World-wide injuries account for a substantial proportion of the disability attributable to alcohol, with about 40% of the alcohol-attributable disease burden in injuries (Shield, Gmel, Patra, & Rehm, 2012). The proportion of injuries that can be attributed to alcohol has typically been based on nonrepresentative samples and has assumed that risk of injury related to alcohol is similar across all countries and cultures. Although a high prevalence of heavy, problem, and dependent drinking has been found among emergency department (ED) patients seeking treatment for injuries and alcohol has been found to increase risk of injury (Cherpitel & Driggers, 2005), neither monitoring nor surveillance of alcohol-involved injuries nor identification of problem drinkers is routinely carried out in the ED setting in the United States or elsewhere. Although the rationale for screening and brief intervention is compelling in the ED setting, ED practitioners often believe (among other deterrents) that there is not adequate time to identify problem-drinking patients, much less provide an intervention. If patients who are likely to be problem drinkers could be easily identified, practitioners in the ED may more readily initiate screening of these individuals, and severity of injury and related disability may be two such markers.

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The relationship between alcohol consumption and severity of injury has been an issue of on-going debate with mixed findings (Li, Keyl, Smith, & Baker, 1997) and may be because of alcohol's association with such risk factors as speeding, not wearing seat belts or helmets, or other risk-taking behaviors. It has also been argued that those more severely injured are likely to reach the ED sooner and, consequently, more likely to have a positive (and higher) blood alcohol concentration than those less severely injured who arrive later. Injury severity has largely been based on one of the injury severity scoring systems-the Injury Severity Score (Baker, O'Neill, Hadden, & Long, 1974) or the Abbreviated Injury Scale (Association for the Advancement of Automotive Medicine, 1985)-and alcohol intoxication itself can bias injury severity scores upward, resulting in apparently better survival for those with higher blood alcohol concentrations (Waller, 1988). Less is known about the association of alcohol consumption and related disability from nonfatal injury. Although much of the supporting data have come from aggregate-level findings related to disability-adjusted life years (Ezzati, Lopez, Rodgers, Vander Hoorn, & Murray, 2002), many studies have measured injury-related disability because of acute alcohol consumption by hospital length of stay, but like injury severity, findings have been mixed and appear to be related, at least in part, to type of injury (Plurad et al., 2010; Talving et al., 2010).

Although many of these previous studies of alcohol's association with injury severity and disability have included only patients in U.S. EDs, comparative findings of similar data across various countries and cultures would help support the veracity of such associations. With this in mind, a study of alcohol's association with arrival to the ED by ambulance as an indicator of injury severity and admission to the hospital from the ED as an indicator of disability was conducted in 31 EDs across 15 studies in six countries (United States, Canada, Mexico, Australia, Italy, and Spain; Korcha et al., in press). Although considerable variation was found across ED studies, aggregated findings suggested a dose-response relationship between the number of drinks consumed within six hours before injury and both arrival by ambulance to the ED and, separately, hospitalization after ED admission. Interestingly, there was only a small overlap (20%) in individuals arriving by ambulance and those hospitalized, suggesting that these two indicators are not highly related and are capturing different patients but all with alcohol-related injuries.

The data from this international study suggest that patients arriving by ambulance and, separately, those requiring hospitalization may be likely candidates to undergo screening for problem drinking and alcohol-related problems. Patients arriving by ambulance and those admitted to the hospital from the ED are immediately and easily identifiable for initiating screening, unlike awaiting a discharge diagnosis or an assignment of an injury severity score, both of which often do not occur until well after the ED visit. Whereas the burden of injury in ED admissions from alcohol misuse is known to be large and often underidentified (Indig, Copeland, Conigrave, & Rotenko, 2008; Sethi, Racioppi, Baumgarten, & Bertollini, 2006), implementation of culturally relevant brief intervention in the ED has been shown (Cherpitel, Bernstein, Bernstein, Moskalewicz, & Swiatkiewicz, 2009) and appears to be among the least expensive evidenced-based practices to prevent alcohol-related disease and injury (Cobiac, Vos, Doran, & Wallace, 2009). Identification of these patients is the first step in providing appropriate intervention, and nurses in the ED are uniquely positioned to achieve this important goal.

Acknowledgment

This study was supported by a grant from the U.S. National Institute on Alcohol Abuse and Alcoholism (RO1 AA13750-04).

REFERENCES