Alcohol-Related Presentations to Emergency Departments on Days with Holidays, Social, and Sporting Events: An Integrative Literature Review

Introduction: Events, specifically those where excessive alcohol consumption is common, pose a risk to increase alcohol-related presentations to emergency departments (EDs). Limited evidence exists that synthesizes the impact from events on alcohol-related presentations to EDs. Study Objective: This integrative review aimed to synthesize the literature regarding the impact events have on alcohol-related presentations to EDs. Methods: An integrative literature review methodology was guided by the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) Guidelines for data collection, and Whittemore and Knafl’s framework for data analysis. Information sources used to identify studies were MEDLINE, CINAHL, and EMBASE, last searched May 26, 2021. Results: In total, 23 articles describing 46 events met criteria for inclusion. There was a noted increase in alcohol-related presentations to EDs from 27 events, decrease from eight events, and no change from 25 events. Public holidays, music festivals, and sporting events resulted in the majority of increased alcohol-related presentations to EDs. Few articles focused on ED length-of-stay (LOS), treatment, and disposition. Conclusion: An increase in the consumption of alcohol from holiday, social, and sporting events pose the risk for an influx of presentations to EDs and as a result may negatively impact departmental flow. Further research examining health service outcomes is required that considers the impact of events from a local, national, and global perspective.


Introduction
With many emergency departments (EDs) currently at or over capacity, 1 understanding the impact of events on alcohol-related presentations to EDs can assist in health promotion and preventative strategies, future ED forecasting, ED planning, and ED resource allocation. 2 Alcohol consumption has contributed to an increasing number of ED visits 3 and a higher proportion of alcohol-related presentations to EDs are evident amongst males 4 and occur overnight and on weekends. 5][7][8] Alcohol, a central nervous system depressant, alters communication between the brain and body, exhibiting symptoms of poor concentration, slower reflexes, and increases the threat for risk-taking behaviour. 9The impact from the consumption of alcohol in many countries continues to grow 5,10,11 with alcohol associated with many social and cultural events. 10It is not uncommon for alcohol to be served and/or consumed at some of these events, and in large quantities. 12With reports suggesting that binge drinking is attributed to 75% of all alcohol consumed 13 and that 25% of people aged 14 and above consume more than four standard drinks in one sitting, at least monthly, 10 continued cause for concern exists.This is especially so when considering the longer-term consequences of excessive alcohol consumption which increases the risk for preventable illness, disease, and adverse health effects such as: alcoholic liver cirrhosis, alcohol dependence, depression, suicide, cardiovascular disease, cancer, road traffic accidents, and assaults. 14vents that result in changes to alcohol intake volumes external to ED may result in additional patient presentations to ED and disrupt normal operational capacity.Such events may be considered in terms of being planned or unplanned.6][17] Examples of unplanned events include natural disasters such as earthquake, tsunamis, and hurricanes, humanitarian emergencies such as displaced people, and disease outbreaks such as Ebola, Severe Acute Respiratory Syndrome (SARS), and coronavirus disease 2019 (COVID-19). 180][21][22][23][24][25][26][27][28][29] Less is known regarding the impact unplanned events have on alcohol-related presentations to EDs.Today, events are occurring more frequently, posing the risk for an increase in alcoholrelated presentations to EDs; however, the specific impact varied events have on alcohol-related presentations to EDs is unknown.
The overarching aim of this integrative literature review was to synthesize the literature regarding the impact events have on alcohol-related presentations to EDs.The research was guided by the following questions: How do events impact alcohol-related presentations to the ED? Are there certain periods where there has been an increase or decrease in these presentations?And how does this impact functioning of the ED?

Design
This integrative literature review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines 30 for data collection and Whittemore and Knafl's framework 31 for data analysis.An integrative review design was deemed appropriate as it aims to comprehensively synthesize the literature to generate new insights.The identified papers were screened for eligibility 30 against inclusion and exclusion criteria, as outlined in

Inclusion Exclusion
• Full-text article published in English • Peer-reviewed papers • Published between 2012 -2021 (ten years) • Papers relating to emergency department presentations of alcohol intoxication • Papers relating to events, such as: mass gatherings, social events, sporting events, public holidays, policy change • Papers discussing busy or quiet periods within the emergency department • Theoretical papers

Data Analysis
Analysis was undertaken using the approach from Whittemore and Knafl's framework. 31Information extracted from each paper included: a description of the event, inclusive of duration/dates; the impact of alcohol-related presentations to ED (increase, decrease, or no change); demographics, characteristics, and outcomes of alcoholrelated presentations to ED with regards to the identified event; and a summary of the study characteristics including author(s), population, alcohol-related definitions, sample, and design.

Impact of Events on Alcohol-Related Presentations to EDs
An overview of the identified events and their impact on alcoholrelated presentations to ED are outlined in Table 4.The impact was considered in terms of increase, decrease, or no change in alcohol-related presentations to the ED, as elaborated on below.

Increase in Alcohol-Related Presentations to EDs
2][23][24] Four papers reported an increase in alcohol-related presentations following a policy change, such as the implementation of a university policy, 29,43 introduction of a Goods and Services Tax (GST), 39 and a change in trading hours. 44Public holidays were documented in two papers 35,42 with an increased risk and/or increase in alcohol-related presentations noted on: Christmas Eve; Christmas Day; New Year's Eve; New Year's Day; Easter Sunday; June Bank Holiday; St. Patrick's Day; St. Stephen's Day; the day prior to Australian New Zealand Army Corps (ANZAC) day; and the day prior to New Year's Day. 35,42Two papers focusing on social events reported that birthday celebrations, especially ages 19, 20, 21, and 22, 36 and the last working day before Christmas 42 were associated with an increase in alcohol-related ED presentations.Three papers focusing on sporting events reported an increase in alcohol-related presentations, most notably from the EURO-16 Football Cup, 2011 Rugby World Cup, Australian Football League (AFL) grand final day, Commonwealth Games and Melbourne Cup Day sporting events, 19,20,42 and especially on game days as opposed to non-game days. 19crease in Alcohol-Related Presentations to EDs Seven papers reported on eight events that impacted the ED by way of a decrease in alcohol-related presentations. 25,27,28,35,38,39,44Five papers reported a decrease in alcohol-related presentations following policy changes. 25,27,28,38,44Good Friday was the only documented public holiday where a decrease in alcohol-related presentations was reported. 35[40][41][42] Five papers identified no change in presentations following policy changes pertaining to a change in trading hours, increase in alcopops tax, and the implementation of new licensing laws. 26,33,34,40,41One paper identified no change in presentations from public holidays including August, May, and October bank holidays, and Easter Monday and Saturday. 35Two papers identified no change from sporting events including professional golf tournament and Geelong Football games. 25,37One paper focusing on both public holidays and sporting events reported no change in presentations from the following events: Australia Day; Boxing Day; Christmas Day; Easter; Labor Day; Queen's birthday; St. Patrick's Day; Formula 1 Grand Prix; International Soccer matches; and World Cup Soccer matches. 42aracteristics, Demographics, and Outcomes of Alcohol-Related Presentations to EDs from Events Of the included studies, a summary of the characteristics, demographics, and outcomes of alcohol-related ED presentations from events is presented in Supplementary Table S4 (available online only).38,43 Where sex (or gender) was included, men were reported as more likely to present in seven studies; 19,22,27,36,38,39,43 women were more likely to present in two studies. 21,23Four papers included breath or alcohol levels ranging from 104mg/dL to 412mg/dL 21,27,29,43 and one paper elaborated on other substances such as amphetamines and marijuana used in combination with alcohol. 22Eight papers identified outside normal working hours and weekends as busy periods in EDs, specifying times from 5:00PM to 02:15AM are considered "high alcohol times," and individual days such as opening ceremonies for sporting events. 20,22,27,28,35,36,38,43The ED length-of-stay (LOS) was only reported in three United States studies where the events were one music festival, 22 a range of music festivals, 21 and a university alcohol policy. 29For these studies, ED

Discussion
This integrative review of the literature explored the impact events have on alcohol-related presentations to EDs.The rate of alcoholrelated presentations to EDs was not clearly articulated in the studies included in this review.Key findings that emerged from the review indicate that for some events, such as music festivals, public holidays, social events, and large sporting events, there was an increase in alcohol-related presentations to EDs.Impact tended to be reported in terms of number of presentations, ED LOS, and discharge disposition from ED.For those events where there was no change in alcohol-related presentations, this may reflect the nature of the event, availability of medical services at the event, or that there was an increase in ED presentations from the event, but they were not necessarily alcohol-related or given an ICD-10 code of alcohol intoxication due to other illness and accompanying injuries.In order to support and plan for future events and impacts on EDs from people who are intoxicated from alcohol, the following discussion is framed around considerations of clinical, workforce, and policy strategies.

Clinical Strategies
Strategic planning for the impact events may have on EDs should have set goals and outcomes and be guided by prior evidence. 45his review found that certain types of events, including music festivals with crowds of >5000, public holidays, especially Christmas Eve, and large sporting events such as the EURO-16 Football Cup, impacted EDs more so than others in terms of alcohol-related presentations.Clinically driven strategies such as in-event health services 2 and community sobering shelters have been reported to reduce ED presentations of alcohol intoxication, 25 and thus warrant consideration during and following these types of planned events.

Workforce Strategies
With a noted increase in ED presentations from particular events, appropriate staffing is needed to meet patient demands. 45,46  needs of the patient. 45,46Along with and nursing workforce, broader specialist workforce support from social workers and Alcohol and Other Drugs Services (AODS) warrant consideration.The ability to "flex up" the number of these staff and extend usual working hours may be required and should be included in known event planning considerations.Further research regarding the economic benefits of having additional staff at the event versus additional staff in the ED should be explored.

Policy and Education Strategies
When public policy changes were considered as an event, studies included in this review reported either an increase, reduction, or no change in ED impact regarding alcohol-related presentations.Alcohol-related policy measures range from changing liquor licensing opening hours, 28,44 reducing the affordability of alcoholic products, [39][40][41]47 and prohibiting the consumption of alcohol and/ or possession of open containers in public spaces. 48 long with these policy measures, educational efforts to shift the cultural acceptance of alcohol use by advertising the adverse health effects of alcohol should be pursued, especially for the younger, more vulnerable population.49

Limitations
This integrative review was focused on the impact events have on alcohol-related presentations to EDs.Events can impact EDs in other ways, such as trauma/injury presentations, however the focus of this review was on alcohol intoxication.This review purposefully focused on studies of events and the impact of alcohol-related, specifically intoxication, presentations to the ED.Other reviews have included broader alcohol-related impacts such as accident and injuries that were purposefully excluded here.Findings are limited to those nations for which papers were retrieved, and as such, countries such as low-and middle-income countries may not have been included in the review.

Conclusion
This integrative review explored literature regarding the impact events have on alcohol-related ED presentations.With events grouped into six categories, EDs were most impacted by an increase in presentations from music festivals, public holidays, and in some cases, the day prior to public holidays and large sporting events.Disasters had little impact on alcohol-related presentations to the ED.The consumption of alcohol and binge drinking behaviors at events resulting in an ED presentation is cause for continued efforts to direct public health and emergency care strategies to prevent or minimize alcohol-related harm.Further research examining health service outcomes is required that considers the impact of events on EDs from a local, national, and global perspective.
Netherlands).The search strategy for MEDLINE included different combinations of Medical Subject Headings (MeSH) terms, CINAHL included subject headings and keywords that are relevant to the topic, and EMBASE used keywords by way of EmTree headings.All MeSH terms and keywords are outlined in Table 1.Search strings are presented in Supplementary Table S1, Table S2, and Table S3 (available online only).

Table 1 .
MeSH Terms/Key Words Abbreviation: MeSH, Medical Subject Headings.

Table 2 .
Inclusion and Exclusion Criteria

Table 3 .
Description of Study Characteristics (continued ) Hagan © 2023 Prehospital and Disaster Medicine

Table 3 .
Description of Study Characteristics (continued )

Table 3 .
(continued).Description of Study CharacteristicsNote: Population as defined by study authors; sample refers to the cohort of patients included in the study.

Table 4 .
Description of Event and Impact of Alcohol-Related Presentations to the ED (continued )

Table 4 .
(continued).Description of Event and Impact of Alcohol-Related Presentations to the ED Note: ↑ = Increase; ↓ = Decrease; ∼ = No Change.