Elsevier

Drug and Alcohol Dependence

Volume 77, Issue 2, 14 February 2005, Pages 205-208
Drug and Alcohol Dependence

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The half-life of the ‘teachable moment’ for alcohol misusing patients in the emergency department

https://doi.org/10.1016/j.drugalcdep.2004.07.011Get rights and content

Abstract

Background:

To determine whether the length of time between alcohol-related attendance in the emergency department (ED) and follow-up appointment with an alcohol health worker (AHW) alters attendance rate at the AHW clinic.

Methods:

We examined paper and computerized records made by AHWs over a 4-year period, collecting data on the length of time between identification of alcohol misuse and the appointment with the AHW, and whether the appointment was kept.

Results:

There is an inverse relationship between the length of time between identification of alcohol misuse and AHW appointment and the subsequent likelihood of keeping that appointment.

Conclusions:

To maximise attendance rates at AHW clinics, the delay between the identification and intervention for alcohol misusing patients must be kept to a minimum, preferably giving an appointment on the same day as the attendance in the ED.

Introduction

Excessive alcohol consumption has well-documented adverse effects on health and is commonly associated with presentation to emergency departments (EDs) (Royal College of Physicians, 2001, Hungerford and Pollock, 2002, Cabinet Office Prime Minister's Strategy Unit, 2004.

Initial detection of alcohol misuse followed by brief intervention (BI) in the ED has been shown to be effective in reducing alcohol intake and lowering levels of ED re-attendance (D’Onofrio et al., 1998a, D’Onofrio et al., 1998b; Gentilello et al., 1999, Monti et al., 1999, Longabaugh et al., 2001); however the initial detection and subsequent BI were carried out by research workers, as opposed to by ED staff themselves. Practical problems in carrying out opportunistic screening in EDs (Peters et al., 1998) can be mitigated by audit, education and feedback (Huntley et al., 2001), and by the use of a robust pragmatic focused screening tool, e.g. the Paddington Alcohol Test (PAT), used by ED staff themselves (Patton et al., 2004a; Crawford et al., in press). Other brief questionnaires designed for use in EDs include the FAST (Hodgson et al., 2003) and RAPS4 (Cherpitel, 2000); however, their use was by research workers and has not been combined with reviewing attendance rates for subsequent BI.

Since 1994, we in the ED of St Mary's Hospital, London, have used the PAT (Smith et al., 1996, Huntley et al., 2001; Patton et al., 2004a, Patton et al., 2004b) to screen patients for hazardous levels of alcohol misuse. Patients who screen positive are told gently that they are drinking alcohol at a level that may be harmful to their health and are offered an appointment with an alcohol health worker (AHW) (Patton et al., 2003). Of those who keep the appointment, our pilot data showed that two-thirds reported reducing their level of alcohol consumption (Wright et al., 1998), the AHW attending daily and being routinely involved in education and feedback. However, the issue of timing of BI following attendance at the ED and its effect on attendance rate appears not to have been examined previously.

We postulated: (i) that the likelihood of keeping the appointment with the AHW would relate inversely to the delay between the initial ED consultation and the appointment date provided; (ii) that less frequent AHW clinics would result in a lower attendance rate; (iii) that those patients requesting a specific appointment date represent a self-selecting group more likely to attend than those who simply accept the next available appointment.

This is the first report in the literature that addresses the specific issue of the advantages of prompt follow-up on the ‘teachable moment’ of initial ED attendance with subsequent BI and shows the consequences of delay.

Section snippets

Methods

We collected data on all patients who accepted an appointment to see the AHW between 1 January 1998 and 31 December 2001. We recorded the date of the appointment and whether the patient attended or not (as recorded by the AHW). We identified the ED attendance date on which the AHW appointment was made for each of these patients from the department's computerized record system. We completed missing data wherever possible, from various other sources, including formal and informal computer records

Results

A total of 1792 patients had booked clinic appointments over the 4-year study period; complete data were available for 90.29%. The overall attendance rate was 34.7%. Factors affecting the rate of attendance are presented in Table 1. The impact on attendance of increasing the delay between the offer of the appointment and the date of the appointment is illustrated in Fig. 1.

Levels of attendance were higher when the appointment with the AHW was on the same day as the offer of an appointment in

Discussion

Attendance at the ED is unexpected and is usually due to an unpleasant event. The patient's agenda – their presenting complaint – must be attended to first, in order to gain confidence and empathy. The PAT is then applied in a non-judgemental appropriate manner enabling selective focused screening for alcohol misuse. The appreciation of the link between this unpleasantness and attendance creates the ‘teachable moment’ for opportunistic intervention: the acceptance by the patient of the offer of

Acknowledgements

This study was partially supported by a grant from the AERC (Alcohol Education and Research Council) who funded our main randomised controlled trial: Crawford et al., 2004, www.thelancet.com. We are grateful to all of our ED and AHW staff for their work, and especially to our Senior House Officer Teams 24–31.

References (23)

  • Cabinet Office, Prime Minister's Strategy Unit, U.K., 2004. Alcohol Harm Reduction Strategy for...
  • C.J. Cherpitel

    A brief screening instrument for problem drinking in the emergency room: the RAPS4

    J. Stud. Alcohol

    (2000)
  • Crawford, M.J., Patton, R., Touquet, R., Drummond, C., Byford, S., Barrett, B., Reece, B., Brown, A., Henry, J.A.,...
  • J.-B. Daeppen

    Screening and brief alcohol interventions in trauma centers

    Swiss Med. Wkly.

    (2003)
  • G. D’Onofrio et al.

    Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review

    Acad. Emerg. Med.

    (2002)
  • G. D’Onofrio et al.

    Patients with alcohol problems in the emergency department. Part 1. Improving detection

    Acad. Emerg. Med.

    (1998)
  • G. D’Onofrio et al.

    Patients with alcohol problems in the emergency department. Part 2. Intervention and referral

    Acad. Emerg. Med.

    (1998)
  • L.M. Gentilello et al.

    Alcohol interventions in a trauma center as a means of reducing the risk of trauma recurrence

    Ann. Surg.

    (1999)
  • R. Hodgson et al.

    Fast screening for alcohol misuse

    Addict. Behav.

    (2003)
  • Hungerford, D.W., Pollock, D.A. (Eds.), 2002. Alcohol problems among emergency department patients. In: Proceedings of...
  • D.W. Hungerford et al.

    Emergency department services for patients with alcohol problems: research directions

    Acad. Emerg. Med.

    (2003)
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