Literature Review On The Impact Of Alcohol And Drug Abuse On Emergency Presentations

Alcohol and Drug Abuse in Emergency Presentations

Question:

Discuss about the Regulatory Versus Voluntary Licensing Conditions.

The aim of the assignment is to perform the literature review on the impact of the Alcohol and drug abuse on emergency presentations. In Australia, New Zealand and in other countries the emergency departments are at forefront of dealing with the patients presented with effects of alcohol and drug abuse (Egerton-Warb et al., 2016). The emergency departments need to be prepared for the alcohol related presentations and the harmful effects of alcohol consumption. The application of the issue to personal practice is explained. Based on the findings from the critical literature review the assignment presents recommendations for emergency nursing practice.

The rationale for the choice of the topic is the significant effect of the alcohol on the other members in the emergency department or in the hospital. The harmful effects of the alcohol and drug abuse significantly impact the morale of the workforce, other patients and functioning of the emergency department (Sanjuan et al. 2014). In response to this, a scenario from personal clinical practice would be appropriate to narrate here.

A patient Mr. X was 55-year-old patient admitted last month with complaints of anxiety/fear, and sensory-perceptual alterations in emergency room. His breathing pattern was ineffective. The patient though did not seem to cause any harm appeared to be very frustrated and irritated. On examination, he was found to have alcohol withdrawl delirium. His body temperature was elevated. He accompanied along with his friend, whose behaviour was suspicious.  Suddenly both turned to be very talkative and tend to disturb others as I was taking the drug history. As I was preparing for sedation, the patient attacked a nurse threatening to give psycho stimulants. The ward manager and other ward members in the ward soon protected us. The early intervention into crisis was possible due to CCTV surveillance of the emergency room. As I encountered this scenario for the first time in my clinical practice, I lost my confidence to care for substance abuse emergency presentations.

Other than such incidents, there is a growing body of evidence on the increasing extent of burden placed by the alcohol and drug abuse on emergency services. The evidence is presented as literature review in the subsequent sections.

In 2016, the descriptive study by Egerton-Warburton et al. (2016) measured the frequency of aggression experienced by carers in emergency room due to the alcohol-affected patients. Using the mixed-method online survey the researcher presented that 97% of the staff experienced the verbal and physical aggression of the patients. Consequently the nurses and the ED doctors feels unsafe and insecured by such behaviour. It has been found to negatively affect the waiting times of other patients and schedule of the nurses. It also affects the carers of the other patients in same department. However, factors other than aggression should have been considered in the study.  In addition, it is hampering the staff’s mental and physical wellbeing.  It could have been better if the paper has mentioned about the comprehensive public health approach for changing this culture. It may be considered in the future studies. It would be better if the author has mentioned about how the informed consent was taken or confidentiality was maintained.

Literature Review

Exploratory study by Gunasekara et al. (2011), showed unintentional injuries to be common among the ED staff caused by the alcohol effected patients. It leads to violence and behavioural disturbances among the staff. The study also highlighted that this incidents have become an inevitable event despite the increasing frequency of emergency presentations of the alcohol and drug abuse. This incident increases the workload of the other nurses and greatly hampers the staff mood. There was lack of sufficient evidence on the perceptions of the ED staff in this regard. The study also highlighted that there is a lack of comprehensive study in this field in New Zealand. The future studies must focus on collecting data from other countries as well. The ethical issues do not seem to be present in this study as ethical approval was obtained. The ethical principle of beneficence seemed to be maintained as no subjects were harmed or forced to participate.

Alcohol and drug using patients present various problems to the emergency department staff. The impact as assess by the survey of Crothers and Dorrian (2011) includes negative attitude of staff in care provision. The outcome is due to the personal and professional alcohol related events encountered by the nurses. Further, lack of alcohol and drug training of nurses contributed to the average nurses showing positive attitude towards patients. Very few nurses considered it rewarding to work with drinkers. The negative attitude was not only related to ED presentations of the patients but due to lack of confidence, self-esteem and stereotyping attitude or negative attitude towards such patients. The future studies should focus only on the attitude of nurses towards the care after the emergency presentations by alcohol and drug users. The study did not highlight about the informed consent being-taken by the participants. It indicates the research respected the subjects’ right to autonomy. Privacy and confidentiality issues were not highlighted. There was no written consent given by the author for the research in this regard. However, the study has received ethics approval, which implies that the research considered the ethical issues.

The survey conducted by Parker et al. (2012), to determine the impact of treatment on emergency room in US hospital showed that many times ED nurses  had to care for multiple patients who were in life threatening situations. It slipped there mind that screener was present. Patients with drug seeking posed serious challenges to the ED nurses. It was difficult for the nurses to identify if the patient is experiencing legitimate pain, or the patient is seeking drugs to fuel the addiction. In some cases, patients were found to seek drugs to sell on the streets. It was also difficult to identify the patients with real symptoms and scripted the textbook ones. Nurses missed opportunities a very few accepted the substances issues. Drug seekers when screened scored very less on score and some presented to be too sick to be screened or switch to another ED in same city.  A large sample size was considered but ethical approval was not highlighted. There is no hint on the confidentiality, informed consent and privacy matter being considered, which are the main ethical issues are. The future studies need to consider the interventions to mitigate this issue. 

Aggression and Violence

As per the narrative review by Sanjuan et al. (2014), possible premature deaths, alcohol-impaired driving, and continued problem drinking are predicted by single alcohol related emergency department visit. These visits are twice as much as injury-related events per year in a hospital. The rate of the emergency presentations for these patients increases. It leads to ever increasing demands for the emergency staff and increase in their responsibilities. During the peak hours the screening methods seems to be ineffective.  As brief interventions are rarely performed, the emergency department miss the opportunity to address alcohol-related problems. Since it is a narrative review there is no ethical issues identified. In the similar study conducted by Cherpitel (2014), it was  highlighted that the injury associated presentations increases in emergency room when drug is consumed in combination with the alcohols. The study needs to focus on the interventions or recommendation for the ED staff and brief interventions

As per the survey conducted by Institute of Alcohol Studies in UK, a shocking evidence was obtained. The strength of the paper is the  presentation of the tabulated charts and graphs of the data collected. The statistically significant results showed that the alcohol related incidents makes the staff in the emergency services very stressed. The services feel stretched due to tightening budgets and the combination of the alcohol related incidents. The study was able to highlight that the emergency department staff feels the need to plug the gap. It was found that during these incidents the ambulance or the paramedics in 90% of the cases perform duties that they feel belong to the other staff of the emergency department.  The other theme that emerged from this study is the hampering of the work life balance of the emergency service staff. It was evident that the frontline staff especially nurses are in need of more help with the severity of the need and specific requirements posed by it. Another theme that was consistent in the study is the lack of sufficient training of nurses and the ambulance service staff to deal with the assault or attempt to murder during convulses after alcohol. The drawback of the study is the lack of recommendations specific to the emergency presentations to mitigate the issue (www.ias.org.uk., 2017). The study lacks any details on the ethics approval and may hamper the reliability of the data.  It is not evident if during the data collections efforts were taken to prevent potential harm.

Unintentional Injuries

Based on the literature review it is recommended for the nurses in emergency setting that they must seek the education and training for quality, safety and injury prevention. There is a need of legislative changes to prevent fatalities and injuries caused by alcohol and drug presentations in emergency room (Miller et al. 2014). The health care providers and nurses should undertake educational programmes for the substance abuse and treatment. It will help avoid negative or stereotype attitude towards drug addicts. It is recommended that instead of formal treatment protocol the nurses should opt for the brief interventions. There is a wealth of evidence pertaining to brief interventions, which help in reducing alcohol consumption for long-term (Haegerich et al. 2014).  There is a need of incorporating the harm reduction strategies to help the people with addiction to get right treatment. Incorporating the evidence-based interventions will help prevent the overuse of emergency room and provide right level of health possible. The health care providers must be ready with resources for relapse treatment as comorbidity exist between addiction and mental illness (Bartlett et al. 2013).

References

Bartlett, R., Brown, L., Shattell, M., Wright, T. and Lewallen, L., 2013. Harm reduction: Compassionate care of persons with addictions. Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses, 22(6), p.349.

Cherpitel, C.J., 2014. Focus on: the burden of alcohol use—trauma and emergency outcomes. Alcohol research: current reviews, 35(2), p.150.

Crothers, C.E. and Dorrian, J., 2011. Determinants of nurses’ attitudes toward the care of patients with alcohol problems. ISRN nursing, 2011.

Egerton-Warburton, D., Gosbell, A., Wadsworth, A., Moore, K., Richardson, D.B. and Fatovich, D.M., 2016. Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations. The Medical Journal of Australia, 204(4), p.155.

Gunasekara, F.I., Butler, S., Cech, T., Curtis, E., Douglas, M., Emmerson, L., Greenwood, R., Huse, S., Jonggowisastro, J., Lees, C. and Li, Y., 2011. How do intoxicated patients impact staff in the emergency department? An exploratory study. The New Zealand Medical Journal (Online), 124(1336).

Haegerich, T.M., Paulozzi, L.J., Manns, B.J. and Jones, C.M., 2014. What we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug and alcohol dependence, 145, pp.34-47.

Miller, P., Curtis, A., Palmer, D., Busija, L., Tindall, J., Droste, N., Gillham, K., Coomber, K. and Wiggers, J., 2014. Changes in injury?related hospital emergency department presentations associated with the imposition of regulatory versus voluntary licensing conditions on licensed venues in two cities. Drug and alcohol review, 33(3), pp.314-322.

Parker, G., Libart, D., Fanning, L., Higgs, T. and Dirickson, C., 2012. Taking on substance abuse in the emergency room: One hospital’s SBIRT story. International Journal of Mental Health and Addiction, 10(6), pp.984-990.

Sanjuan, P.M., Rice, S.L., Witkiewitz, K., Mandler, R.N., Crandall, C. and Bogenschutz, M.P., 2014. Alcohol, tobacco, and drug use among emergency department patients. Drug and alcohol dependence, 138, pp.32-38.

www.ias.org.uk., 2017. Alcohol’s impact on emergency services. [online] https://www.ias.org.uk. Available at: https://www.ias.org.uk/uploads/Alcohols_impact_on_emergency_services_full_report.pdf [Accessed 4 Oct. 2017].