could an advance practice nurse improve detection of alcohol misuse in the emergency department?

Feature Article_797 1..9

Could an advance practice nurse improvedetection of alcohol misuse in theemergency department?

Anthony O’Brien,1,2 Louise Leonard3 and Daryle Deering4

1School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland and 2Liaison Psychiatry,Auckland District Health Board, Ecom House, Grafton, Auckland, 3Community Alcohol and Drug Service, Hamilton,and 4Department of Psychological Medicine, National Addiction Centre (Aotearoa New Zealand), University ofOtago, Christchurch, New Zealand

ABSTRACT: Alcohol misuse is a prevalent problem in New Zealand society, and one that exacts aconsiderable cost in terms of health, social cohesion, and economic productivity. Despite the burden ofalcohol misuse, screening, brief assessment, and interventions for alcohol problems are frequentlypoorly performed within general health services. In this paper we explore the response to alcoholproblems in a New Zealand emergency department and discuss difficulties encountered in improvingrates of detection by emergency department personnel. We report the results of a clinical audit ofalcohol screening and brief assessment and a staff education programme designed to improve practicein this area, but which met with limited success. The potential role for an advanced practice nurseproviding a clinical consultation and liaison service to the emergency department staff is explored. Weargue that such a role has potential to reduce the health and social costs of alcohol misuse, and to meetthe national policy objective of providing a treatment response to people with alcohol-related problemsin contact with health services.

KEY WORDS: alcohol, brief intervention, emergency department, nurse specialist, screening.

INTRODUCTION

As in other developed countries alcohol misuse is a preva-lent problem in New Zealand society (Cagney & Cossar2006). Use of alcohol underpins our way of life, with ahigh level of cost to health, social cohesion, and economicproductivity (Connor et al. 2005; Sellman et al. 2008).The most recent national mental health survey reported

that excessive drinking is common, with a conservativeestimate of 25% of New Zealand drinkers aged 16 yearsand above having a sustained pattern of problematicdrinking (Wells et al. 2006). Intoxication is tolerated, withmany drinkers exhibiting a binge drinking pattern andshowing little awareness of the potential harm to theirphysical and mental well being (Alcohol Advisory Councilof New Zealand 2004). Of further concern is that bingedrinking is increasing among young people (Habgoodet al. 2001), particularly young women (McPherson et al.2004). Although average consumption per day is similarfor Maori and non-Maori, Maori are twice as likely toconsume alcohol at hazardous levels (Ministerial Com-mittee on Drug Policy 2007), with consequently greateradverse impact on health (Bramley et al. 2003). Theproblem of alcohol is recognized in public policy, whereone of the 10 priorities of the New Zealand mental health

Correspondence: Anthony O’Brien, School of Nursing, Faculty ofMedical and Health Sciences, The University of Auckland, Building505, Room 2065, 85 Park Road, Grafton, Auckland, Private Bag 92019,Auckland 1142, New Zealand. Email: [email protected]

Anthony O’Brien, RN BA MPhil (Hons) FNZCMHN.Louise Leonard, RN, B Hlth Sc (Nursing), BA (Psychol), PG Cert

Hlth Sc (Addiction), PG Dip Hlth Sc, MNurs.Daryle Deering, RN, PhD.Accepted November 2011.

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International Journal of Mental Health Nursing (2012) ••, ••–•• doi: 10.1111/j.1447-0349.2011.00797.x

© 2012 The AuthorsInternational Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

and addictions sector is improving the availability andaccess to addiction services (Ministry of Health 2005).

Alcohol is a significant contributor to death andmorbidity and is linked to multiple conditions, includingheart disease and breast cancer, motor vehicle and otheraccidental injuries, and suicide (Babor et al. 2003).Alcohol contributes to psychiatric morbidity, includingself-harm, depression, and suicide (Borges & Loera 2010;Sher 2006). Comorbid alcohol misuse is common inpeople with schizophrenia (Arndt et al. 1992; McCreadie2002) and bipolar disorder (Goldstein et al. 2006), andcontributes to frequency of acute episodes and dimin-ished response to treatment.

International research has identified alcohol as afactor in many emergency department presentations. AnAustralian study found alcohol, especially in excess ofrecommended guidelines, to be associated with severityof injury (Watt et al. 2006). In the UK, estimates ofalcohol-related presentations to emergency departmentsvary between 12% (Pirmohamed et al. 2000) and 40%(Touquet & Brown 2006). A significant proportion of pre-sentations to emergency departments in New Zealand arealcohol-related, with one study recording 35% of present-ers as having consumed alcohol prior to sustaining injury(Humphrey et al. 2003).

Despite the high rate of alcohol-related hospital pre-sentations, screening and intervention for alcohol prob-lems is frequently poor. A systematic review of hospitalscreening examined 65 studies representing 100 000participants in 17 countries, finding that few hospitalshad resources, including time, to undertake widespreadscreening (Roche et al. 2006). Additional limiting factorswere lack of practitioner confidence and lack of perceivedrole legitimacy. In a New Zealand retrospective analysisof 120 cases of unintentional injury randomly selectedfrom a trauma registry, Hosking et al. (2007) found thatonly 23% had a blood alcohol test, of which half werepositive (>3 mmol/L). Although 70% of charts contained acomment about alcohol, only 7.3% recorded sufficientinformation to detect a possible alcohol problem, andonly 1.5% recorded an alcohol intervention. The authorsconcluded that screening and intervention were infre-quent and that the low level of screening represented amissed opportunity to address alcohol-related harm andto prevent further alcohol-related injury.

In a second New Zealand study, Pulford et al. (2007)examined alcohol assessment practice, knowledge, andattitudes of staff of a large metropolitan hospital by meansof an audit of 120 randomly selected files and a survey ofstaff. In this setting, a standard heading ‘Alcohol (amountand duration)’ in the social history section of the clinical

history was used to record alcohol intake. Informationwas typically meagre, with responses such as ‘nil’ and‘occasional’. Unsurprisingly, the utility of information waspoor, and the rates of detection lower than expected giventhe known prevalence of problem drinking. Staff knowl-edge of standard drinks and recommended drinking levelswas also poor.

Assessment of alcohol use offers an opportunity foreducation and intervention and there is evidence that evenbrief interventions can be effective in reducing consump-tion. Screening and brief intervention have been advo-cated for almost three decades (Babor et al. 2007). Theresearch literature reflects mixed results from studiesinvestigating the effectiveness of brief interventions ingeneral health settings and identifies a multitude of influ-encing factors. However, there is a sufficient body ofevidence to suggest that there is merit in incorporatingbrief interventions into routine care (Roche et al. 2006). Ina systematic review of 13 emergency department studies,Havard et al. (2008) found evidence of reduced rates ofalcohol-related injury, although no change in consump-tion. Emmen et al. (2004) conducted a systematic reviewof eight studies of brief intervention conducted in ageneral hospital setting, finding that evidence of effective-ness was inconclusive. A Cochrane review conducted byMcQueen et al. (2009) was inconclusive overall, but iden-tified two studies that reported reduced consumption.Crawford et al. (2004) found that emergency departmentidentification and referral for alcohol misuse to be associ-ated with reductions in alcohol consumption and subse-quent presentations to the emergency department.

Various instruments have been reported to be effec-tive in detecting problematic alcohol use in emergencydepartments, such as the Cut down, Annoyed, Guilty,Eye-opener (CAGE) test (Hadida et al. 2001), the AlcoholUse Disorder Inventory Test (AUDIT) (Cherpitel 1995),and the Paddington Alcohol Test (PAT) (Patton et al.(2004; Touquet & Brown 2009). Canagasaby and Vinson(2005) suggest that problem drinking can be detected withas little as a single question, with a positive response actingas trigger for a full screen using an instrument such as theAUDIT. Following a systematic review of hospital screen-ing studies, Roche et al. (2006) advocated that if hospitalresources were limited, screening of groups with high-riskconsumption should be carried out followed by furtherexploration as indicated for possible dependence. Thegoals of such a stepped assessment process would be to: (i)prevent the development of longer-term harm; (ii) mini-mize acute effects, such as injury, from isolated episodesof binge drinking; and (iii) identify dependence to avert ormanage clinical syndromes, such as delirium tremens and

2 A. O’BRIEN ET AL.


Wernicke’s encephalopathy. Assessment can also lead toreferral for more intensive alcohol and other drug (AOD)-related interventions.

Consultation–liaison services provide a model ofspecialist response to mental health and addiction issueswithin general health settings (Wise 2008). Although ini-tially conceptualized as a role for a consultant psychiatrist,nurses have also developed roles in consultation liaisonpsychiatry (Minarik & Neese 2002; Robinson 1968;Sharrock & Happell 2001). Internationally, consultation–liaison nursing services are now well established, includ-ing in emergency departments, where they have proved tobe well accepted by service users (Eales et al. 2006; Wand& Schaeken 2006). In respect to substance use, educationfrom specialist nurses has been found to improve alcoholassessment by nurses and doctors (Burns & Adams 1997).In the UK, Wright et al. (1998) reported improvementin detection and referral for alcohol problems followingthe introduction of a consultation–liaison nursing role. Inthe study on alcohol screening and referral conducted byCrawford et al. (2004), the intervention was provided byspecialist nurses.

In New Zealand, nursing consultation liaison roles tendto focus on mental and psychosomatic illness, with lessemphasis on substance use-related problems. However,despite the lack of formal AOD consultation–liaisonnursing roles, a survey of New Zealand nurses working inthe addiction area found that consultation–liaison consti-tutes part of their work (Deering 2007). There is also anincreasing focus in New Zealand on the development ofadvanced nursing roles, including nurse practitioner, as ameans of improving health outcomes (Ministerial Task-force on Nursing 1998; Ministry of Health 2002a).

STUDY SETTING

The research took place in the emergency departmentof a 600-bed New Zealand metropolitan hospital servingan urban and rural catchment of 339 000. The emergencydepartment provided 51 000 consultations in the year2008–2009. From the findings of previous research (Pir-mohamed et al. 2000 (12%); Touquet & Brown, 2006(40%)), we estimated that 5000 to 17 000 of these presen-tations might have involved alcohol. In addition, alcoholis likely to be a distal contributor to other emergencydepartment presentations, as well as a health problemexperienced by a proportion of all those presenting.Despite this, only 15 referrals to the region’s alcohol anddrug service were received in 2008–2009 (M. Harvey,Waikato District Health Board Alcohol and Drug Service,pers. comm., 2008).

AIMS

The aims of the present study were to determinethe extent of alcohol assessment in the emergency depart-ment and to investigate the effectiveness of a staff educa-tional programme designed to improve assessment anddetection of alcohol problems.

DESIGN

The design for this study comprised two aspects: a clinicalaudit and an educational intervention. Clinical audit is partof the quality improvement process (Ministry of Health2002b) and aims to provide clinicians with information andknowledge to inform their clinical practice. Clinical auditis a cyclical process in which data on indicators of qualityare collected and used to improve service provision(Cooper & Benjamin 2004). The education programmeaimed at improving rates of detection of alcohol issues.Educational interventions have been shown to lead toimproved detection and referral by medical and nursingpractitioners (Babor et al. 2004; Walsh et al. 2002; Watson1999). The study received ethics approval from the Min-istry of Health’s Northern Y Regional Ethics Committee.

CLINICAL AUDIT

Design of the clinical audit was based on a model of theaudit cycle provided by the Ministry of Health (Ministryof Health 2002b). An audit tool was developed to measurebest practice in brief alcohol assessment. The audit toolcollected demographic data (age, sex, and ethnicity), timeand day of presentation, and information on the natureof alcohol assessment, including screening for quantityof consumption, severity of dependence, advice providedto patients, and referral to alcohol services. An additionalquestion related to chronic heavy alcohol use soughtinformation on administration of thiamine. The audit toolis included in Appendix I. A sample of 100 files of patientsover the age of 15 years presenting in September 2008were selected for inclusion in the initial audit. A further40 files were selected for re-audit following the inter-vention. The sample size was determined in consultationwith the hospital statistician. Files were drawn by a hos-pital administrator using randomly generated numbers.Data from the files were extracted by one of the research-ers (L. L.). Analysis used descriptive statistics.

Alcohol assessment was measured by counting howmany alcohol questions had been asked (sections 6–9of the audit tool). This gave a total of nine questions,and, hence, a possible range of zero to nine. Additional

ALCOHOL MISUSE DETECTION AND THE ADVANCED PRACTICE NURSE 3


information on alcohol assessment was sought by review-ing the clinical records for informal questions or com-ments made about alcohol consumption.

EDUCATIONAL INTERVENTION

The educational intervention consisted of two 1-hourteaching sessions designed to be delivered by one of theresearchers (L. L.) to emergency department doctors andnurses. The first session covered the New Zealand guide-lines on safe drinking (MacEwan 1995), screeningand brief assessment, the use of the AUDIT, and referralfor alcohol problems (e.g. Babor & Kadden 2005). Thesecond session covered prevention and treatment ofWernicke’s encephalopathy and included identification,diagnosis, at risk groups, thiamine deprivation and braindamage, and thiamine treatment. Additional resourceswere provided in handouts, and included information onthe local alcohol and drug treatment service and addi-tional information and assessment tools.

Sessions were scheduled for handover times in the caseof nurses, and at planned staff development sessions in thecase of doctors and senior nurses. Repeat sessions wereprovided to maximize coverage as staffing schedules madeit impossible to address all nurses as a group. Limitationson staff availability meant that four out of the six sessionsfor nurses were reduced to 30 min. The longer sessionsprovided to doctors and senior nurses meant that a morein-depth coverage was provided to this group. In total, 76out of 80 nurses and nine out of 14 resident medicalofficers received the educational intervention.

RESULTS

Of the initial sample of 100 files for the pre-interventionaudit, 17 were discarded because of incomplete records(admission notes missing), leaving a total of 83 files foraudit.

Demographic dataDemographic data are presented in Tables 1–3. Pre-intervention and post-intervention groups were similarin age, gender, and ethnicity. A smaller number of

18–24 year olds were included in the post-interventiongroup (3 vs 13), but this age group represented only 15.8%of the pre-intervention sample so this difference was con-sidered unlikely to influence the results. Maori comprised27.5% of the post-intervention group compared to 18.7%of the pre-intervention group, but this difference was alsoconsidered unlikely to have a significant influence on theresults. When data for both samples were pooled, peopleaged 65 years and over (n = 30) were overrepresented at162% of their rate by a population estimate. However, thisoverrepresentation is consistent with the higher propor-tion of older people using emergency department services(Hider et al. 2001). Due to missing data, there are smalldiscrepancies in total numbers.

Day and time of presentationFor both the pre-intervention and post-interventiongroups, most presentations occurred during the day(08.01–16.00 hours), with smaller proportions, respec-tively, presenting in the evening (16.01–00.00 hours) andovernight (00.01–08.00 hours) (see Table 4).

Pre-intervention recording of alcohol questions showedan average of 0.57 questions asked, with post-interventionshowing a nonsignificant reduction to 0.44. Table 5 showsthe number of questions asked of each group before andafter the educational intervention.

TABLE 1: Cross-sample comparison of age groups

<18years

18–24years

25–44years

45–64years

>65years Total

Pre-intervention 2 13 24 20 23 82% 2.4 15.8 29.2 24.3 28.0Post-intervention 0 3 14 16 7 40% 0.0 7.5 35 40 17.5

TABLE 2: Cross-sample comparison of gender

Male Female Total

Pre-intervention 29 52 81% 35.8 64.2Post-intervention 15 24 39% 38.5 61.5Total 44 76 120

TABLE 3: Cross-sample comparison of ethnicity

NZEuropean Maori

PacificIsland Asian Other

Notrecorded Total

Pre-intervention 45 14 0 2 10 4 75% 60 18.7 0 2.7 13.3 5.3Post-intervention 23 11 1 0 5 0 40% 57.5 27.5 2.5 0.0 12.5 0.0Total 68 25 1 2 15 4 115

TABLE 4: Presentation by time of day

0801–1600 1601–2400 0001–0800 Total

Pre-intervention (%) 50.6 34.9 14.5 100Post-intervention (%) 60.0 35.0 5.0 100



Consistent with the results of the formal alcohol assess-ment audit, more informal assessment was also reducedfollowing the educational intervention. Audit of clinicalrecords revealed notes such as ‘no alcohol’, ‘alcohol onweekends’, ‘alcohol? quantity’ and ‘ETOH+++’. Suchnotes were found in 40% of the clinical records prior tothe educational intervention and 23% of records followingintervention. Over the study period, only one person wasreferred to alcohol and drug services and only one filecontained evidence of advice to reduce drinking.

DISCUSSION

The clinical audit showed that despite high levels of drink-ing in New Zealand and high rates of alcohol-relatedmorbidity and death, rates of screening and assessmentare low. This finding is consistent with previous NewZealand research (Hosking et al. 2007; Pulford et al.2007). The low level of screening is striking and supportsthe concern expressed by Pulford et al. (2007) that hospi-tal admissions in New Zealand represent a missed oppor-tunity to reduce alcohol-related harm. It is also concerningthat rates of assessment did not improve followingan educational intervention, and actually decreased. Thefinding of little change in alcohol screening and referralfollowing an educational intervention is not new, havingbeen previously reported by Lock et al. (2006). Difficultyin changing practice related to alcohol assessment was alsoreported by Peters et al. (1998), who attempted a random-ized controlled trial of alcohol intervention by emergencydepartment nurses but gained a low level of engagementand were forced to abandon the trial. However, it is impor-tant to consider the possible reasons for the lack ofimprovement following education.

The low rates of screening in the pre-interventionaudit showed that alcohol assessment and screening is anunfamiliar skill. Such skills, when newly acquired, requiresignificant reinforcement (Billet 2001), which was notprovided with this intervention. Although one-off educa-tion sessions might be appealing, given the time con-straints of emergency departments, they do not bring

about a change in practice behaviour and without greatersystems involvement are ineffective. Education sessionsprovided to most nurses were curtailed due to difficultyin scheduling the hour session originally planned. Thesessions were also provided in the clinical workplace athandover, a time when nurses were either planning theshift ahead or had finished clinical duties and were due toleave work. The timing and length of the sessions mighthave been a factor limiting their effectiveness and mightalso have been perceived as reflecting a low level of pri-ority attached to the issue of alcohol, limiting participants’engagement with the issue and commitment to change.Billet (2001; 7) describes the workplace as ‘contestedterrain’, with the competing interests of different groupsnot always supporting workers to develop their vocationalpractice. These limitations, however, cannot be a com-plete explanation for the lack of improvement as they didnot apply to the doctors or senior nurses whose sessionswere provided at protected staff development time.

Roche and Freeman (2004) view the problem of lowtake up of alcohol screening and intervention as one oftranslating efficacy into effectiveness. In the primary caresector, this is the case for a variety of common healthproblems, such as smoking, alcohol, and other substanceuse, with general practitioners (GPs) showing low uptakeof screening and intervention. Despite the literatureshowing that brief interventions with good efficacy areavailable, GPs report a perception of themselves aslacking skills and confidence in providing AOD interven-tions, a perception possibly shared by our participantsdespite the educational intervention (Roche & Freeman2004). Such perceptions might relate to the issue of per-ceived role legitimacy (Roche 2001). Roche and Freeman(2004) note that where education is provided, lack ofinstitutional support might constitute a further barrier.Lack of institutional support might have contributed tothe limited response to the educational intervention in thecurrent study, as structural and attitudinal barriers havebeen noted to limit alcohol assessment in emergencydepartments (Charalambous 2002).

Availability of an alcohol worker, such as an advancedpractice nurse, to emergency department staff, wouldassist with practice development, awareness of alcoholissues, and acquisition of new skills. Advanced practicenurses are nurses with well-developed clinical skillswithin a specific scope of practice, who also integrateresearch, education, and clinical leadership into theirroles (Bryant-Lukosius et al. 2004). Nursing literaturedescribes both nurse practitioner and clinical nurse spe-cialist as advanced practice roles, with nurse practitionerstending to work with discrete populations of patients,

TABLE 5: Numbers and proportions of patients questioned betweenpre-education and post-education

0 1 2 3 4 5 6 Total

Pre-education 51 23 5 2 2 0 0 83% 61.5 27.7 6.0 2.4 2.4 0.0 0.0Post-education 31 7 0 0 0 1 1 40% 77.5 17.5 0.0 0.0 0.0 2.5 2.5Total 82 30 5 2 2 1 1 123



often with undifferentiated health conditions. Prescribingis often a defining characteristic of the nurse practitionerrole, and this is the case in the New Zealand context(Ministry of Health 2002a). Under recently gazettedregulations, nurses in New Zealand may practice inextended roles, where their practice incorporatesactivities previously undertaken by other professionals(Nursing Council of New Zealand 2010). Whether a nursepractitioner or nurse specialist is ideally best placed toundertake the role of alcohol assessment and interventionin emergency departments is an issue that has not beenexplored in the nursing literature, and might depend onwhether prescribing is considered essential to the role.Given that nurse practitioners in New Zealand requireextensive postgraduate education in health assessmentand prescribing (Nursing Council of New Zealand 2008),the most pragmatic immediate solution would be todevelop a role for nurse specialists. Subject to evaluation,consideration could be given to future development ofthe role into that of nurse practitioner. We suggest thatdevelopment of a specialist nursing role of this naturewould help meet the need for staff training, as clinicianswould learn about the role through case consultation, asreported by Wright et al. (1998).

The positive impact of a nurse practitioner in relationto self-harm has been described by Wand and White(2007), and has implications for alcohol assessment in theemergency department. Nurse specialists have also beenused in emergency departments to increase case findingand referral for older adults with complex medical, social,and physical problems (Mion et al. 2001). In a studyof a nurse specialist alcohol worker, Wright et al. (1998)report a significant reduction in drinking for dependentand hazardous drinkers. The same study also found thatthe presence of the nurse specialist had a positive impacton staff’s perceptions of the management of alcohol prob-lems and facilitated education of staff in alcohol issues.

Any specialist intervention needs to be provided in atimely way. Williams et al. (2005) found an inverse rela-tionship between the length of time between identifica-tion of alcohol misuse and an appointment with an alcoholspecialist and the subsequent likelihood of keepingthat appointment. Availability of an alcohol worker wouldhelp ensure timely intervention. Williams et al. argue thatappointments should be given on the day of presentationto improve adherence. Another approach, suggested byRoche (2001), focuses on workforce development ratherthan availability of an expert clinician within the emer-gency department. For both approaches, the issue ofalcohol assessment requires commitment at the level ofhospital policy, similar to that which has been successfully

applied to self-harm (Gairin et al. 2003), intimate partnerviolence (Kendall et al. 2009), and child protection (King& Reid 2003).

CONCLUSION

The findings of this clinical audit indicate that a concertedeffort is needed to realize the objective included in NewZealand’s mental health and addiction policy of improving‘the understanding of the nature of addictive behaviourand the use of early intervention to prevent or limit harm’(Ministry of Health 2005). National mental health policyon reducing the harm caused by alcohol needs to betranslated into clinical practice in the emergency depart-ment, and into models of service delivery that will leadto acceptable levels of assessment and intervention.An advanced practice nursing role with the necessaryinstitutional support has the potential to lead to changesin practice and a consequent reduction in alcohol-relatedproblems.

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APPENDIX I

Alcohol assessment clinical audit tool1. Age

18–24 years 25–44 years 45–64 years 65+ years

2. Sex

Male Female

3. Ethnicity

NZEuropean Maori

PacificIsland Asian Other

Notrecorded

4. Presentation

Weekday Weekend

5. Time

08.01–16.00 hours 16.01–24.00 hours 00.01–08.00 hours

6. Has an alcohol assessment question been asked?

Yes No

7. Was the questioning adequate for the purpose ofscreening?

a. Type of alcohol consumed? Yes/No

b. Amount consumed? Yes/No

c. Standard drinks recorded? Yes/No

d. Frequency of consumption? Yes/No

8. Did questioning attempt to determine severity ofdependence?

a. Duration of consumption? Yes/No

b. Problems arising from use? Yes/No

c. History of withdrawal? Yes/No

9. Is the presence of an alcohol problem detected and is itclearly identified?

Yes No

10. If so, what?

Alcohol misuse Alcohol abuse Alcohol dependence

11. If chronic and heavy alcohol use was identified, wasthe patient given thiamine?

Yes No

Oral IVI IMI

Dose . . . . . . . . . . . . . . . . . . . . . . . .

12. Was the patient advised to reduce their alcoholconsumption?

Yes No

13. Was a referral made to AOD Services?

Yes No



could an advance practice nurse improve detection of alcohol misuse in the emergency department?

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