Improving detection of alcohol misuse in patients presenting to an accident and emergency department

Objectives—To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT).

Design—Prospective study of the effects of audit feedback.

Setting—An urban accident and emergency department.

Subjects—Senior house officers (SHO) (n = 13).

Outcome measurements—PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT.

Results—1062 of 1737 patients (61.1%) were defined as PAT possible—that is, presented with ≥ one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p<0.0001). The response to audit and feedback showed marked inter-SHO variation. When feedback was withdrawn (month 4), there was a significant reduction in PAT use (p=0.003). Three other indices of detection followed this trend: (a) number of PAT positive patients identified, (b) proportion of PAT possible patients identified as PAT positive, and (c) number of PAT positive patients referred to the alcoholic health worker. The 10 most common PAT positive categories, accounting for 77% of all PAT positive complaints were: fall > collapse (including "fit", "blackout") > head injury (including "facial injury") > assault (including "domestic violence" and `other') > non-specific gastrointestinal problem > "unwell" > psychiatric (including "depression", "overdose", "confusion") > cardiac (including "chest pain" and "palpitations") > self neglect > repeat attendance.

Conclusions—Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.