Developing a standardized measurement of alcohol intoxication

Introduction of an Electronic Mobile Device Version of an Alcohol Impairment Scale (the Hack's Impairment Index Score) Does Not Impair Nursing Assessment of Patients in Emergency Departments

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Annually, there are up to 5 million visits to EDs across the country of patients with a primary complaint of “Alcohol Intoxication”.

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ED Health Care Providers are charged with initial assessment, serial evaluations and then deciding when these patients are clinically improved to the point when they are ready for disposition.

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Previously, there was no widely accepted tool for providers to use to perform a standardized, formal examination of these patients.

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Hack's Impairment Index (HII Score) is a clinical tool currently being used at the bedside by nurses at select institutions across the United States using paper prompts.

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An App version of the HII Score for use on mobile devices was developed.

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This study evaluated the effects on nursing performance with the tool when paper charting was replaced.

Background

There is no formal assessment to determine level of disability in the millions of patients with alcohol-induced impairment who present to emergency departments annually. Hack's Impairment Index (HII) is a standardized, serializable clinical tool designed to quantify ability. Nursing staff members at this center perform the HII and determine a score using paper prompts.

Objective

We developed an HII electronic application and investigated whether or not an electronic version on a mobile device would affect nursing performance.

Methods

A chart review-based quality improvement project compared the number, repetitions, and completeness of HII score documentation performed by nurses over 6.5 months. Group 1: paper-based HII scores for the 90-day period before intervention; group 2: iPad-based HII scores for the 90 days after intervention. There was a 2-week period for staff training and electronic version feedback between groups. Informal, ad hoc interviews were performed with nurses at investigation termination.

Results

Group 1: 476 emergency department patients with alcohol-induced impairment had HII scores ordered; 339 (71.2%; 95% CI, 67.1, 75.3%) had HII assessments with a total of 539 HII scores documented. An average (SD) 1.60 (0.01) serial assessments occurred per patient, 5 (1.1%; 95% CI, (0, 2.2%) scores were incomplete. Group 2: 569 alcohol-induced impairment emergency department patients were seen and had HII scores ordered; 420 (73.8%; 95% CI, (70.2, 77.4%) had HII assessments with a total of 639 HII scores documented. An average (SD) 1.52 (0.03) serial assessments occurred per patient, 4 (0.9%; 95% CI, (0.81, 0.99%) had incomplete HII scores.

Conclusions

Although our study took place at 1 center, was a chart review, and not directly observed, we found that the mobile device-based HII application to determine a score did not interfere with nursing performance. Specifically, the repetition and completeness of nursing assessments of emergency department patients with impairment from alcohol use was not altered when comparing paper chart documentation with electronic format documentation. (Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)

Effect of haemolysis on an enzymatic measurement of ethanol

Introduction

We investigated the interference of haemolysis on ethanol testing carried out with the Synchron assay kit using an AU680 autoanalyser (Beckman Coulter, Brea, USA).

Materials and methods

Two tubes of plasma samples were collected from 20 volunteers. Mechanical haemolysis was performed in one tube, and no other intervention was performed in the other tube. After centrifugation, haemolysed and non-haemolysed samples were diluted to obtain samples with the desired free haemoglobin (Hb) values (0, 1, 2, 5, 10 g/L). A portion of these samples was then separated, and ethanol was added to the separated sample to obtain a concentration of 86.8 mmol/L ethanol. After that, these samples were diluted with ethanol-free samples with the same Hb concentration to obtain samples containing 43.4, 21.7, and 10.9 mmol/L. Each group was divided into 20 equal parts, and an ethanol test was carried out. The coefficient of variation (CV), bias, and total error (TE) values were calculated.

Results

The TE values of haemolysis-free samples were approximately 2-5%, and the TE values of haemolysed samples were approximately 10-18%. The bias values of haemolysed samples ranged from nearly - 6.2 to - 15.7%.

Conclusions

Haemolysis led to negative interference in all samples. However, based on the 25% allowable total error value specified for ethanol in the Clinical Laboratory Improvement Amendments (CLIA 88) criteria, the TE values did not exceed 25%. Consequently, ethanol concentration can be measured in samples containing free Hb up to 10 g/L.

Performance of the Hack's Impairment Index Score: A Novel Tool to Assess Impairment from Alcohol in Emergency Department Patients

BACKGROUND

Over 35 million alcohol-impaired (AI) patients are cared for in emergency departments (EDs) annually. Emergency physicians are charged with ensuring AI patients' safety by identifying resolution of alcohol-induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients.

OBJECTIVE

The objective was to evaluate a novel standardized ED assessment of alcohol impairment, Hack's Impairment Index (HII score), in a busy urban ED.

METHODS

A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both "usual" and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2-5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated.

RESULTS

A total of 8,074 visits from 3,219 unique patients were eligible for study, including 7,973 (98.7%) with ethanol levels, 5,061 (62.7%) with complete HII scores, and 3,646 (45.2%) with health care provider assessments. Correlations between HII scores and ethanol levels were poor (Pearson's R²  = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients' visits.

CONCLUSIONS

The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with health care provider evaluations.