EMS Triage and Transport of Intoxicated Individuals to a Detoxification Facility Instead of an Emergency Department

Comparison of 4 tests' utility for predicting need for emergency department care in patients with alcohol-related complaints

INTRODUCTION

Intoxication is a common presenting complaint in emergency departments (ED), but many patients with intoxication do not need emergency care. Three screens (BLINDED, Brown, and San Francisco) attempt to determine which intoxicated patients can be triaged to a lower level of care.

METHODS

Observational multi-center cohort study of patients presenting to one of three ED with complaints consistent with acute intoxication. When a qualifying patient was brought to the emergency department, a team member interviewed the triaging provider. Interviews covered all three screens and the provider's gestalt. Receiver operating curve (ROC) analysis was used to determine which screen performed best. Cases were reviewed to determine need for emergency care.

RESULTS

Of the 199 subjects studied, 91% (181/199) were male and were 50 years old on average (SD = 12 years). Of the 55 subjects tested (28%), their average alcohol level was 251 mg/dL (SD = 146 mg/dL). Only 117 subjects (59%) had complete information for inclusion in the final comparison of screens. Provider gestalt performed best (AUC = 0.69), but there were no meaningful differences between any of the screens (AUC = 0.62-0.66, p > 0.05 for all comparisons). Inability to sit up was sensitive for needing emergent care (88%), but it was non-specific (17%). Similarly, signs of trauma were specific (99%) for ED care, but insensitive (18%).

CONCLUSIONS

The three formal screens and provider gestalt performed similarly.

Post-discharge Health Services Use for Patients with Serious Mental Illness Treated at an Emergency Department Versus a Dedicated Community Mental Health Center

Emergency Medical Service (EMS) alternative destination programs may lead to improved care quality among those experiencing mental health crises but the association with cost and emergency department (ED) recidivism remains unexamined. We compare rates of post-discharge health services use and Medicaid spending among patients transported to an ED or community mental health center (CMHC) finding higher ED recidivism for patient treated in the ED, compared to those treated in a CMHC (68% vs 34%, p < 0.001). There were no differences in Medicaid spending or health services use post-discharge suggesting EMS-operated alternative destination programs may be cost-neutral for Medicaid programs.

Sobering centers, emergency medical services, and emergency departments: A review of the literature

BACKGROUND

Acute alcohol intoxication accounts for a large proportion of potentially unnecessary emergency department visits and expenditure. Sobering centers are a cheaper alternative treatment option for alcohol intoxication and can provide an opportunity to treat the psychosocial aspects of alcohol use disorder.

OBJECTIVE OF THE REVIEW

The objective of this review is to analyze the existing literature regarding the use of sobering centers, EMS and their role in transporting to sobering centers, and the appropriate triage of the intoxicated patient.

DISCUSSION

Excessive alcohol consumption accounts for an estimated $24.6 billion in healthcare costs and patients are often referred to the emergency department for expensive care. Current literature suggests sobering centers are an alternative to acute hospitalization and are safe, relatively inexpensive, and may facilitate more aggressive connection to resources such as longitudinal rehabilitation programs for the acutely intoxicated patient. EMS plays a pivotal role in triage and transportation of intoxicated individuals, but demonstration of outcomes in lacking.

CONCLUSIONS

Sobering centers are a cost effective alternative to emergency department visits for acute alcohol intoxication and further research is required to identify safe, effective protocols for EMS to triage patients to appropriate treatment destinations.

Cost impact of sobering centers on national health care spending in the United States

Acute alcohol intoxication is responsible for a sizable share of emergency department visits. Intoxicated individuals without other medical needs may not require the high level of care provided by an emergency department. We estimate the impact on U.S. health care spending if individuals with uncomplicated, acute alcohol intoxication were treated in sobering centers instead of the emergency department. We performed a budget impact analysis from the perspective of the U.S. health care system based on published and gray literature reports. Ninety-five percent confidence intervals (CI) were estimated using Monte Carlo modeling with random variation for three variables (cost of an emergency department visit, cost of a sobering center visit, and start-up costs per sobering center visit) and the percentage of cases diverted from emergency departments to sobering centers. Outcomes were expressed in terms of national savings in 2017 U.S. dollars. Assuming a diversion rate of 50% based on previous studies, national savings range from $230 million to $1.0 billion annually. In the Monte Carlo modeling, we found annual national savings of $99.02 million (95% CI: $95.89-$102.19 million), $792.34 million (95% CI: $767.09-$817.58 million), and $1,185.51 million (95% CI: $1,150.64-$1,226.37 million) with diversion rates of 5%, 40%, and 60%, respectively. Implementing sobering centers as a treatment alternative for individuals with uncomplicated acute alcohol intoxication could yield substantial cost savings for the U.S. health care system.

Homeless people under the influence of alcohol admitted to hospital emergency departments in Poland

Aim:

To assess the incidence of diagnoses related to alcohol use in the population of homeless people admitted to hospital emergency departments (EDs).

Material and method:

Data were analysed from three hospitals concerning stays of homeless people in three EDs in Bydgoszcz, Poland, in 2013–2015; 3133 stays were identified. The data were compiled using Microsoft Excel and Statistica 10 statistical software.

Results:

At the time of admission to EDs, 31% of homeless people were considered to be under the influence of alcohol. Diagnoses related to alcohol use accounted for 25% of all diagnoses. The average blood alcohol concentration in the patients was 2.97 per mille. The average blood alcohol concentration in the group of men was significantly higher than that in the group of women (p = 0.015). The average length of stay in the ED of patients under the influence of alcohol was significantly longer (p < 0.0001) than among sober patients.

Conclusions:

Homeless people under the influence of alcohol account for a third of the population of homeless patients admitted to hospital emergency departments, while alcohol-related ICD-10 diagnoses account for a fourth of all diagnoses in these patients. Homeless patients under the influence of alcohol stay longer in hospital emergency departments than do sober homeless people, which may translate into more frequent acts of aggression towards medical personnel. In Poland there are no systemic ED-level solutions as regards dealing with homeless patients for whom alcohol dependence is in many cases a reality.

Evaluating alcohol intoxication management services: the EDARA mixed-methods study

Background

Front-line health-care services are under increased demand when acute alcohol intoxication is most common, which is in night-time environments. Cities have implemented alcohol intoxication management services to divert the intoxicated away from emergency care.

Objectives

To evaluate the effectiveness, cost-effectiveness and acceptability to patients and staff of alcohol intoxication management services and undertake an ethnographic study capturing front-line staff’s views on the impact of acute alcohol intoxication on their professional lives.

Methods

This was a controlled mixed-methods longitudinal observational study with an ethnographic evaluation in parallel. Six cities with alcohol intoxication management services were compared with six matched control cities to determine effects on key performance indicators (e.g. number of patients in the emergency department and ambulance response times). Surveys captured the impact of alcohol intoxication management services on the quality of care for patients in six alcohol intoxication management services, six emergency departments with local alcohol intoxication management services and six emergency departments without local alcohol intoxication management services. The ethnographic study considered front-line staff perceptions in two cities with alcohol intoxication management services and one city without alcohol intoxication management services.

Results

Alcohol intoxication management services typically operated in cities in which the incidence of acute alcohol intoxication was greatest. The per-session average number of attendances across all alcohol intoxication management services was low (mean 7.3, average minimum 2.8, average maximum 11.8) compared with the average number of emergency department attendances per alcohol intoxication management services session (mean 78.8), and the number of patients diverted away from emergency departments, per session, required for services to be considered cost-neutral was 8.7, falling to 3.5 when ambulance costs were included. Alcohol intoxication management services varied, from volunteer-led first aid to more clinically focused nurse practitioner services, with only the latter providing evidence for diversion from emergency departments. Qualitative and ethnographic data indicated that alcohol intoxication management services are acceptable to practitioners and patients and that they address unmet need. There was evidence that alcohol intoxication management services improve ambulance response times and reduce emergency department attendance. Effects are uncertain owing to the variation in service delivery.

Limitations

The evaluation focused on health service outcomes, yet evidence arose suggesting that alcohol intoxication management services provide broader societal benefits. There was no nationally agreed standard operating procedure for alcohol intoxication management services, undermining the evaluation. Routine health data outcomes exhibited considerable variance, undermining opportunities to provide an accurate appraisal of the heterogenous collection of alcohol intoxication management services.

Conclusions

Alcohol intoxication management services are varied, multipartner endeavours and would benefit from agreed national standards. Alcohol intoxication management services are popular with and benefit front-line staff and serve as a hub facilitating partnership working. They are popular with alcohol intoxication management services patients and capture previously unmet need in night-time environments. However, acute alcohol intoxication in emergency departments remains an issue and opportunities for diversion have not been entirely realised. The nurse-led model was the most expensive service evaluated but was also the most likely to divert patients away from emergency departments, suggesting that greater clinical involvement and alignment with emergency departments is necessary. Alcohol intoxication management services should be regarded as fledgling services that require further work to realise benefit.

Future work

Research could be undertaken to determine if a standardised model of alcohol intoxication management services, based on the nurse practitioner model, can be developed and implemented in different settings. Future evaluations should go beyond the health service and consider outcomes more generally, especially for the police. Future work on the management of acute alcohol intoxication in night-time environments could recognise the partnership between health-care, police and ambulance services and third-sector organisations in managing acute alcohol intoxication.

Trial registration

Current Controlled Trials ISRCTN63096364.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 24. See the NIHR Journals Library website for further project information.

Public Intoxication: Sobering Centers as an Alternative to Incarceration, Houston, 2010-2017

In 2010, the Houston police department admitted 20 508 publicly intoxicated individuals into its jail. To address jail overcrowding, the city created a jail diversion policy that allowed law enforcement to admit publicly intoxicated individuals into a new sobering center. By 2017, public intoxication jail admissions had decreased by 95%, freeing valuable resources. A promising public health intervention, sobering centers offer an alternative to incarceration and relieve overuse of emergency services while assisting individuals with substance use issues.

EMS Can Safely Transport Intoxicated Patients to a Sobering Center as an Alternate Destination

STUDY OBJECTIVE

We evaluate a sobering center as an alternate destination for acute intoxication. Our aims are to count patient visits that originated from emergency medical services (EMS) or the emergency department (ED) that then result in a secondary transfer from the sobering center to the ED, and to describe and categorize the clinical reasons for transfer to the ED.

METHODS

The San Francisco Sobering Center, a continuously nurse-staffed facility operating since 2003, provides short-term (6- to 8-hour) care for adults with acute alcohol intoxication. Paramedics use a county EMS protocol to triage low-risk intoxicated patients to the sobering center. A case review was performed on all visitors during 3 years who were secondarily transferred from the sobering center. Reason for transfer was categorized by clinical indication.

RESULTS

From July 2013 to June 2016, 11,596 visits (from 3,268 unduplicated adults) were documented. Of these, 4,045 (35%) were referred by EMS and 1,348 (12%) were referred from the ED. Other referring parties included the mobile van service, police, homeless service provider, self-referral, and others. Of the total visitors, 506 (4.4%; 95% confidence interval 4.0% to 4.8%) were secondarily transferred to an ED; 151 were referred by EMS and 62 by the ED. Clinical indications for ED transfer included pulse greater than 100 beats/min (26%), alcohol withdrawal (19%), pain (excluding chest pain) (19%), altered mental status (13%), and emesis (13%). Most clients had more than one clinical indication for transfer (median 2; range 1 to 5).

CONCLUSION

The San Francisco Sobering Center is an appropriate, safe EMS destination for patients with acute alcohol intoxication.

Mass-Gathering Medical Care Provided by a Collegiate-Based First Response Service at an Annual College Music Festival and Campus-Wide Celebration

Background

There is insufficient research on medical care at mass-gathering events (MGEs) on college and university campuses. Fun Day is an annual celebratory day held at Skidmore College (Saratoga Springs, New York USA), a small liberal arts college in the Northeastern United States. Fun Day is focused around an outdoor music festival; students also congregate and celebrate throughout the surrounding campus. To improve care and alleviate strain on local resources, a model was developed for the provision of emergency care by a collegiate-based, volunteer first-response service – Skidmore College Emergency Medical Services (EMS) – in coordination with a contracted, private ambulance service.

Study/Objective

The aims of this study were to: (1) analyze medical usage rates and case mixes at Fun Day over a four-year period, and to (2) describe the collegiate-based first response model for MGEs.

Methods

Data were collected retrospectively from event staff, college administrators, and Skidmore College EMS on event-related variables, patient encounters, and medical operations at Fun Day over a four-year period (2014-2017).

Results

Annual attendance at the music festival was estimated at 2,000 individuals. Over four years, 54 patients received emergency medical care on campus on Fun Day, and 18 (33.3%) were transported to the emergency department. On-site contracted ambulances transported 77.8% of patients who were transported to the emergency department; mutual aid was requested for the other 22.2% of transports. The mean (SD) patient presentation rate (PPR) was 7.0 (SD = 1.0) per 1,000 attendees. The mean (SD) transport-to-hospital rate (TTHR) was 2.0 (SD = 1.0) per 1,000 attendees. Thirty (55.6%) patients presented with intoxication, seven (13.0%) with laceration(s), and five (9.3%) with head trauma as the primary concern. Medical command was established by volunteer undergraduate students. Up to 16 volunteer student first responders (including emergency medical technicians [EMTs]) were stationed on campus, in addition to two contracted ambulances at the Basic Life Support (BLS) and Advanced Life Support (ALS) levels. Operational strategies included: mobile first response crews, redundant communication systems, preventative education, and harm reduction.

Conclusion

High medical usage rates were observed, primarily due to alcohol/illicit substance use and traumatic injuries. The provision of emergency care by a collegiate-based first response service in coordination with a contracted, private ambulance agency serves as an innovative model for mass-gathering medical care on college and university campuses.

FriedmanNMG, O’ConnorEK, MunroT, GoroffD.Mass-gathering medical care provided by a collegiate-based first response service at an annual college music festival and campus-wide celebration. Prehosp Disaster Med. 2019;34(1):98–103.

Alcohol as a Factor in 911 Calls in Denver

BACKGROUND

Excessive alcohol consumption is associated with a substantial number of emergency department visits annually and is responsible for a significant number of lives lost each year in the United States. However, a minimal amount is known about the impact of alcohol on the EMS system.

OBJECTIVES

The primary objective was to determine the proportion of 9-1-1 calls in Denver, Colorado in which (1) alcohol was a contributing factor or (2) the individual receiving EMS services had recently ingested alcohol. The secondary objectives were to compare the characteristics of EMS calls and to estimate the associated costs.

METHODS

This was a prospective observational cohort study of EMS calls for adults from July 1, 2012, to June 30, 2014. Primary outcomes for the study were alcohol as a contributing factor to the EMS call and recent alcohol consumption by the patient receiving EMS services. Logistic regression was utilized to determine the associations between EMS call characteristics and the outcomes. Cost was estimated using historic data.

RESULTS

During the study period, 169,642 EMS calls were completed by the Denver Health Paramedic Division. Of these 71% were medical and 29% were trauma-related. The median age was 45 (interquartile range [IQR] 29-59) years, and 55% were male. 50,383 calls (30%) had alcohol consumption, and 49,165 (29%) had alcohol as a contributing factor. Alcohol related calls were associated with male sex, traumatic injuries including head trauma, emergent response, use of airway adjuncts, cardiac monitoring, glucose measurement, use of restraints, use of spinal precautions, and administration of medications for sedation. Estimated costs to the EMS system due to alcohol intoxication exceeded $14 million dollars over the study period and required in excess of 37 thousand hours of paramedic time.

CONCLUSIONS

Compared to 9-1-1 calls that do not involve alcohol, alcohol-related calls are more likely to involve male patients, emergent response, traumatic injuries, advanced monitoring, airway adjuncts, and medications for sedation. This represents a significant burden on the emergency system and society. Further studies are needed to evaluate whether additional interventions such as social services could be used to lessen this burden.

Acute Crisis Care for Patients with Mental Health Crises: Initial Assessment of an Innovative Prehospital Alternative Destination Program in North Carolina

OBJECTIVE

Emergency Departments (ED) are overburdened with patients experiencing acute mental health crises. Pre-hospital transport by Emergency Medical Services (EMS) to community mental health and substance abuse treatment facilities could reduce ED utilization and costs. Our objective was to describe characteristics, treatment, and outcomes of acute mental health crises patients who were transported by EMS to an acute crisis unit at WakeBrook, a North Carolina community mental health center.

METHODS

We performed a retrospective cohort study of patients diverted to WakeBrook by EMS from August 2013-July 2014. We abstracted data from WakeBrook medical records and used descriptive statistics to quantify patient characteristics, diagnoses, length of stay (LOS), and 30-day recidivism.

RESULTS

A total of 226 EMS patients were triaged at WakeBrook. The median age was 38 years, 55% were male, 58% were white, and 38% were uninsured. The most common chief complaints were suicidal ideation or self-harm (46%) and substance abuse (19%). The most common diagnoses were substance-related and addictive disorders (42%), depressive disorders (32%), and schizophrenia spectrum and other psychotic disorders (22%). Following initial evaluation, 28% of patients were admitted to facilities within WakeBrook, 40% were admitted to external psychiatric facilities, 18% were stabilized and discharged home, 5% were transferred to an ED within 4 hours for further medical evaluation, and 5% refused services. The median LOS at WakeBrook prior to disposition was 12.0 hours (IQR 5.4-21.6). Over a 30-day follow-up period, 60 patients (27%) had a return visit to the ED or WakeBrook for a mental health issue.

CONCLUSIONS

A dedicated community mental health center is able to treat patients experiencing acute mental health crises. LOS times were significantly shorter compared to regional EDs. Successful broader programmatic implementation could improve care quality and significantly reduce the volume of patients treated in the ED for acute mental health disorders.

Impact of a Mass Gathering Alcohol Sobering Facility on Emergency Resources

OBJECTIVE

Alcohol consumption has been implicated as an important factor driving the demand for medical care at mass gatherings. Patients exhibiting signs of possible alcohol intoxication are frequently diverted from traditional medical support facilities located within mass gathering events due to their disruptive behavior or need for prolonged observation. This conventional strategy can place additional stress on Emergency Medical Services (EMS) and Emergency Department (ED) resources. The purpose of this study was to determine if incorporation of an on-site alcohol sobering facility to supplement existing on-site medical support resources was associated with changes in EMS and ED resource utilization during an annual mass gathering.

METHODS

This retrospective observational study of a large, annual mass gathering included prospectively collected data from before and after the deployment of an on-site alcohol sobering facility. One year of EMS data along with 2 years of ED data from the pre-deployment time period were compared to 3 years of post-deployment data. The primary outcomes for this study were the number of EMS transports and ED visits.

RESULTS

Average single day event attendance was 176,116 during the 2012-13 time period before the ACS was deployed and 183,544 in the 3 years following. The odds of an EMS transport from the event to the ED decreased in the post-deployment period, OR 0.37 (95% CI = 0.16-0.86; p = 0.01). ED volume increased by 7.23% (p = 0.56) and ED LOS increased by 1.29% (p = 0.97) in the post-deployment period.

CONCLUSION

This study reports on a unique strategy to improve resource utilization at large mass gatherings and the impact of this strategy on EMS and ED resource utilization. It appears that the addition of an on-site alcohol sobering facility to existing medical support services was associated with a significant decrease in EMS transports but no change in ED resource utilization. Further work is needed to determine if these findings can be reproduced at other mass gatherings.

911 Patient Redirection

Sporer KA . 911 patient redirection. Prehosp Disaster Med. 2017;32(6):589-592.

Managing alcohol-related attendances in emergency care: can diversion to bespoke services lessen the burden?

Acute alcohol intoxication (AAI) has a long history of burdening emergency care services. Healthcare systems around the world have explored a variety of different services that divert AAI away from EDs to better manage their condition. Little formal evaluation has been undertaken, particularly in the UK where alcohol misuse is one of the highest in the world. In this article, we outline a brief history of diversionary services, introduce the concept of Alcohol Intoxication Management Services (AIMS) and describe examples of AIMS in the UK. We then describe Evaluating the Diversion of Alcohol-Related Attendances, a natural experiment including six cities with AIMS compared with six cities without, that involves an ethnographic study, records patient experiences in both AIMS and EDs, assesses impact on key performance indicators in healthcare and evaluates the cost-effectiveness of AIMS.

Utilization of a Sobering Center for Acute Alcohol Intoxication

OBJECTIVE

The objective was to describe the population utilizing a sobering center for public alcohol intoxication and compare between single-visit users, repeat users, and high users.

METHODS

We conducted a secondary analysis of 1,271 adults cared for in a sobering center from July 2014 to June 2015. We divided the population into three groups-single use (one visit), repeat users (two to five visits), and high (six or more) users-and evaluated demographics, lifetime health diagnoses utilizing the Elixhauser Comorbidity Index, rates of public service utilization including ambulance and emergency department, and related costs.

RESULTS

The population was primarily male, middle-aged, and ethnically diverse. Compared to single-visit users (n = 869), repeat (n = 287) and high users (n = 115) were older, were more likely to be currently homeless, and had spent more time homeless. Repeat and high users had significantly higher rates of hypertension, liver disease, diabetes, depression, psychoses, and drug abuse diagnoses compared to single-visit users. In addition to sobering visits, utilization of ambulance and ED and related costs were significantly greater for the high users compared to repeat and single-visit users.

CONCLUSIONS

From an overall heterogeneous population, more frequent utilizers of the sobering center, both high and repeat users compared to low users, had significantly greater prevalence of chronic disorders, service utilization, and homelessness. Findings indicate that a sobering center can have a prominent role in the care for those with acute alcohol intoxication, particularly those individuals with chronic public intoxication who are likewise homeless. Further longitudinal research could offer important insights as to the population served over time, investigating changes in utilization and efforts toward health and housing stabilization.

Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review

OBJECTIVES

This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome.

METHODS

An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes.

RESULTS

The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients.

CONCLUSIONS

The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.

Can Paramedics Safely Refuse Transport of Non-Urgent Patients?

OBJECTIVE

The goal of this search was to review the current literature regarding paramedic triage of primary care patients and the safety of paramedic-initiated non-transport of non-urgent patients.

METHODS

A narrative literature review was conducted using the Medline (Medline Industries, Inc.; Mundelein, Illinois USA) database and a manual search of Google Scholar (Google; Mountain View, California USA).

RESULTS

Only 11 studies were found investigating paramedic triage and safety of non-transport of non-urgent patients. It was found that triage agreement between paramedic and emergency department staff generally is poor and that paramedics are limited in their abilities to predict the ultimate admission location of their patients. However, these triage decisions and admission predictions are much more accurate when the patient's condition is the result of trauma and when the patient requires critical care services. Furthermore, the literature provides very limited support for the safety of paramedic triage in the refusal of non-urgent patient transport, especially without physician oversight. Though many non-transported patients are satisfied with the quality of non-urgent treatment that they receive from paramedics, the rates of under-triage and subsequent hospitalization reported in the literature are too high to suggest that this practice can be adopted widely.

CONCLUSION

There is insufficient evidence to suggest that non-urgent patients can safely be refused transport based on paramedic triage alone. Further attempts to implement paramedic-initiated non-transport of non-urgent patients should be approached with careful triage protocol development, paramedic training, and pilot studies. Future primary research and systematic reviews also are required to build on the currently limited literature. Fraess-Phillips AJ . Can paramedics safely refuse transport of non-urgent patients? Prehosp Disaster Med. 2016;31(6):667-674.

Alcohol use in the prehospital setting: a diagnostic challenge in patients treated by a physician staffed mobile intensive care unit

Background

Alcohol use among emergency patients has been studied earlier, but the data regarding alcohol use especially among critically ill and injured patients treated in the prehospital setting is scarce. The aim of this study was to evaluate the incidence of alcohol use and the characteristics of cases attended by a physician staffed mobile intensive care unit (MICU).

Findings

During a 2 month period, exhaled air alcohol concentration—measured as a part of routine patient examination in all adolescent and adult patients treated by the MICU—was recorded. The MICU encountered 258 patients, of which 82 could be tested for alcohol use. Of the tested patients 43 % gave a positive breath test result. Proportion of male patients providing a positive result in the breath test did not differ significantly those of women. The primary reason for not to test the patient was a decreased level of consciousness in one-fifth of the initial 258 patients.

Conclusions

A significant proportion (47 %) of the encountered patients could not be tested due to their critical condition. Alcohol use was observed in 43 % of those capable of providing a breath test sample. The rate of positive tests seemed to be higher than those reported from emergency departments. Novel diagnostic methods to detect alcohol consumption in non-cooperative patients are warranted.

On-Premise Alcohol Establishments and Ambulance Calls for Trauma, Assault, and Intoxication

Alcohol contributes to intentional and unintentional injury. We explored on-premise licensed alcohol establishments (LAEs) and emergency medical service (EMS) ambulance calls.We completed a retrospective population-based study in the Region of Peel, Ontario, 2005 to 2014, where alcohol sales are tightly regulated and healthcare is universally available. We included participants age ≥ 19 years. Longitude-latitude coordinates of all 696 LAEs and all 267,477 EMS ambulance calls were ascertained, and then assigned to 1 of 1568 dissemination areas (DA) in Peel. Relative risks (RRs) described the association between density of on-premise LAEs (by DA deciles) and the rate of EMS calls, adjusted for material deprivation, and density of beer/liquor stores in each DA.There was a curvilinear relation between LAE density and EMS calls for trauma, rising from 45.3 per 1000 in DAs with no LAEs to 381.0 per 1000 in decile-10 (adjusted RR 7.83, 95% confidence interval [CI] 6.15-9.97). This relation was more pronounced for alcohol-focused LAEs, and highest among younger males. Calls for assault (RR 2.67, 95% CI 1.26-5.65) and intoxication (RR 4.00, 95% CI 1.41-11.38) were more likely on the last day of the month and the day thereafter, compared to 1 week prior. At 02:00 hours, when LAEs must stop selling alcohol, there was a considerable rise in assault-related calls in DAs with LAE but not in DAs without LAEs.On-premise LAEs contribute to EMS calls for trauma and assault, especially among young males, around last call, and when monthly pay cheques are cashed.

Can Medical Decision-making at the Scene by EMS Staff Reduce the Number of Unnecessary Ambulance Transportations, but Still Be Safe?

OBJECTIVES

The aim of this study was to evaluate the procedures adopted by the staff of the Shiraz Emergency Medical Services (EMS) and the outcome of the patients discharged from the scene over a one-year period.  

BACKGROUND

Unnecessary use of ambulances results in the overloading of EMS and the over-crowding of emergency departments. Medical assessment at the scene by EMS staff may reduce these issues. In an earlier study in Shiraz, 36% of the patients were left at home/discharged directly from the scene with or without treatment by EMS staff after consulting a physician at the dispatch center. However, there has been no evaluation of this system with regard to mortality and morbidity.  

MATERIALS AND METHODS

Retrospective data on all missions performed by the Shiraz EMS (2012-2013) were reviewed. All the patients discharged from the scene by the EMS staff on the 5th, 15th, and 25th days of each month were included. A questionnaire with nine questions was designed, and available patients/relatives were interviewed prospectively (2014; follow-up period 4-12 months).  

RESULTS

Out of 3019 cases contacted, 994 (almost 33%) replied. There were 26%-93% reductions in the complaints in all disease categories. A group of the patients left the scene at their own will. Of those who were discharged by the EMS staff at the scene, over 60% were without any complaints. Twelve out of 253 patients died after they were sent home by the EMS staff.  

CONCLUSIONS

Patients may be discharged at the scene by EMS staff and after consulting a physician. However, there is a need for a solid protocol to ensure total patient safety. This calls for a prospective study.