A comparison of maxillofacial trauma before and after implementation of lockout laws in Sydney

Copyright © 2018. Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Lockout reforms were introduced in February 2014 by the New South Wales government in an attempt to curb alcohol-related violence in Sydney, following a number of fatalities. Changes include 1.30 am venue lockouts and the 3 am cessation of alcohol service. This study aims to assess the results of these reforms through analysis of departmental treatment data. All maxillofacial fractures that required operative management at St Vincent’s Hospital, Sydney, over a two-year period pre and post reforms were analysed.


Introduction
Thousands of people each weekend visit the plethora of bars, clubs and restaurants within Sydney's entertainment precincts. 1,2 The majority of patrons peacefully enjoy the broad spectrum of entertainment that Sydney has to offer yet alcoholrelated violence has been on the increase in recent years.
While the relationship between alcohol and violence is complex, a high blood alcohol concentration level is a risk factor for violence.
Australian research suggests that alcohol is a factor in 23-73 per cent of assaults. 3,4,5 Alcohol-related violence has long been an issue of public concern in Australia, particularly in the state of New South Wales (NSW) following a number of fatalities from 'coward punches' or 'king hits' (a single punch to the head knocking someone unconscious or down to the ground). Some of the key restrictions included in the reforms were: 1. 1.30 am Lockouts at hotels, registered clubs, nightclubs and karaoke bars in two designated areas: the Sydney CBD entertainment and Kings Cross precincts.
2. 3.00 am Cessation of alcohol service in venues in these precincts.

A freeze on new liquor licences and approvals
for existing licences across the Sydney CBD entertainment precinct and continuation of the existing freeze in the Kings Cross precinct. 4. A ban on takeaway alcohol sales after 10 pm across NSW. 5. The extension of temporary and long-term banning orders issued to designated alcohol/ trauma convicted or known felons to prevent them entering most licensed premises in the two precincts. 6 Restrictions to last drink timings have been enforced in many metropolitan cities around the Despite the introduction of the reforms, assault was still the most common method of injury in both periods-64.5% to 44.8% (p=0.02) ( Table 1).
The number of operations secondary to a fall (such as alcohol-related or perhaps syncopal events etc.) fell slightly from 28 to 22. Motor vehicle accidents accounted for only a small proportion of known cases and did not change over the two years-sic pre (4.3%) and three post (5.2%).
Fracture patterns were also analysed between the two periods. Before the reforms the most common fracture operated on was on the mandible followed by nasal bones, which reversed in order post-

reforms. Orbital fractures halved and zygomatic
operations fell by 83.3 per cent. The only fracture pattern that increased was frontal sinus injuries from three to four ( Table 2).
Approximately half of cases (57%) in the last two years were related to alcohol compared to a higher proportion prior (70%). However, the fall in intoxicated cases had not statistically changed.
These numbers included sober individuals that were assaulted by an intoxicated person, or who were sober at the time of presentation to the emergency department (typically the following morning) but reported being intoxicated at the time. Alcohol/drug related injuries without clear ORIGINAL ARTICLE Chopra, van der Rijt, Ngo et al: A comparison of maxillofacial trauma before and after implementation of lockout laws in Sydney documentation of the patient's alcohol status or formal blood alcohol count measured were regarded as 'unknown' ( Table 3).
There has been speculation that the reduction in alcohol-related assaults is a consequence of patrons This is the first published paper on the effect of the reforms on maxillofacial surgery and by having a hospital uniquely placed in the centre of the two restriction zones also means that our results are the most indicative. Assault has now succeeded motor vehicle accidents as the most common cause of maxillofacial surgery occurring in the street or within establishments that serve alcohol. We hope that the results from this study will be used by key stakeholders and policy makers to amend and refine strategies on a complex and multi-factorial problem. Further, more targeted interventions may be necessary than reforms that restrict all.

Limitations
The limitation to this study is that this is just one specialty area within a broad scope of trauma.
Even though the study was conducted over a two year period, ideally, it also needed to be statistically