illicit drug use, and in 14% (28/198) alcohol abuse was combined with illicit drug use. Among the 54 patients with illicit drug use (with or without alcohol abuse) the most frequently reported drugs were cannabis (54%), cocaine (41%), amphetamines (39%) and opiates (39%). With regard to referral to appropriate psychosocial services it was striking that 53% (19/36) of trauma patients with chronic substance abuse were not offered that type of help. We conclude that abuse of alcohol--and to a much lesser degree illicit drugs--is a frequent cause of emergency department admissions. Our data may help to convince and/or reinforce health care policy makers, emergency department medical directors and the public that alcohol consumption (much more than illicit drugs) is responsible for avoidable morbidity and mortality, and that well-co-ordinated strategies against unhealthy alcohol use are urgently needed. In this respect, the importance of detection and referral of emergency department patients with unhealthy alcohol use should be stressed.
Alcohol misuse are severe financial burden for health care system in Poland. AUDIT and CAGE are two questionnaires used for diagnosis of alcohol abuse. We analyzed the incidence of alcohol problem among emergency unit's patients and correlation of this phenomenon with the reason of admittance to the hospital. 30% patients of Clinical Hospital Emergency Unit of Gdańsk misuse alcohol. Injuries and acute intoxications were considerably more frequent reason of attendances to emergency unit in population of patients with drinking problem. AUDIT questionnaire is more effective and sensitive diagnostic instrument comparing to CAGE and may be useful for identification for both, addicted and misusing alcohol patients.
Schätzung der Prävalenz von AlkoholmiBbrauch und–Abhängigkeit in der Notfallambulanz eines Allgemeinkrankenhauses
- Polte
Actualisation des conférences de consensus « Les crises convulsives aux urgences (1991) » « L’ivresse éthylique aux urgences (1992) »
- Busseuil
Prompting alcoholics to be referred to an alcohol clinic: the effectiveness of a simple letter
- Batel