Prevalence and characteristics of patients with risky alcohol consumption presenting to emergency departments in rural Australia

Objective: This study measures the prevalence of problematic alcohol consumption in patients of EDs in rural areas of Australia, relative to the general population in the same rural communities. It also identifies the characteristics associated with risky drinking in rural ED patients. Methods: Surveys containing the Alcohol Use Disorders Identification Test (AUDIT) and questions corresponding to the 2001 Australian Alcohol Guidelines were completed by 1056 patients presenting to five EDs in rural areas of New South Wales, and 756 residents of the same five communities. Results: Relative to the general community, ED patients were statistically significantly more likely to engage in risky alcohol consumption according to the AUDIT (39% vs 20%), alcohol consumption posing a high risk of short‐term harm (26% vs 18%) and alcohol consumption posing a high risk of long‐term harm (7% vs 3%). Although being aged under 40 years of age, being unmarried, not completing school and being assigned less urgent triage categories were associated with risky alcohol use among ED patients, rates of risky consumption were high across all patient subgroups. Conclusions: Risky drinking, across a number of measures, is overrepresented in patients of rural Australian EDs relative to the general community, and this type of consumption is not limited to certain subgroups of patients. There is a need for interventions that address both heavy single occasion drinking and excessive regular consumption in patients of rural Australian EDs, with universal interventions recommended rather than targeted programmes.     

Identification of Hazardous/Harmful Drinking among Subcritically Injured Patients

Objectives: To examine the relationship between a saliva alcohol test (SAT) and hazardous/harmful drinking, as measured by the Alcohol Use Disorders Identification Test (AUDIT), among a sample of subcritically injured patients.
Methods: Patients ( n = 78) seeking treatment for a subcritical injury were saliva-tested for alcohol and interviewed regarding their drinking behaviors and related difficulties. Associations of SAT values with AUDIT results were determined.
Results: SAT results and hazardous/harmful drinking were not independent events (p < 0. 001). Estimates of sensitivity and specificity (using a dichotomous SAT result [≥ 4 mmol/L] to identify positive AUDIT patients) were 65. 2% and 83. 6%, respectively. SAT-positive people had significantly higher AUDIT scores than did SAT-negative individuals (p < 0. 0001). Patients experiencing assault-type injuries were much more likely to be SAT-positive than were patients incurring other types of injury. Discriminant function analysis suggests that AUDIT scores can successfully identify SAT-positive and SAT-negative patients; the analysis accounted for 42. 5% of the variance and correctly classified 84. 6% of the sample.
Conclusions: The use of an easy-to-administer, noninvasive, routine SAT, among patients presenting for a subcritical injury in a hospital ED, provides a mechanism for the identification of individuals with a history of hazardous/harmful drinking. However, since discrimination of hazardous/harmful drinking is imperfect, some caution is warranted when conducting such screening activities.     

Marijuana Use and Prior Injury among Injured Problem Drinkers

OBJECTIVES: The purpose of this paper is to better understand marijuana use among injured problem drinkers in the emergency department (ED). The specific objectives are: 1) to assess the prevalence of marijuana use; 2) to identify factors associated with marijuana use; 3) to determine whether prior injury is associated with marijuana use; and 4) to determine whether marijuana-using problem drinkers want to change behaviors. METHODS: The authors conducted a post-hoc analysis on data obtained prospectively. Subjects had injury and problem drinking: either measurable alcohol level (blood alcohol concentration, BAC), report of drinking, or an Alcohol Use Disorders Identification Test (AUDIT) score of > or =8. The study was conducted on weekend nights; 3,776 injured ED patients were screened, 383 refused, 578 were enrolled, and 433 had complete data. RESULTS: Of the 433 subjects, 48.3% reported using marijuana in the three months prior. Marijuana-using problem drinkers had more hazardous drinking, higher AUDIT scores (14.0 vs. 11.4, p < 0.001), and higher risk-taking scores (12.4 vs. 10.1, p < 0.001). More used other drugs (69.7% vs. 30.3%, p < 0.001). In regression analyses, marijuana use remained an independent predictor of prior injury (OR = 2.16, 95% CI = 1.25 to 3.75), particularly prior alcohol-related (OR = 2.26, 95% CI = 1.45 to 3.53) and motor-vehicle-related (OR = 1.69, 95% CI = 1.03 to 2.79) injury. Readiness-to-change scores were similar (4.14 vs. 4.22, p = 0.21) between users and nonusers. CONCLUSIONS: Marijuana use among injured problem drinkers is prevalent. Their risk of prior injury is increased. Counseling for alcohol and injury should address marijuana use.     

Alcohol use and misuse in older people: a local prevalence study comparing English and Irish inner‐city residents living in the UK

Background: Alcohol consumption was assessed in English and Irish men and women aged 65 and over, living in an inner‐city area of London, UK.

Method: Participants were assessed using Quantity/Frequency measures of alcohol use and validated questionnaires (SMAST‐G, 10‐item AUDIT, SF‐36).

Results: Sixty subjects with a mean (SD) age of 77.5 (1.2) years were recruited. English subjects showed greater changes between lifetime and last year drinking patterns (chi‐square = 18.9, d.f. = 4, p = 0.001). Irish subjects had a significantly higher mean AUDIT score (2.8 vs. 1.0; Mann–Whitney U = 225, Z = ?3.5, p<0.0001) and were significantly more likely (14/30 vs. 3/30) to have a family psychiatric history (chi‐square = 10.6, d.f. = 1, p = 0.001). Irish subjects were more likely to drink at least once a week, showed a higher mean alcohol intake (6.4 vs. 2.4 g) over the previous year and were more likely to show binge drinking (8/30 vs. 1/30) and drinking above sensible limits (8/30 vs. 1/30). None of these latter observations retained their significance after statistical correction.

Conclusions: The main implication of the study is that closer attention is required in screening for alcohol use in older Irish men in the UK.     

Effectiveness of a Specialized Brief Intervention for At‐risk Drinkers in an Emergency Department: Short‐term Results of a Randomized Controlled Trial

Background

Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have been developed, evaluated, and shown to be effective, particularly in primary care and general practice. Nevertheless, effectiveness of SBIRT in emergency departments (EDs) has not been clearly established.

Objective

We aimed to evaluate the feasibility and efficacy of an SBIRT program conducted by highly specialized professionals in the ED of a tertiary hospital.

Methods

We conducted a randomized controlled trial to study the feasibility and efficacy of an SBIRT program conducted by alcohol specialists for at‐risk drinkers presenting to the ED, measured with the three‐item version of the Alcohol Use Disorder Identification Test (AUDIT‐C). Patients were randomized to two groups, with the control group receiving two leaflets—one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment. The primary outcomes were the proportion of at‐risk alcohol use measured by AUDIT‐C scale and the proportion of patients attending specialized treatment at 1.5 months.

Results

Of 3,027 patients presenting to the ED, 2,044 (67%) were potentially eligible to participate, 247 (12%) screened positive for at‐risk drinking, and 200 agreed to participate. Seventy‐two percent of the participating sample were men, and the mean (±SD) age was 43 (±16.7) years. Follow‐up rates were 76.5%. At 1.5 months, the intervention group showed greater reductions in alcohol consumption and fewer patients continuing with at‐risk alcohol use (27.8% vs. 48.1%; p = 0.01). The SBIRT program also increased the probability of attending specialized treatment, compared to the control condition (23% vs. 9.8%, p = 0.0119)

Conclusion

The SBIRT program in the ED was found to be feasible and effective in identifying at‐risk drinkers, reducing at‐risk alcohol use, and increasing treatment for alcohol problems.

     

Review article: Effectiveness of ultra‐brief interventions in the emergency department to reduce alcohol consumption: A systematic review

To assess the effectiveness of ultra‐brief interventions (ultra‐BI) or technology‐involved preventive measures in the ED to reduce alcohol harm and risky drinking. Medline, Embase, PsycINFO, CINAHL and EBM reviews were searched for articles published between 1996 and 2015. Randomised controlled trials and quasi‐randomised trials, which compared an ultra‐BI with screening, standard care or minimal intervention for adults and adolescents at risk for alcohol‐related harm presenting to an ED, were included. Outcomes of interest were frequency of alcohol consumption, quantity of alcohol consumed, binge drinking and ED representation. Thirteen studies (nine single centre and four multicentre) were included. Six studies showed a significant reduction in the quantity consumed with intermediate effect size at 3 months (d = ?0.40) and small effect size at 12 months (d = ?0.15). Two studies showed a significant reduction in binge drinking with small effect size at 3 months (d = ?0.12) and 12 months (d = ?0.09). No studies showed an effect on frequency of alcohol consumption or ED representation. Heterogeneity in study design, definition of risky, harmful or hazardous alcohol use, intervention types, outcomes, outcome timeframes and outcome measures prevented the performance of quantitative meta‐analysis. Despite its limited effectiveness in reducing alcohol use in the short‐term, with the large number of people attending EDs with risky drinking, the use of an effective ultra‐BI would have the potential to have a measurable population effect.     

Predictors of hazardous drinking among home drinkers

Introduction and Aims: The United Kingdom has witnessed a shift from drinking in bars to drinking at home; to date, this phenomenon has received little international attention. The aim of this study was to examine the predictors of hazardous drinking (HD) levels when drinking at home. Design: An internet survey of university staff (n = 488) was given. Methods: Following an elimination process (p ≤ 0.05), a regression analysis was conducted using AUDIT scores as cutoffs of ≥6 females, and ≥8 males; these are consistent with most international research. Results: There were 286 hazardous drinkers (HD) (181, females 63.3%) and (105, males 36.7%). The variables that predicted HD were female (OR = 5.42 95% CI 1.87–15.66), younger age, greater frequency of consuming alcohol at home, preloading (drinking before going out), purchasing alcohol in an off license, and drinking alcohol at home because it is cheaper than drinking out. Discussion and Conclusions: These findings point to an interaction of gender, age purchasing patterns, and motivations contributing to hazardous drinking at home and indicate further profitable areas of national and international research.     

Effects of an intervention brochure on emergency department patients' safe alcohol use and knowledge

Alcohol abuse is a leading cause of morbidity and mortality in the United States, contributing to over 100,000 deaths and costing society over 185 billion dollars each year. The objective of this study was to evaluate the effects of the American College of Emergency Physician's brief alcohol use intervention brochure on patients' hazardous drinking behavior and knowledge of safe alcohol use. We conducted a controlled trial comparing Emergency Department (ED) subjects receiving the alcohol use intervention brochure vs. receiving no brochure. One-month outcome measures included the following: 1) change in days of hazardous drinking; 2) change in knowledge of safe alcohol use; and 3) movement along a readiness-to-change continuum for excessive alcohol use. Of 277 subjects, 252 (91.0%) agreed to participate, and 188 of these (74.6%) were successfully contacted for 1-month follow-up assessment. We did not find any significant decreases in days of hazardous drinking or increases in knowledge of safe drinking limits for either the intervention or comparison groups. However, among the subgroup of excessive alcohol users (n = 100), we found that significantly more intervention subjects had advanced along the readiness-to-change continuum than comparison subjects (p < 0.01). This effect was even greater among the intervention group subjects who stated that they read the brochure (p < 0.001). A brief alcohol use intervention brochure does not affect ED patients' hazardous drinking behavior or knowledge of safe alcohol use. The brochure, however, may affect certain patients' motivation to change their drinking behavior. Changing drinking behavior requires more than simply handing out a brochure in the ED; referral to community resources for those motivated to change is likely an important component to successful management of this problem.     

Alcohol consumption among Australian nurses: A cross-sectional national survey study

BackgroundNurses are the largest profession within the health workforce. Limited available literature suggests high rates of alcohol consumption may occur among Australian nurses.AimTo determine the prevalence of high-risk alcohol consumption among Australian nurses.MethodsA cross-sectional national survey was distributed via professional groups and social media to Australian nurses. Participants provided demographic information and completed a modified Perceptions of Work Stress Scale. The 10-item Alcohol Use Disorders Identification Test (AUDIT) was used to explore nurses’ self-reported alcohol consumption. Surveys were conducted between July and October 2021.FindingsThe overall prevalence of risky drinking was 36.9% among participants; 26.1% at risky or hazardous levels, 5.6% at the high-risk or harmful level, and 5.1% at high-risk, almost certainly dependent levels. Correlations between work setting, stress, and risky alcohol consumption revealed nurses working in Emergency Departments were most likely to report higher perceived stress and AUDIT scores.DiscussionThe prevalence of high-risk alcohol consumption among Australian nurses was higher than previously reported. The COVID-19 pandemic emerged as a potential factor contributing to increased stress and alcohol consumption among Australian nurses.ConclusionGiven the current vulnerability in the nursing workforce, tailored interventions are urgently required to address high-risk alcohol consumption.     

Predictors of hazardous alcohol consumption among patients with cluster headache

The purpose of this study was to identify predictors of hazardous alcohol consumption in patients with cluster headache (CH). We investigated 246 German CH patients with the Alcohol Use Disorders Identification Test (AUDIT). The average daily alcohol consumption was 6.5 g. Predictors for hazardous drinking (AUDIT>or=5 points; 21.5% of patients) were male gender [odds ratio (OR) 4.15, 95% confidence interval (CI) 1.35, 12.71], episodic as opposed to chronic CH (OR 4.8, 95% CI 1.38, 16.67) and a low demanding job as opposed to a high demanding job (OR 2.28, 95% CI 1.15, 4.51). Our data indicate that CH patients drink less alcohol compared with the German population and that CH seems to protect against hazardous alcohol consumption. Moreover, predictors for hazardous alcohol consumption in CH patients are not different from the general population.     

Hazardous and harmful drinking: a comparison of the AUDIT and CAGE screening questionnaires

BACKGROUND: Hazardous and harmful use of alcohol remains a public health concern, and many general hospital admissions are alcohol-related. AIM: To compare the CAGE and Alcohol Use Disorders Identification Test (AUDIT) questionnaires in screening general medical admissions for harmful or hazardous drinking. DESIGN: Prospective questionnaire-based study. METHODS: Both questionnaires were administered, and demographic data collected. RESULTS: One hundred and three patients were included. Of these, 36% were identified by the AUDIT to be drinking hazardously or harmfully, and 22% were identified as CAGE cases. All CAGE cases were also AUDIT cases. DISCUSSION: As the CAGE and the AUDIT are designed to identify different populations, it is not surprising that significantly fewer cases were identified using the CAGE. The AUDIT identifies not just the harmful drinkers detected by the CAGE, but also hazardous drinkers, who have not yet reached that level of harm. As drinkers at an earlier stage may respond better to interventions aimed at reducing their consumption, the AUDIT is preferable in clinical practice.     

Readiness to change problematic drinking assessed in the emergency department as a predictor of change

OBJECTIVES: The goal of this study was to determine if baseline readiness to change the drinking behavior (pre-contemplation, contemplation, preparation, and action stages) was predictive of change in drinking after unrelated emergency department (ED) visit and screening and interviewing for alcohol problems. METHODS: From August 1998 through December 2000, the Alcohol Use Disorders Identification Test (AUDIT) was administered to all consented ED patients aged 18 to 29 years. A brief motivational interviewing was provided to screen-positive patients (AUDIT score >5 of 40). Outcome at 3-month follow-up was measured as a decrease in the scores within the AUDIT domains of alcohol intake, harm, and dependency. RESULTS: Sixty percent of the screen-positive patients continued to drink at 3 months. Patients became more open to change their drinking behavior. Compared with patients in the pre-contemplation stage, those in the action stage were twice as likely to reduce their alcohol intake (OR, 2.24; 95% CI, 1.06-4.72), nearly 3 times as likely to reduce their alcohol-related harm behavior (OR, 2.80; 95% CI, 1.59-4.91), and almost 4 times more likely to decrease their dependency symptoms (OR, 3.59; 95% CI, 1.97-6.57). Compared with pre-contemplation patients, those in the contemplation stage were nearly twice as likely to reduce their alcohol-related harm (OR, 1.85; 95% CI, 1.02-3.33) and those in the preparation stage were more than twice as likely to reduce their dependency symptoms (OR, 2.20, 95% CI, 1.13-4.27). CONCLUSIONS: Stages of change at baseline appeared to be significant predictors of change in alcohol intake, harm, and dependency symptoms among young adult ED patients.     

Tropisetron versus metoclopramide for the treatment of nausea and vomiting in the emergency department: A randomized,double‐blinded,clinical trial

Aim: We aimed to compare the relative efficacy of tropisetron and metoclopramide in treating nausea/vomiting in undifferentiated ED patients. Methods: We undertook a randomized, double‐blinded, clinical trial. Adult patients requiring treatment for nausea/vomiting were randomly assigned to either tropisetron (5 mg) or metoclopramide (10 mg), by i.v. bolus. The primary end‐point was incidence of vomiting. Secondary end‐points were decrease in nausea score from baseline (0–100 VAS), the requirement of ‘rescue’ anti‐emetics, ongoing nausea over 48 h and side‐effects. Results: Fifty patients were enrolled in each group. The demographic variables, presenting complaints and nausea scores at baseline did not differ (P > 0.05). By 180 min, two (4.0%) and nine (18.0%) patients had vomited in the tropisetron and metoclopramide groups respectively (difference 14.0%, 95% CI 0.1–28.0, P= 0.05). Also, there were two and 20 episodes of vomiting respectively. Vomiting rates were 0.02 and 0.16 episodes/person‐hour (difference 0.14 episodes/person‐hour, 95% CI 0.07–0.21, P < 0.001) respectively. By 60 min and thereafter, the decrease in nausea score from baseline was greater (although not significantly so) in the tropisetron group. At 180 min, the decreases were 47.9 mm and 37.0 mm respectively (difference 10.9 mm, 95% CI ?0.7–22.6). Five (10.0%) and 13 (26.0%) patients required a rescue anti‐emetic respectively (difference 16.0%, 95% CI ?0.7–32.7, P= 0.07). Of patients followed up, 13/47 (27.7%) and 20/49 (40.8%) had ongoing nausea respectively (difference 13.2%, 95% CI ?7.7–34.0, P= 0.25). The tropisetron group had less akathisia. Conclusions: Tropisetron was associated with a significantly lower vomiting rate and shows promise as an alternative anti‐emetic in the ED.     

Helping methadone patients who drink excessively to drink less: short-term outcomes of a pilot motivational intervention

Opiate addicts receiving methadone treatment who drink alcohol excessively tend not to reduce their drinking, which may imperil continued treatment as well as increasing health risks. The first study asked 136 methadone patients in a community treatment service about their alcohol consumption and requested the 116 who reported drinking during the previous year to complete the AUDIT. Thirty-two (24% of all) reported drinking above 'safe limits' (< 21 units per week for men, < 14 for women) during the previous week: 49 (36% of all) had AUDIT scores of 8 or more. A significant minority are potentially at risk. The second study explored the possibility of helping such patients to drink less by offering nine sessions of focussed help (involving the Drinkers' Check-up) using motivational interviewing techniques. Of the 39 patients referred, 22 attended for assessment, were identified as having a drinking problem, and were offered the structured intervention. Fourteen took up the offer, of whom 11 had good short-term outcomes (10 stopped drinking, and one reduced weekly consumption from 90 units to 30); three did not reduce their consumption. These short-term results encourage the development of ways of helping this group: the experience of providing the service suggests ways of doing this.     

Analgesic usage and reasons for emergency department attendance in ambulatory care patients with minor injury

Objective: The aim of the present study was to determine the reasons for which patients with minor injury attend the ED, comparing those who have and have not self‐administered analgesia. Secondary outcomes were to quantify the proportion of patients who present without having taken analgesia, to describe the reasons why analgesia was not taken, and to compare pain scores between the two groups. Methods: Prospective observational study of adult patients with minor injury presenting to the Emergency Department of Palmerston North Hospital, Palmerston North, New Zealand. Participants answered a questionnaire about their analgesic usage and reasons for ED attendance. Results: Four hundred and seventy‐three patients were enrolled, of which 63.9% had not self‐administered analgesia. The most common primary reasons for ED attendance were for diagnosis (49.6%), and for treatment (31.3%). Patients who had not self‐administered analgesia were significantly less likely to be seeking analgesia than those who had (22.8% vs 39.2% [P < 0.001]). They were also less likely to want an X‐ray (31.8% vs 46.8% [P= 0.001]) and had a significantly lower pain score than those who had taken analgesia (47.2 vs 59.8, [P < 0.001]). They were significantly more likely to have come primarily for treatment (35.8% vs 23.1% [P= 0.017]). The most commonly cited reasons for not taking analgesia were ‘didn't have any handy’ (31.0%), or ‘didn't have time’ (27.4%). Conclusion: The majority of patients who attend ED with minor injury have not taken analgesia. They come primarily for diagnosis and treatment, and often believe that their condition is too urgent to stay at home and take analgesia. Pain is usually not their main concern.     

Screening for hazardous/harmful alcohol consumption amongst general hospital in-patients: establishing concurrent validity of the Alcohol Use Disorders Identification Test in the UK

Aim The study aimed to establish the concurrent validity of the Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for use in the identification of potential problem drinkers amongst general hospital in-patients in the UK.

Design Survey/correlational.

Setting General medical, surgical, otolaryngology and dermatology wards of a general hospital.

Participants One hundred and eighty-three male and thirty-two female, general hospital in-patients aged between 18 and 75 years.

Measurements Self-reports of weekly alcohol consumption (WAC), AUDIT, and Short Alcohol Dependence Data (SADD) questionnaire.

Findings Correlations were computed using Spearman's rank correlation coefficient. The linear relationship between the scores obtained from the AUDIT and SADD indicated a good concurrent validity (r = 0.87, P < 0.001). The correlations between the AUDIT and WAC also suggested a significant correlation (r = 0.76, P < 0.001).

Conclusions The data presented in this study can be interpreted as important in supporting evidence for the concurrent validity of the AUDIT in the UK, for the given setting and subjects described. The efficacy of the AUDIT as a screening instrument within the UK amongst both similar and diverse samples and settings merits future research.     

Comparison of two clinical scoring systems for emergency department risk stratification of suspected acute coronary syndrome

Objective: To compare two methods of risk stratification for suspected acute coronary syndrome (ACS) in the ED. Methods: A prospective observational multicentre study was undertaken of patients undergoing evaluation in the ED for possible ACS. We compared the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline and the Thrombolysis in Myocardial Infarction (TIMI) risk score for differentiating high‐ and low‐risk patients. Composite outcome was all cause death, myocardial infarction or coronary revascularisation within 30 days. Results: Of 1758 enrolments, 223 (13%) reached the study outcome. Area under the receiver operator characteristic (ROC) curve was 0.79 (95% CI 0.76–0.81) for the NHF/CSANZ group and 0.71 (0.68–0.75) for TIMI score based on initial troponin result (P < 0.001), and 0.82 (95% CI 0.80–0.84) and 0.76 (0.73–0.79) respectively when the 8–12 h troponin result is included (P = 0.001). Thirty day event rates were 33% for NHF/CSANZ high‐risk vs 1.5% for combined low/intermediate risk (P < 0.001). For TIMI score, 30 day event rates were 23% for a score ≥2 and 4.8% for TIMI < 2 (P < 0.001). The NHF/CSANZ guideline identified more patients as low risk compared with the TIMI risk score (61% vs 48%, P < 0.001). Conclusions: The NHF/CSANZ guideline is superior to the TIMI risk score for risk stratification of suspected ACS in the ED.     

Reduced access block causes shorter emergency department waiting times: An historical control observational study

Objective: To study the effect of changes in hospital occupancy and ED occupancy on ED waiting times during a 13‐day period of improved bed access. Methods: A comparative, observational study of 1133 ED attendances in the study period and 2332 attendances in a historical control period. Results: During the study period, mean hospital occupancy decreased from 94.9% to 89.0% (P < 0.001), mean ED occupancy decreased from 19.1 to 14.8 patients (P < 0.001) and the mean ED waiting time decreased from 58.5 to 37.1 min (P < 0.001). There were statistically significant reductions in waiting times for patients in Australasian triage scale (ATS) categories 2–5. Departmental staffing levels, attendances and patient acuity were not significantly different during the study and control periods. Conclusions: Modest decreases in hospital occupancy resulted in highly significant reductions in ED waiting times. Emergency department overcrowding due to large numbers of admitted patients awaiting hospital admission is a major cause of ED dysfunction.     

Outcomes in patients with an emergency department diagnosis of fever of unknown origin

Objective: To describe the outcomes in patients given an ED diagnosis of fever of unknown origin (FUO). Methods: A retrospective analysis of ED records linked to hospital morbidity, mortality and microbiology records of patients presenting to Western Australia’s teaching hospitals from July 2000 to July 2003. Results: There were 3218 presentations diagnosed with FUO, 2049 (63.7%) children (median age 1.8 years) and 1169 (36.3%) adults (median age 56.0 years). FUO accounted for 0.3% of adult and 1.5% of paediatric ED presentations. Overall, 1997 (62.1%, 95% confidence interval 60.4–63.8%) were admitted (82% adults vs 50.7% children; P < 0.001). Adults had a longer median length of stay than children (4 days vs 2 days; P < 0.001) and a higher proportion of positive blood cultures (admissions 15.1%vs 4.9%; P < 0.001) commonly with Escherichia coli. Streptococcus pneumoniae was the most common organism isolated from children. Of 3053 FUO index presentations, 338 (11.1%, 95% confidence interval 10.0–12.2%) re‐presented. Children were more likely to re‐present than adults (13.5% of 1959 vs 6.8% of 1094; P < 0.001). Conclusions: Fever of unknown origin is diagnosed less frequently in adults than in children. Adult patients are more likely to be admitted, have longer lengths of stay and have positive blood cultures. Although FUO is diagnosed infrequently in the ED, blood cultures remain useful in the evaluation of unexplained fever, particularly in adults as age increases.     

Adolescent Suicide Risk Screening in the Emergency Department

Objectives: Many adolescents who die by suicide have never obtained mental health services. In response to this, the National Strategy for Suicide Prevention recommends screening for elevated suicide risk in emergency departments (EDs). This cross‐sectional study was designed to examine 1) the concurrent validity and utility of an adolescent suicide risk screen for use in general medical EDs and 2) the prevalence of positive screens for adolescent males and females using two different sets of screening criteria. Methods: Participants were 298 adolescents seeking pediatric or psychiatric emergency services (50% male; 83% white, 16% black or African American, 5.4% Hispanic). The inclusion criterion was age 13 to 17 years. Exclusion criteria were severe cognitive impairment, no parent or legal guardian present to provide consent, or abnormal vital signs. Parent or guardian consent and adolescent assent were obtained for 61% of consecutively eligible adolescents. Elevated risk was defined as 1) Suicidal Ideation Questionnaire‐Junior [SIQ‐JR] score of ≥31 or suicide attempt in the past 3 months or 2) alcohol abuse plus depression (Alcohol Use Disorders Identification Test‐3 [AUDIT‐3] score of ≥3, Reynolds Adolescent Depression Scale‐2 [RADS‐2] score of ≥76). The Beck Hopelessness Scale (BHS) and Problem Oriented Screening Instrument for Teenagers (POSIT) were used to ascertain concurrent validity. Results: Sixteen percent (n = 48) of adolescents screened positive for elevated suicide risk. Within this group, 98% reported severe suicide ideation or a recent suicide attempt (46% attempt and ideation, 10% attempt only, 42% ideation only) and 27% reported alcohol abuse and depression. Nineteen percent of adolescents who screened positive presented for nonpsychiatric reasons. One‐third of adolescents with positive screens were not receiving any mental health or substance use treatment. Demonstrating concurrent validity, the BHS scores of adolescents with positive screens and the POSIT scores of those with positive screens due to alcohol abuse and depression indicated substantial impairment. The addition of alcohol abuse with co‐occurring depression as a positive screen criterion did not result in improved case identification. Among the subgroup screening positive due to depression plus alcohol abuse, all but one (>90%) also reported severe suicide ideation and/or a recent suicide attempt. This subgroup (approximately 17% of adolescents who screened positive) also reported significantly more impulsivity than other adolescents who screened positive. Conclusions: The suicide risk screen showed evidence of concurrent validity. It also demonstrated utility in identifying 1) adolescents at elevated risk for suicide who presented to the ED with unrelated medical concerns and 2) a subgroup of adolescents who may be at highly elevated risk for suicide due to the combination of depression, alcohol abuse, suicidality, and impulsivity.