Understanding Alcohol Misuse in Scotland HARMFUL DRINKING. 4: The use of intravenous B vitamins

Scottish Emergency Department Alcohol AuditSEDAA Understanding Alcohol Misuse in Scotland HARMFUL DRINKING 4: The use of intravenous B vitamins

Scottish Emergency Department Alcohol AuditSEDAA Understanding Alcohol Misuse in Scotland HARMFUL DRINKING 4: The use of intravenous B vitamins

NHS Quality Improvement Scotland 2008 First published February 2008 You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document. www.nhshealthquality.org

Contents Foreword 7 Summary and key findings 8 Introduction 10 Methods 12 Results 13 Conclusion 31 References 32 Appendix 1 33

6 Understanding Alcohol Misuse in Scotland

Foreword This is the fourth in a series of reports which aim to gather evidence on the impact of alcohol-related problems on the health service in Scotland. This initiative developed from A Plan for Action on Alcohol Problems (Scottish Executive, 2002) 1 which included a commitment to consider the development of standards for the treatment and management of people with alcohol problems. NHS Quality Improvement Scotland (NHS QIS) was asked to take this work forward and a short-life Alcohol Advisory Group was established to explore how best to support the implementation of key policies and the improvement of alcohol services. One of the key conclusions from the group s work was that there is generally a lack of accurate, up-to-date information regarding the extent and impact of alcohol use and misuse. Without this information it is very difficult to know where to focus future work. We decided that priority should be given to gathering the necessary evidence and, with this in mind, we set up the NHS QIS Scottish Emergency Department Alcohol Audit (SEDAA) Group. This group has developed a five-part programme of work (available at www.nhshealthquality.org) and focuses on: the size of the problem alcohol and assaults alcohol and self-harm the use of intravenous B vitamins, and alcohol and young people. This report looks at the number and characteristics of patients with serious alcohol problems presenting to emergency departments in Scotland. In particular, the report gathers evidence on the treatment and management of this group of patients, paying particular attention to the prevalence of intravenous B vitamin administration. An overview report summarising the findings of all five reports and considering the next steps will be published in March 2008. NHS QIS commissioned the Scottish Trauma Audit Group (STAG), a national audit team based in mainland emergency departments in Scotland, to carry out this work and we are grateful to its project manager, the audit co-ordinators and particularly the emergency department staff. Thanks to their efforts, we now have a growing evidence base on alcohol misuse in Scotland. David R. Steel Chief Executive Harmful Drinking: The use of intravenous B vitamins 7

Summary and key findings Aim The aim of the study was to determine the number and nature of attendances to emergency departments in Scotland by people with serious alcohol-related problems (defined throughout as the presence of one or more of the conditions listed in Appendix 1). The study also sought to determine the extent to which parenteral B vitamins (PBVs)* were administered as part of the routine treatment and management of this patient group. Fifteen out of a total of 25 mainland emergency departments took part in the study over 14 days from February to April 2006. Key findings The prevalence of attendance by patients with serious alcohol problems During the 14 audit days, a total of 927 eligible patients were seen in the emergency departments. A number of patients attended more than once, bringing the total number of attendances by those with serious alcohol problems to 985. 4.2% of emergency department attendances are by people with serious alcohol problems. Almost three quarters (73%) of these patients were men. Three out of ten patients were younger than 40 years of age. There were no discernable patterns in terms of the time and day of presentation. Gastrointestinal complaints and trauma were the most prevalent reasons for presenting to the emergency department. Those admitted to a hospital tended to be older and their presenting and pre-existing complaints more chronic than those discharged. The role of alcohol Six out of ten people with serious alcohol problems attending the emergency department had consumed alcohol in the past 24 hours. Of those thought to have a serious alcohol problem, 97% had a history of chronic alcohol dependency. Eleven per cent of patients experienced alcohol-related seizures and 8% had a gastrointestinal haemorrhage. Those admitted to a hospital were more likely to present with the most chronic alcohol-related complaints than those discharged. * B vitamins administered via a parental (intravenous or intramuscular) route 8 Understanding Alcohol Misuse in Scotland

Treatment and management of patients in the emergency department Around a quarter of patients with serious alcohol problems had been prescribed oral thiamine prior to presentation at the emergency department (for an explanation of the vitamins used in the treatment of people with serious alcohol problems see Introduction, page 10). PBVs were administered in 17% of attendances. The recommended PBV dose of 4 vials (2 pairs) was administered in less than half (44%) of emergency department-based treatments. People presenting with alcoholic hallucinosis (67%) and acute alcohol withdrawal syndrome (59%) were treated with PBVs in more than half of presentations. Among those admitted to hospital, patients presenting with one of the four main alcohol-related conditions were treated with PBVs in more than half of presentations. On a typical day, 59% of patients with serious alcohol problems were admitted to a hospital ward. Nearly all patients (93%) for whom PBV administration was planned, and a high percentage of those receiving PBVs in the emergency department (80%), were admitted to a ward. Study limitations This audit involved 15 of Scotland s 25 mainland emergency departments. At the time of the study there were no audit co-ordinators in post at the other relevant centres to allow them to participate. Data were collected on 14 days from February to April 2007 and comprised two cohorts of patients (see Methods, page 12). On 7 days of the audit, data were collected on all patients, whether admitted or discharged from the emergency department. On the other 7 days, only discharged patients were included in the audit. The intermittent nature of the data collection suggests that the extent of multiple attendances may be underestimated. Also, the short time frame for the audit means that seasonal variations are not taken into account. Comparing admitted and discharged attendances and patients throughout the analysis aims to overcome the bias towards discharges introduced by the audit design. Documentation of alcohol consumption and vitamin B administration was variable. Therefore, whilst our figures offer a robust examination of these issues in relation to the target population, incomplete documentation may produce errors or bias in analysis of the data. Harmful Drinking: The use of intravenous B vitamins 9

Introduction Misuse of alcohol is a serious problem in Scotland. It is estimated to cost the Scottish economy at least 1 billion a year in reduced productivity, accidents and injuries, increased crime and violence and direct costs to the NHS, social services and the criminal justice system 2. In terms of the number and nature of their illnesses and the amount of resources their treatment consumes, those who consume excessive quantities of alcohol on a regular basis are a major concern for health services. Excessive use of alcohol is therefore a major issue and the evidence suggests that the problem is getting worse: Consumption of alcohol in the adult population has increased by 23% over the last 10 years 3. The most recent Scottish Health Survey shows that, in a usual week, 27% of men and 14% of women drink in excess of the recommended weekly number of alcohol units 4. Sixty-three per cent of men and 57% of women in Scotland are drinking in excess of recommended daily levels at some point in a usual week, with 37% of men and 28% of women binge drinking during that time 4. Four per cent (39,061 discharges) of general hospital discharges in 2005/06 were associated with an alcohol-related diagnosis 4. One in 30 deaths is directly related to alcohol, with alcohol-related death rates more than tripling in the past 25 years 3. Emergency departments are in the front line in responding to many of the health issues related to alcohol misuse. Those with serious alcohol problems may present to the emergency department for a range of reasons, and their immediate management and treatment may be complicated by the presence of co-existing health problems or ongoing substance misuse. Although responding to the needs of this group of patients is clearly a part of the day-to-day work of the emergency department, no national data has previously been collected to quantify the volume and nature of such presentations. The management of patients with alcohol-related brain damage (ARBD) represents a challenge for health services. Wernicke s encephalopathy, for example, is an acute neuropsyhciatric condition caused by the depletion of intracellular thiamine (vitamin B1). However, research has established that Wernicke s encephalopathy can be prevented or reversed in its early stages by the administration of B vitamins 5. By treating Wernicke s encephalopathy, the chronic phase of the disease, Korsakoff s syndrome, may also be prevented. As such, the emergency department may offer clinicians an opportunity to provide rapid initial treatment of this potential condition as part of the routine management of ill or injured patients with serious alcohol problems. 10 Understanding Alcohol Misuse in Scotland

The medicine used to treat patients with serious alcohol problems, thiamine (vitamin B1), comes in two forms. Thiamine is commonly prescribed for oral administration (current brands include Betamine and Thiamilate). In addition, thiamine may also be administered parenterally in Pabrinex. Pabrinex is packaged as two ampoules containing sterile aqueous solutions which are mixed prior to administration. The safety and efficacy of PBV has been established and its use as a preventative treatment recommended in reports by the Royal College of Physicians 5 and the Scottish Intercollegiate Guidelines Network (SIGN) 6. In line with the recommendations of these reports, NHS boards are advised to embody this advice within their own locally-issued guidelines on the management of patients with alcohol withdrawals. However, in addition to the lack of information on emergency department presentations by such patients, their treatment and the implementation of these guidelines has not yet been fully explored. This audit aims to address these knowledge deficits, providing a contemporary account of patients with serious alcohol problems in Scottish emergency departments. Harmful Drinking: The use of intravenous B vitamins 11

Methods The study examined patients with serious alcohol-related problems presenting at 15 emergency departments over 14 days from February to April 2007. Based on the experience of a 7-day pilot in January 2007, it was anticipated that the volume of eligible patients would be high and that data collection would have presented a significant challenge for both emergency department staff and local audit co-ordinators. The decision was made to limit the sample size by restricting data collection on 7 of the 14 audit days to those patients who were discharged from the emergency department. The 7 unrestricted data collection days and 7 discharge only days that were audited both covered every day of the week. In order to counteract possible biases arising from the selection of discharged patients on half of the audit days, attendances resulting in admission and discharge (either by staff or patients themselves) were analysed separately where appropriate. In order to form an accurate picture of the prevalence of attendance by patients with serious alcohol problems, STAG audit co-ordinators recorded the total number of emergency department attendances for each of the data collection days. In view of the methods employed to restrict the sample size, data were collected on the number of admissions on each of the discharge days, so that eligible attendances could be expressed as a percentage of all emergency department attendances resulting in discharge. The proforma used in the audit was designed to facilitate comparison with previous alcohol audits conducted on behalf of NHS QIS (items relating to alcohol use and patient discharge were not changed). In addition, aspects of SIGN Guideline 74 6 and local hospital guidelines 7 on the management of alcohol withdrawal in the emergency department were referred to when designing the proforma to ensure that it explored the relevant issues comprehensively. Local audit co-ordinators identified all patients who met the eligibility criteria on the data collection days by checking all ambulance patient report forms and emergency department notes for any reference to alcohol abuse. As part of this data collection procedure, distinctions were made between new and repeat attendances. Unlike previous STAG alcohol audits where clinical staff were encouraged to record excessive drinking, alcohol intake, etc, in their notes, no reminders were issued during this audit. Not doing so ensured that the data collected represented a true baseline audit of current documentation in respect of this patient group. 12 Understanding Alcohol Misuse in Scotland

Results 1 Number and characteristics of patients During the study period, 927 patients were identified as eligible for inclusion in the audit. In all, 985 attendances were documented. Based on the 7 unrestricted data collection days, attendances by those with serious alcohol problems (685) accounted for 4.2% of all presentations (16,325). In order to overcome biases resulting from the selection criteria used on some audit days, attendances were divided into two groups on the basis of outcome: those resulting in admission (attendances n: 379, patients n: 377) and those resulting in discharge (attendances n: 606, patients n: 558). Eight (0.9%) patients were both admitted and discharged by a hospital on separate occasions during the audit period. Overall, 41 (4.4%) patients attended more than once, with one patient attending on seven occasions. As the audit ran intermittently over a period of 2 months, with restricted inclusion criteria on some days, the resulting data are unlikely to reflect the extent of re-attendance. Only two (0.5%) admitted patients were admitted to a hospital on more than one occasion during the audit. By comparison, 34 (6.1%) discharged patients attended and were discharged from an emergency department more than once during the audit. In total, 677 (73%) men and 250 (27%) women with serious alcohol problems presented to an emergency department. The median age of males was 47 years while women were, on average, four years younger. 289 (30%) patients were younger than 40 years of age. When analysed separately on the basis of outcome, the median age of patients admitted was 49 years (male: 51, female: 47) compared to a median age of 43 years (male: 45, female: 41) among discharged patients. Figure 1: Number of patients by age and sex (n=927) 70+ Age 60-69 50-59 40-49 30-39 20-29 <20 200 150 100 50 0 50 100 150 200 Number of patients Female Male Harmful Drinking: The use of intravenous B vitamins 13

14 Understanding Alcohol Misuse in Scotland

2 Circumstances of presentation The timing of presentations by people with serious alcohol problems did not conform to any readily discernable pattern. Almost two thirds (65%, 637) of attendances occurred outside normal working hours (8am to 6pm, Monday to Friday). When analysed separately, 59% (223) of attendances resulting in admission and 68% (414) resulting in discharge occurred out of hours. When the distinction between in and out of hours attendance was applied across the entire week, the daily peaks observed at the weekend flattened considerably (Figure 2). Most patients presenting to the emergency department with serious alcohol problems arrived by ambulance (62%, 609), whilst a significant minority selfpresented (31%, 301). When analysed by outcome type, the mode of arrival differed significantly between attendances resulting in admission (21% selfpresented and 72% arrived by ambulance) and those resulting in discharge (37% self-presented and 56% arrived by ambulance). Figure 2: Number of presentations by time and day (n=985) 100 Number of presentations 80 60 40 20 0 Mon Tues Wed Thur Fri Sat Sun Day of presentation 8:00-18.00 (In hours) 18:00-8.00 (Out of hours) Harmful Drinking: The use of intravenous B vitamins 15

3 Presenting and pre-existing complaints Presenting complaints The presenting complaint of patients with serious alcohol problems was recorded in the emergency department. Overall, of the 985 eligible attendances, gastrointestinal problems was the most frequently recorded presenting complaint, documented in 219 (22%) cases. As Figure 3 illustrates, different patterns of presenting complaints were evident when data were analysed by sex. The percentage of females presenting with psychiatric problems (30%, 76) was significantly higher than the equivalent percentage of males (13%, 98). Men, meanwhile, were more likely to present with cardiac problems (12%, 90) than women (4%, 10). Figure 3: Percentage of presentations by presenting complaint and sex (male n=730, female n=255)* 30 Female Percentage of presentations 25 20 15 10 5 Male 0 Cardiac Central nervous system Psychiatric Gastrointestinal Intoxication Trauma ** Respiratory Presenting complaint Other Collapse *Percentages exceed 100% because more than one response could be recorded for each presentation. **An example of trauma would be a head injury. When data were analysed by outcome type (Figure 4), respiratory complaints were more than twice as prevalent amongst attendances resulting in admission to a hospital (9%, 33) as those resulting in discharge (4%, 23). Gastrointestinal complaints were also more common among those admitted (27%, 102) as those leading to a discharge (19%, 117). Conversely, intoxication and trauma were more common among those discharged than among those admitted to hospital, intoxication significantly so (20%, 119 compared to 8%, 29). 16 Understanding Alcohol Misuse in Scotland

Figure 4: Percentage of presentations by presenting complaint and outcome (admissions n=379, discharges n=606)* 30 Admissions Percentage of presentations 25 20 15 10 5 Discharges 0 Cardiac Central nervous system *Percentages exceed 100% because more than one response could be recorded for each presentation. **An example of trauma would be a head injury. Pre-existing complaints Psychiatric Gastrointestinal Intoxication Trauma ** Respiratory Presenting complaint Collapse The audit also recorded the current and pre-existing complaints experienced by patients with serious alcohol problems. The largest percentage of patients (29%, 281) had no current or pre-existing complaint at the time of presentation. Psychiatric and cardiac problems were the most prevalent current or pre-existing conditions recorded during the audit (22% and 16% respectively). As illustated in Figure 5, when analysed by sex the percentage of women with pre-existing or current psychiatric problems (32%, 82) was again higher than the equivalent prevalence rate among males (18%, 132), and also higher than the percentage of women presenting with no complaints (28%). However, men were more likely than women to have experienced problems with their central nervous system (12%, 88 compared to 6%, 16). On the basis of outcome type (Figure 6), the most prevalent response among patients admitted to hospital (25%, 94) and those discharged (31%, 187) was that they had no pre-existing complaints. Patients whose attendances resulted in an admission to hospital were around twice as likely to have pre-existing cardiac (23%, 87) or gastrointestinal (22%, 83) problems when compared to discharged patients (12%, 72 and 11%, 67 respectively). In addition, those patients admitted to hospital also appeared to have a slightly raised prevalence of other types of complaints (eg central nervous system or respiratory). Other Harmful Drinking: The use of intravenous B vitamins 17

Figure 5: Percentage of presentations by current/pre-existing complaint and sex (male n=728, female n=255)* Percentage of presentations 35 30 25 20 15 10 5 Female Male 0 None Cardiac Central nervous system Not known Current/pre-existing complaint *Percentages exceed 100% because more than one response could be recorded for each presentation. **An example of trauma would be a head injury. Figure 6: Percentage of presentations by current/pre-existing complaint and outcome (admissions n=378, discharges n=605)* 35 Percentage of presentations 30 25 20 15 10 5 Admissions Discharges 0 None Cardiac Central nervous system Psychiatric Respiratory Gastrointestinal Trauma ** Unconfirmed Other Gastrointestinal Trauma ** Unconfirmed Other Psychiatric Respiratory Current/pre-existing complaint Not known *Percentages exceed 100% because more than one response could be recorded for each presentation. **An example of trauma would be a head injury. 18 Understanding Alcohol Misuse in Scotland

4 Specific alcohol-related conditions As little change was anticipated in the number and type of alcohol-related illnesses experienced by individuals over the course of the audit, specific conditions were analysed at the level of the patient rather than at the level of the attendance. The prevalence rates for the conditions identified in the proforma were relatively low except for history of alcohol excess/chronic alcohol dependence, which was identified in 97% (903) of cases. The next most prevalent conditions were alcohol-related seizures (11%, 101) and gastrointestinal haemorrhage (8%, 75). Due to the vast difference in the prevalence of conditions, history of alcohol excess/chronic alcohol dependence is excluded from Figures 7, 8 and 9 below. When the remaining conditions were analysed by sex (Figure 7) a number of differences emerged. Men (8%, 55) were around twice as likely to present with acute alcohol withdrawal syndrome as women (3%, 8). Similarly, the prevalence of alcohol-related seizures in men (13%, 86) was double the prevalence of the same condition in women (6%, 15). However, the opposite was true of chronic liver disease and was recorded in 4% (27) of alcoholrelated conditions in men compared to 8% (19) of women. Figure 7: Percentage of patients by alcohol-related condition and sex (male n=677 female n=250) Acute alcohol withdrawal Alcoholic hallucinosis Acute or chronic pancreatitis Acute liver disease Chronic liver disease Wernicke-Korsakoff syndrome Gastrointestinal haemorrhage Alcohol-related seizures 0 3 6 9 12 15 Female Male Percentage of patients Harmful Drinking: The use of intravenous B vitamins 19

When analysed by age (Figure 8), both acute and chronic liver disease and Wernicke-Korsakoff syndrome displayed a tendency to increase in prevalence with age. Alcoholic hallucinosis and alcohol-related seizures the most prevalent condition besides history of excess showed the opposite tendency, reducing in prevalence as patient age increased. Figure 8: Percentage of patients by alcohol-related condition and age (under 45 n=425, 45-59 n=345, 60 and over n=157) Acute alcohol withdrawal Alcoholic hallucinosis Acute or chronic pancreatitis Acute liver disease Chronic liver disease Wernicke-Korsakoff syndrome Gastrointestinal haemorrhage Alcohol-related seizures 0 2 4 6 8 10 12 60 and over 45 to 59 Under 45 Percentage of patients When these conditions were analysed by outcome, alcohol-related conditions were notably more prevalent amongst admitted patients than those who were discharged in all but three categories (alcoholic hallucinosis, alcohol-related seizures and Wernicke-Korsakoff syndrome). Figure 9: Percentage of patients by alcohol-related condition and outcome type (admissions n=377, discharges n=558) Acute alcohol withdrawal Alcoholic hallucinosis Acute or chronic pancreatitis Acute liver disease Chronic liver disease Wernicke-Korsakoff syndrome Gastrointestinal haemorrhage Alcohol-related seizures Admissions Discharges 0 3 6 9 12 15 20 Understanding Alcohol Misuse in Scotland

5 Involvement of alcohol in current presentation When information was recorded about recent drinking patterns, 705 (72%) patients were adjudged by clinicians to have been drinking excessively. Further, in six out of every ten presentations (59%, 579), the patient had consumed alcohol in the previous 24 hours. In only one in twenty presentations (5%, 50), had the patient been abstinent at some point within the past year. When compared by sex, females with serious alcohol problems were slightly more likely than males to be drinking excessively, to have consumed alcohol in the past day and to have stopped drinking alcohol within the past 12 months. When analysed by outcome, patients whose attendances resulted in discharge were more likely to conform to a pattern of heavy drinking. The figures above probably underestimate the role played by alcohol. For 27% (265) of attendances there was no documentation of alcohol consumption within the past 24 hours. Figure 10: Percentage of presentations according to alcohol issues (n=985) Abstinent within past year Not documented Consumed alcohol in past 24 hours No Yes Drinking excessively 0 20 40 60 80 100 Percentage of presentations Data on the number of units of alcohol consumed each week by individual patients are presented in Table 1. Based on the median volume of alcohol consumed on a weekly basis for each gender, male patients drank an average of 97 units per week and female patients drank an average of 56 units per week. As an illustration of the median volumes of alcohol consumed during this audit, this is the equivalent of 3.7 bottles of vodka for men and 2.1 bottles of vodka for women. It can be seen that for both sexes average consumption amongst patients with serious alcohol problems decreases with age. Figure 11 further illustrates these data. It is evident that while few patients with serious alcohol problems drank within recommended limits, the proportion of patients consuming an extremely high number of units per week apparently decreased with age (it is not within the remit of this report to speculate on why this effect occurred). Harmful Drinking: The use of intravenous B vitamins 21

While the data presented here are not comprehensive, they do provide some insight into the level of alcohol consumption by so-called heavy drinkers presenting to Scottish emergency departments. No difference was observed in the median number of alcohol units consumed per week by patients in each outcome group (both 84). Table 1: Number of units of alcohol consumed per week by patients (n=225) Number of units consumed per week Count Minimum Maximum Mean Median Male <44 68 0 840 159 102 45 59 58 0 483 130 102 >60 30 0 307 90 79 All males 156 0 840 135 97 Female <44 45 0 560 109 75 45 59 18 6 560 93 53 >60 6 20 112 39 24 All females 69 0 560 98 56 All patients 225 0 840 124 84 Figure 11: Number of alcohol units consumed per week by age and sex 100 (n=225) 200 or more units Percentage of patients 80 60 40 20 100 to 199 units 50 to 99 units Above recommended limit to 49 units* Within recommended limits units* 0 Under 45 45-59 60 and over Total Under 45 45-59 60 and over Total Male Female * Currently no more than 21 units for men and 14 units for women per week. 22 Understanding Alcohol Misuse in Scotland

6 Parenteral vitamin B (PBV) administration Despite the patient s current medication being documented in seven out of ten cases (69%, 696), there was a high rate of non-documentation in relation to the prescription of oral thiamine prior to presentation in the emergency department (62%, 608). Differences between sets of clinical notes meant that it was not possible to state with certainty whether non-documentation related to an omission in recording prescribed drugs or an indication that drugs were not prescribed; non-documented cases were therefore not excluded from the analysis. Overall, in 24% (231) of attendances, 25% (181) of males and 20% (50) of females were documented as receiving prescribed vitamin supplements prior to attendance. In 28% (105) of attendances, admitted patients were prescribed oral thiamine compared to only 21% (126) of attendances by discharged patients. In order to examine PBV administration amongst an appropriate and eligible group of attendances, incomplete stays were excluded (eg patients who died, did not wait for treatment or self-discharged). The study found that PBVs were administered in the emergency department in 13% (117) of cases, administration on the ward was planned in another 3% (28) of attendances and was not applicable in 2% (17) of cases because the patient was a recovering alcoholic for more than 1 year. Overall, PBVs were administered following an emergency department presentation in 17% (155) of complete stays. Data on PBV dose was available in 109 cases and only in a minority of treatments (48, 44%) was the recommended dose administered to patients attending the emergency department. Almost two thirds of females (64%, 14) received the recommended dose compared to only 39% (34) of males. When analysed on the basis of outcome, it was found that PBVs were administered following 33% (123) of admitted attendances compared to only 6% (32) of discharges. The vast majority (93%, 26) for whom PBV administration was planned were admitted to a ward, as were a high percentage (80%, 93) of those who received PBVs in the emergency department. Of those patients given PBVs in the emergency department, 46% (40) of attendances resulting in ward admission and 36% (8) of those resulting in discharge received the recommended dose. In order to gain a clearer idea of practice in the emergency department, PBV administration was also examined in relation to certain alcohol-related conditions which, it was thought, should ordinarily merit such treatment. Figure 12 shows PBV administration in relation to these index conditions. Harmful Drinking: The use of intravenous B vitamins 23

24 Understanding Alcohol Misuse in Scotland

Figure 12: PBV administration among patients with specific alcohol-related conditions Percentage of eligible attendances 100 80 60 40 20 Not applicable - abstinent 1+ yrs No Yes 0 Alcoholic hallucinosis (n=9) Acute alcohol withdrawal (n=58) Wernicke- Korsakoff syndrome (n=9) Alcoholrelated seizures (n=94) Oral thiamine prescribed (n=218) Alcohol-related condition In only two conditions alcoholic hallucinosis (67%, 6) and acute alcohol withdrawal syndrome (59%, 34) were more than half of presentations treated with PBVs. However, when examining admissions only it was seen that more than half of presentations across the four alcohol-specific conditions were treated with PBVs: acute alcohol withdrawal syndrome (82%, 28), alcohol hallucinosis (60%, 3), Wernicke-Korsakoff syndrome (80%, 4) and alcohol-related seizures (63%, 26). Harmful Drinking: The use of intravenous B vitamins 25

7 Time spent in the emergency department Information on the time and date of emergency department arrival and departure was available for 884 presentations. After excluding ineligible attendances (ie incomplete stays), 822 cases were analysed. The median length of stay among this group was 2.5 hours. 678 (83%) patients with serious alcohol problems were discharged from the emergency department within 4 hours, while 16 (2%) patients stayed for more than 8 hours. Little difference in length of emergency department stay was observed between attendances resulting in a ward admission and eligible attendances where the patient was discharged. The median length of stay for admitted patients was 2.5 hours and 2.4 hours for discharged patients. Figure 13: Total length of time spent in the emergency department (n=822) 2% 16% 37% Over 8 hours 4 to 8 hours 2 to 4 hours Within 2 hours 45% 26 Understanding Alcohol Misuse in Scotland

8 Subsequent management of patients Overall, 11% (98) of eligible attendances led to a referral to specialist services, for example social work or an alcohol liaison nurse. Thirteen per cent (32) of female attendances were referred compared to 10% (66) of male attendances. Analysis by outcome suggests that only 16 (4%) ward admissions and 82 (15%) eligible attendances resulting in discharge were referred to specialist services. These figures are likely to underestimate the number referred to such specialities overall many patients would have seen a speciality during their ward stay or may subsequently have been referred by their GP, having been discharged to their care by the emergency department. Figure 14 shows the percentage of eligible attendances resulting in admission by alcohol-related condition. Patients with alcoholic hallucinosis were most likely to be admitted (5, 83%), while those with a history of alcohol excess or chronic dependency were least likely (367, 58%). Chronic dependency, alcoholic-related seizures and Wernicke-Korksakoff syndrome appeared to result in a slightly lower rate of ward admission than other conditions. Figure 14: Ward admissision among patients with specific alcohol-related conditions 100 Percentage of eligible attendances 80 60 40 20 Discharge Admission 0 Alcoholic hallucinosis (n=6) Gastrointestinal haemorrhage (n=57) Chronic liver disease (n=33) Acute liver disease (n=30) Acute alcohol withdrawal (n=45) Acute or chronic pancreatitis (n=49) Alcoholrelated Wernicke- Korsakoff syndrome (n=8) seizures (n=70) History of excess/ chronic dependency (n=629) Alcohol-related condition Harmful Drinking: The use of intravenous B vitamins 27

28 Understanding Alcohol Misuse in Scotland

Figure 15 shows the disposal from the emergency department of 685 patients with serious alcohol problems who attended on a day when data collection was not restricted. 356 (52%) patients were transferred to a hospital ward and 245 (36%) patients were sent home directly from the emergency department. 38 (6%) attendances resulted in a patient self-discharging or failing to wait for treatment. It is not known whether disposal to a psychiatric unit was for the purpose of assessment or admission. One presentation (0.1%) resulted in a death in the emergency department. Figure 15: Percentage of patients according to destination (n=685)* Did not wait Psychiatric unit 3% 2% Other 1% Police 2% Irregular discharge 4% Home 36% Other Did not wait Psychiatric unit Police Irregular discharge Ward Ward 52% Home * Other comprises mortuary, specialist NHS treatment, community non-nhs counseling. Harmful Drinking: The use of intravenous B vitamins 29

30 Understanding Alcohol Misuse in Scotland

Conclusion The health problems experienced by people with serious alcohol problems are diverse, often complex and may lead to presentation at the emergency department for a range of different reasons. In addition, treatment may be made more demanding by intoxication upon presentation and accompanying co-morbidities. For this group, whose attendance tends not to adhere to any identifiable pattern, the emergency department is often the main point of contact with health services. This audit sought to establish the extent and nature of such presentations to emergency departments and to record the treatments provided to these patients. Specifically, as recommendations are now in place regarding the role which PBVs can play in preventing or alleviating some of the effects of ARBD, the extent to which emergency departments are using such interventions to opportunistically treat heavy drinkers was given particular emphasis throughout. In summary, around 4% of presentations were by people with serious alcohol problems, most of whom were men in their forties. Patients presented with a range of complaints, nearly all had a history of chronic alcohol dependence and the majority had recently consumed alcohol. Around a quarter of patients had been prescribed oral thiamine prior to presentation but less than a fifth were given PBVs following an attendance. Those suffering alcoholic hallucinosis or acute alcohol withdrawal syndrome were most likely to receive PBVs, of which the recommended dosage was provided in less than half of treatments. Over half of patients with serious alcohol problems were typically admitted to a ward following presentation. The comparison of admissions and discharges as two separate outcome groups throughout the report suggests that patients in the former group are older, their presenting and pre-existing complaints more chronic, and are more likely to experience a specific alcohol-related condition. Whilst emergency departments appeared to be reacting to the needs of patients with serious alcohol problems, proactive treatments aimed at disease prevention among such patients were not administered as widely as would be desired. Whilst adherence to guidelines on PBV administration was apparent in many instances, some treatment opportunities were evidently not being taken. Further research needs to be undertaken on the links between treatment in the emergency department and inpatient or community-based treatments for patients with serious alcohol problems. However, enhancing awareness of the recommendations on vitamin B administration is a simple and potentially crucial step towards improving patient outcomes. Work is progressing in one remaining field, alcohol and young people, which will add to our current knowledge about alcohol misuse in Scotland and help develop more effective ways of responding to this challenge. An overview report summarising all aspects of this audit will be published in March 2008. Harmful Drinking: The use of intravenous B vitamins 31

References 1 Scottish Advisory Committee on Alcohol Misuse (SACAM). A plan for action on alcohol problems. Edinburgh: Scottish Executive Health Department; 2002 [cited 2007 Aug 30]; Available from: www.alcoholinformation.isdscotland.org/alcohol_misuse/ai_mainpage. jsp?pcontentid=2054&p_applic=ccc&p_service=content.show& Url 2 Scottish Executive Health Economics Unit. Cost to society of alcohol misuse in Scotland: an update to alcohol misuse in Scotland trends and costs. Edinburgh: Scottish Executive; 2004 [cited 2007 Aug 30]; Available from: www.scotland.gov.uk/resource/doc/35596/0012562.pdf 3 ISD Scotland. Alcohol statistics Scotland 2005. Edinburgh: ISD Scotland; 2005 [cited 2007 Aug 30]; Available from: www.alcoholinformation.isdscotland.org/alcohol_misuse/files/ AlcoholStatisticsScotland2005.pdf 4 ISD Scotland. Alcohol statistics Scotland 2007. Edinburgh: ISD Scotland; 2007 [cited 2007 Aug 30]; Available from: www.alcoholinformation.isdscotland.org/alcohol_misuse/files/ Alcohol%20Bulletin.pdf 5 Thomson A, Cook C, Touquet R, Henry J. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke s encephalopathy in the accident and emergency department. Alcohol & Alcoholism. 2002;37(6);513-521. 6 Scottish Intercollegiate Guidelines Network (SIGN). The management of harmful drinking and alcohol dependence in primary care: A national clinical guideline. Edinburgh: SIGN; 2003 [cited 2007 Aug 30]; Available from: www.sign.ac.uk/pdf/sign74.pdf 7 Lothian University Hospital Trust. Guidelines for management of alcohol withdrawal. 2004. [Unpublished] 32 Understanding Alcohol Misuse in Scotland

Appendix 1 Specific conditions for eligibility Acute alcohol withdrawal syndrome Delirium tremens (DTs) Alcohol detoxification Alcoholic hallucinosis DTs Acute confusion Acute delirium Acute liver disease (alcohol related in all cases) Alcoholic liver disease (ALD) Acute liver failure Jaundice Acute hepatitis in drinker Alcohol-related gastrointestinal (GI) haemorrhage Gastritis Alcohol related gastritis Alcoholic gastritis Varices Oesphageal Varices Alcohol-related seizures: Alcohol withdrawal seizures Seizures (particularly late onset or in known alcoholics) Chronic liver disease (alcohol related in all cases) Cirrhosis Alcohol-related liver disease Hepato-renal disease Chronic alcoholic hepatitis Ascites Jaundice Ethanol (EtOH) abuse Brought in drunk Drunk and fell over Drunk and incapable Patients presenting as a result of ethanol abuse were included in the study only if they had a documented history of alcohol excess or specific alcohol-related condition. Patients who attended the emergency department drunk but did not have a history of alcohol abuse were excluded from the audit. History of alcohol excess/chronic alcohol dependency. Alcoholic Alcohol abuse Pancreatitis Chronic and acute pancreatitis Wernicke-Korsakoff syndrome Wernicke s encephalopathy Encephalopathic Harmful Drinking: The use of intravenous B vitamins 33

You can read and download this document from our website. We can also provide this information: by email in large print on audio tape or CD in Braille, and in community languages. NHS Quality Improvement Scotland Edinburgh Office Glasgow Office Elliott House Delta House 8-10 Hillside Crescent 50 West Nile Street Edinburgh EH7 5EA Glasgow G1 2NP Phone: 0131 623 4300 Phone: 0141 225 6999 Textphone: 0131 623 4383 Textphone: 0141 241 6316 Email: comments@nhshealthquality.org Website: www.nhshealthquality.org