Cause of casualty and drinking patterns: an emergency room study of unintentional injuries

Surveillance of alcohol-related injuries in two Canadian emergency department settings: an analysis and commentary

A descriptive epidemiological study was conducted to: (1) describe patterns of alcohol-related injury observed in two emergency departments (EDs) in Kingston, Ontario, and (2) discuss limitations inherent to the collection of these data. The study examined all persons presenting for injury treatment where alcohol was indicated as being involved. In total, 1,970 alcohol-related injuries were identified for the years 1994-1996. Major patterns of alcohol-related injury presenting to the ED include: (1) fights

Alcohol and risk of admission to hospital for unintentional cutting or piercing injuries at home: a population-based case-crossover study

Background

Cutting and piercing injuries are among the leading causes of unintentional injury morbidity in developed countries. In New Zealand, cutting and piercing are second only to falls as the most frequent cause of unintentional home injuries resulting in admissions to hospital among people aged 20 to 64 years. Alcohol intake is known to be associated with many other types of injury. We used a case-crossover study to investigate the role of acute alcohol use (i.e., drinking during the previous 6 h) in unintentional cutting or piercing injuries at home.

Methods

A population-based case-crossover study was conducted. We identified all people aged 20 to 64 years, resident in one of three regions of the country (Greater Auckland, Waikato and Otago), who were admitted to public hospital within 48 h of an unintentional non-occupational cutting or piercing injury sustained at home (theirs or another's) from August 2008 to December 2009. The main exposure of interest was use of alcohol in the 6-hour period before the injury occurred and the corresponding time intervals 24 h before, and 1 week before, the injury. Other information was collected on known and potential confounders. Information was obtained during face-to-face interviews with cases, and through review of their medical charts.

Results

Of the 356 participants, 71% were male, and a third sustained injuries from contact with glass. After adjustment for other paired exposures, the odds ratio for injury after consuming 1 to 3 standard drinks of alcohol during the 6-hour period before the injury (compared to the day before), compared to none, was 1.77 (95% confidence interval 0.84 to 3.74), and for four or more drinks was 8.68 (95% confidence interval 3.11 to 24.3). Smokers had higher alcohol-related risks than non-smokers.

Conclusions

Alcohol consumption increases the odds of unintentional cutting or piercing injury occurring at home and this risk increases with higher levels of drinking.

Alcohol and driving factors in collision risk

In this study we examine the effect of several alcohol-related measures on self-reported collision involvement within the previous 12 months while controlling for demographic and driving exposure factors based on a large representative sample of adults in Ontario. Data are based on the 2002-2006 Centre for Addiction and Mental Health Monitor, an ongoing cross-sectional telephone survey of Ontario adults aged 18 and older (n=8542). Three logistic regressions of self-reported collision involvement in the past 12 months were implemented, each consisting of 3 steps: (1) demographic factors and driving exposure entered, (2) driving after drinking within the last 12 months entered, and (3) one of three alcohol-related measures (AUDIT subscales of alcohol consumption, dependence and problems) entered. In each step, measures from the preceding step were included in order to control for those variables. In Step 1, age (OR=0.989), region overall, Central East region (OR=0.71), West region (OR=0.67), and North region (OR=0.67), income overall and those who did not state income (OR=0.64), marital status overall and those married or living common law (OR=0.60), and number of kilometers driven in a typical week (OR=1.00) were found to be significant predictors of collision involvement. The analyses revealed that driving after drinking was a significant predictor of collision involvement in Step 2 (OR=1.51) and each of the Step 3 models (ORs=1.52, 1.37, 1.34). The AUDIT Consumption subscale was not a significant factor in collision risk. Both the AUDIT Dependence and AUDIT Problems subscales were significantly related to collision risk (ORs=1.13 and 1.10, respectively). These findings suggest that alcohol, in addition to its effects on collision risk through its acute impairment of driving skills, may also affect collision risk through processes involved when individuals develop alcohol problems or alcohol dependence.

Causes, types and severity of injury among army soldiers hospitalized with alcohol comorbidity

AIM

To examine the relationship between alcohol use and the cause, type and severity of hospitalized injuries.

DESIGN/SETTING

We used the Total Army Injury and Health Outcomes Database (TAIHOD) to conduct cross-sectional analyses of the association between alcohol comorbidity and the cause, type and severity of soldiers' non-combat injuries requiring hospitalization.

PARTICIPANTS

Subjects were active-duty US army soldiers (n = 211 790) hospitalized with a primary diagnosis of injury between 1980 and 2002.

FINDINGS

Alcohol comorbidity was positively associated with hospitalized injuries resulting from fights and falls and negatively associated with sports injuries; positively associated with hospitalized cases of head injury, open wounds and poisonings and negatively associated with musculoskeletal injury; and, overall, associated with shorter length of stay. Controlling for demographic factors did not moderate the association between alcohol and cause, type or severity of injury.

CONCLUSION

Alcohol comorbidity is specifically associated with injuries related to impairment and antisocial behavior.

Frequency of heavy episodic drinking among nonfatal injury patients attending an emergency room

This study investigated the relationship between frequency of heavy episodic drinking and nonfatal injury in four categories: environment, external cause, diagnosis, and activity at the time of injury. Data were collected over 18 months at the emergency room facility of a Swedish hospital. Injury patients aged 18-70 years answered an alcohol screening questionnaire. Heavy episodic drinking was measured as drinking six glasses (72 g alcohol) or more per occasion, for both males and females. A total of 2211 patients were enrolled in the study (79.5% completion rate). Demographic and drinking characteristics for the patients were compared to those of the general population, data for which were derived from a population-based survey. The proportion of people who reported heavy episodic drinking once a month or more was nearly twice as large among the injury patients as in the general population. However, age and sex outweighed heavy episodic drinking as risk factors for most injury types. There were 11 significant associations between frequency of heavy episodic drinking and injury types in the four injury categories, yet no linear trends of increased likelihood of injury with increased frequency of heavy episodic drinking could be discerned.

Usual drinking patterns and non-fatal injury among patients seeking emergency care

OBJECTIVES

To explore the association between drinking patterns, irrespective of whether alcohol was consumed in the event of the injury or not, and different injury variables; and to identify settings and situations in which risky drinkers have an increased likelihood of injury.

STUDY DESIGN

The study population consisted of all patients aged 18-70 years registered for an injury according to ICD-10 at a Swedish emergency department during an 18-month period. After informed consent, the injury patients were screened for drinking habits by the AUDIT-C questionnaire. The gender, age and drinking pattern of injury patients were compared with the general population.

METHODS

A total of 2782 patients aged 18-70 years were registered for an injury during the study period. The number of drop-outs was 631. Drop-outs include those who did not consent to participate, were severely injured, too intoxicated or did not fill out the questionnaire satisfactory. Thus, 77.3% of the target group were included for further analysis (1944 drinkers and 207 abstainers). The patients were categorized into three drinking categories: abstainers, non-risky and risky drinkers. Risky drinkers were defined according to usual weekly consumption of 80g or more of alcohol for women and 110g or more for men and/or heavy episodic drinking (i.e. having six glasses or more one glass=12g alcohol), or both, on one occasion at least once a month, valid for both women and men. To estimate the relationship between drinking patterns and the injury variables (environment, cause of injury, activity and diagnosis), odds ratios (OR) were calculated by logistic regression. Multiple logistic regression was used in order to control for age and sex differences between the various drinking and injury categories.

RESULTS

The proportion of risky drinkers was higher in the study population compared with the general population in the same area. When controlling for age and sex, risky drinkers (OR 6.4(adj) Confidence interval CI 1.9-21.2) and non-risky drinkers (OR .4.5(adj) CI 1.4-14.5) displayed an increased risk for injury compared with abstainers, in amusement locations, parks, by or on lakes or seas, especially while engaged in play, hobby or other leisure activities (risky drinkers: OR 2.8(adj) CI 1.3-5.6; non-risky drinkers: OR 2.4(adj) CI 1.2-4.6). All differences between drinking patterns in external cause of injury disappeared when age and sex were considered. During rest, meals and attending to personal hygiene, the non-risky drinkers had a lower probability of injury compared with abstainers (OR 0.3(adj) CI 0.1-0.8). Non-risky drinkers had a higher probability than abstainers of suffering luxation (dislocation) or distortion (OR 1.6(adj) CI 1.1-2.5). Nine per cent of the study population reported that they believed that their injury was related to intake of alcohol. Half of this group were non-risky drinkers (CI for the 13.7% difference was 9.7-17.6).

CONCLUSIONS

Few significant associations between drinking pattern and injury remained when age and sex were controlled for.

Alcohol-related Injuries at an emergency department in Eastern Taiwan

BACKGROUND/PURPOSE

Injuries are major causes of mortality and morbidity in Taiwan. Alcohol involvement often plays a role in injuries. The purpose of this study was to determine the prevalence of alcohol-related injuries at an emergency department in Eastern Taiwan and their associated factors.

METHODS

All injured patients who made emergency visits between October 2002 and September 2003 were enrolled. For each patient, the attending nurse completed an injury-coding sheet, which included the results of an assessment of whether the patient had an alcohol odor or alcohol consumption related behavior. Nurses recorded suspicion of alcohol consumption based on possible categories of "no alcohol odor", "alcohol odor", "intoxicated", "suspected" or "unknown". Blood alcohol testing was also performed based on the decision of the attending physician. Injuries were defined as alcohol-related based on the report of "alcohol odor" or "intoxicated" by the nurse or a positive blood alcohol test. Logistic regression was used to assess the significance of the association of possible related factors with alcohol-related injury.

RESULTS

A total of 8822 eligible visits were studied and 14% were classified as alcohol-related. The proportion of alcohol-related injuries was 14.9% for vehicle-related injuries, and 51.3% for assaults. Male, young to middle aged, aboriginal ethnicity and visits after midnight were factors associated with increased likelihood of alcohol-related injuries. Multiple logistic regression analysis revealed that the three factors most significantly associated with alcohol-related injuries were visits after midnight (odds ratio, OR, 7.5; 95% confidence interval, CI, 6.4-8.9], assaults (OR, 3.4; 95% CI, 2.3-4.8), and head injuries (OR, 2.7; 95% CI, 2.3-3.2).

CONCLUSION

Injuries were alcohol related in one out of seven patients this study from an emergency department in eastern Taiwan. Ongoing epidemiologic monitoring of the prevalence and nature of alcohol abuse among patients visiting the ED are urgently needed.

Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis

OBJECTIVE

To determine if brief alcohol interventions in trauma centers reduce health care costs.

SUMMARY BACKGROUND DATA

Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented.

METHODS

This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals.

RESULTS

An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was 89 US dollars per patient screened, or 330 US dollars for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of 3.81 US dollars for every 1.00 US dollar spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach 1.82 billion US dollars annually.

CONCLUSIONS

Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented.

Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis

OBJECTIVE

To determine if brief alcohol interventions in trauma centers reduce health care costs.

SUMMARY BACKGROUND DATA

Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented.

METHODS

This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals.

RESULTS

An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was 89 US dollars per patient screened, or 330 US dollars for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of 3.81 US dollars for every 1.00 US dollar spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach 1.82 billion US dollars annually.

CONCLUSIONS

Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented.

Substance abuse treatment and emergency department utilization among a cohort of HIV-infected persons with alcohol problems

We examined the association between substance abuse treatment services and emergency department (ED) utilization among participants in the HIV-Alcohol Longitudinal Cohort study of HIV-infected persons with a history of alcohol problems. A standardized questionnaire was administered to 350 subjects inquiring about demographics, substance use, use of substance abuse treatment services, and ED attendance. We operationally defined substance abuse treatment services as: stable, unstable, or none. The outcome, ED attendance, defined as presenting to an ED without subsequent hospitalization, occurred in 101 (28.8%) subjects in the past 6 months. Stable substance abuse treatment was significantly associated with lower odds of ED attendance (adjusted odds ratio; 95% CI): (0.5; 0.3-0.9). The relationship between substance abuse treatment and HIV-infected individuals' use of health care services merits additional attention. Substance abuse treatment may present an opportunity to impact health care utilization patterns of HIV-infected persons with a history of alcohol problems.

Feasibility of identification of alcohol intoxication by nurses in emergency departments

Vehicle-related injuries are the major cause of death and injuries in Hualien County, and driving under the influence of alcohol plays a major role in such crashes. From December 1997 to May 1998, we determined the blood alcohol concentrations (BAC) of injured individuals from vehicle crashes at two emergency departments in Hualien. Nurses were asked to record whether the patient presented with an alcohol odor. The accuracy of detection by nurses was assessed from the BAC and groups with increased prevalence were identified for screening. Of 945 patients assessed, 505 (53.4%) tested positive by BAC and 320 (33.9%) were identified with an alcohol odor. With a BAC threshold of more than 50 mg/dL, detection sensitivity was 75.4%, specificity was 90.4%, and accuracy was 85.0% (95% confidence interval: 82.7, 87.3). Patients with an alcohol odor were significantly more likely to be men, aborigines, or head-injured patients. The accuracy of detection showed no significant difference by gender, head injury, or driver status. We suggest that detection of alcohol odor by nurses may be a feasible assessment of the role of alcohol in road traffic accidents. This may provide essential data for injury prevention strategies and programs.

"Ignoring the violence": healthcare policy recommendations for the prevention of community violence re-victimization

Medical centers see 1.4 million serious violent crime victims every year and are the most likely places to intervene for preventing and reducing violence. However, very few medical centers evaluate patients beyond physical conditions, and very few complete toxicology or psychosocial screens to evaluate for substance abuse and psychological conditions as a result of trauma. Unfortunately, victims of violence are given medical assistance and discharged without recognition of the serious after effects of trauma both for themselves and their families. This manuscript discusses the chronicity and consequences of violent victimization, related health care policies that impede violence prevention and victim intervention, and concludes with a proposal for improved policies in the health care arena.

Substance abuse and the emergency room: programmatic implications

A literature review (1984 to 1995) was conducted to identify cost effective policy implications regarding substance use in the emergency room (ER) and trauma unit. Prevalence rates, ranging from 9% to 47%, vary according to where, when and who is tested. Other drugs, most commonly marijuana, benzodiazepines and cocaine, follow a similar pattern to alcohol. The optimal method of measuring substance use depends on the goal of the assessment and a combination of clinical, self-report and biochemical markers is recommended. Simple screening questions such as the TWEAK or AUDIT should be routinely used with all attendants and further assessment provided only when high risk factors have been identified. These include: males, younger patients, metropolitan centres, after midnight and on weekends, injury from violence, accidents including MVAs, high acuity and psychiatric morbidity. Further, this screening should be complimented by an intervention, referral and treatment resource for those in need.

Drinking patterns and problems and drinking in the event: an analysis of injury by cause among casualty patients

The association of alcohol and injury might be expected to vary by the specific cause of injury, but few studies have examined such associations across all causes of injury coming from the same population, largely because of the lack of a sufficient number of cases. This study examines the association of drinking patterns and problems and drinking-in-the-injury-event for six mutually exclusive causes of injury (falls, penetrating trauma, motor vehicle accidents, fires, violence, and other causes) in a merged sample of 3109 patients from four emergency room/trauma center studies that used identical study methodology. The predictive value of drinking and demographic variables are examined separately for each cause of injury, and variables predictive of reporting drinking before the event, feeling drunk at the time of injury, and attributing a causal association of drinking and the injury. Injuries sustained from violence and falls had the greatest association with drinking variables, with those with positive breathalyzer readings, and those who reported drinking before injury, frequent heavy drinking, and frequent drunkenness overrepresented in these two causes. Those who reported a larger number of drinks consumed before injury and those who reported feeling drunk at the time were also overrepresented among those with injuries related to violence and falls. A larger proportion than expected of those who attributed a causal association of drinking with the event sustained injuries related to violence, whereas a smaller proportion sustained injuries from falls. Demographic characteristics were more predictive than drinking characteristics of each cause of injury, whereas drinking characteristics, particularly positive breathalyzer readings, were more predictive of drinking before specific causes of injury. These data provide information that may be useful in developing brief interventions for the prevention of alcohol-related injuries in the emergency room or trauma center setting.