Behavioral correlates and staff recognition of alcohol use in a university hospital trauma service

A case of self‐harm by alcohol intoxication resulted in unintended in‐hospital death

Key Clinical Message

In-hospital hanging during a confusional state from alcohol intoxication is rare. To treat cases of acute alcohol intoxication, careful observation will be needed to avoid accidental psychological reactions.

Substance use and facial injury

Substance use is a major contributing factor to the interpersonal violence that accounts for a significant proportion of facial injuries among adults and adolescents; thus, violence is the main "pathway" through which substance use and injuries are linked. Beyond causality, substance use continues to influence recovery from the injury through its impact on the healing process (eg, patient noncompliance, suppression of T-cell counts, susceptibility to bacterial colonization, and protein production). Further exacerbating this issue are significant rates of injury recidivism and the lack of motivation to seek treatment for underlying substance-use problems. As a frontline care provider, the oral and maxillofacial surgeon has a responsibility to screen and refer patients for any needed specialty treatment (including substance-use treatment, violence reduction, and posttraumatic stress reduction). Recognizing and addressing these issues requires a paradigm shift that involves integration of multidisciplinary expertise.

Drunken patients in the general hospital: their care and management

In Britain alcohol consumption is increasing, 1 in 4 men and 1 in 10 women drink hazardously, 1 in 3 young men, and 1 in 4 young women regularly binge drink. Mortality rates attributable to alcohol have doubled; with 1 in 5 male inpatients having an alcohol related problem. The increasing problem of managing drunken behaviour in accident and emergency departments is discussed. Although an alcohol history is recommended for all admissions, because of various reasons, hazardous drinkers continue to miss the opportunity of effective interventions. In addition to the more formal treatments for alcohol problems, there is a wealth of evidence reporting the effectiveness of brief interventions carried out by a range of health professionals can lead to long term reductions in alcohol consumption. This review discusses practical and legal issues of the assessment, screening tools, and management of intoxicated patients.

Drug and alcohol use among patients admitted to a Danish trauma centre: a prospective study from a regional trauma centre in Scandinavia

OBJECTIVES

The incidence of drug and alcohol use is unknown among Danish trauma patients, and has not been thoroughly investigated in Europe.

METHODS

Patients admitted to the regional trauma centre in Aarhus, Denmark, were prospectively screened by blood and urine tests for the presence of alcohol, and legal and illicit drugs. The correlation with the Injury Severity Score, hospitalization time, and mortality after drug or alcohol intake was investigated.

RESULTS

A quarter of all patients admitted in 1999 and 2000 had an alcohol level exceeding the national legal driving limit of 50 mg/dl, and one or more drugs were found in one in five patients. The presence of any drug or alcohol correlated positively with the Injury Severity Score, whereas alcohol level, hospitalization time, and mortality did not correlate.

CONCLUSION

The rate of trauma patients with a blood serum level of alcohol greater than 100 mg/dl was similar to a previous European study and to US studies. The prevalence of drugs was less, and benzodiazepines were the most used group of drugs in our study. The routine screening of Danish trauma patients in order to implement preventative measures may be beneficial.

The detection and treatment of posttraumatic distress and substance intoxication in the acute care inpatient setting

Each year, approximately 2.5 million Americans require inpatient admissions after sustaining traumatic physical injuries. Few investigations have assessed the routine detection and treatment of acute care inpatients with high levels of posttraumatic distress. A representative sample of 101 hospitalized patients with acute injuries was screened for posttraumatic stress disorder (PTSD) and depressive symptoms, as well as substance intoxication. Patients' medical records were reviewed for documentation of psychiatric symptoms and diagnoses and the initiation of early evaluation and treatment. High levels of PTSD and/or depressive symptoms were present in over 50% of patients. Although providers frequently noted symptomatic distress, few symptomatic patients received formal diagnoses, evaluations or treatment. Patients who had positive substance toxicology screens on admission infrequently received in-depth evaluation or treatment. A substantial number of injured trauma survivors have high levels of symptomatic distress that are inconsistently evaluated and treated in the acute care medical setting. Mental health interventions appear to be feasibly and effectively delivered from trauma centers. Therefore, ongoing investigation and policy initiatives informing the detection and treatment of patients with psychiatric disturbances in acute care could substantially enhance the quality of mental health care for injured survivors of individual and mass trauma.

Hospitalized patients and alcohol: who is being missed?

Research and clinical experience have shown that alcohol use disorders are neither sufficiently identified nor addressed in hospitalized patients. This study sought to quantify and localize these missed opportunities. The setting was an urban medical center with a Level 1 trauma designation. The only eligibility requirement was a Blood Alcohol Level (BAL) greater than 300 ng/dl upon hospital admission, a "nonsubtle" value more than three times the legal intoxication limit. Charts [58] were retrospectively reviewed for treating service (medical, trauma services, or psychiatric) and evidence of psychological signs or behavioral symptoms of withdrawal. Also assessed were the presence or absence of withdrawal monitoring, withdrawal prophylaxis orders, inpatient addictions consultation, and referral for addictions aftercare. Numerous patients with admission BALs >300 failed to be identified as needing assessment for alcohol-related disorders. Patients admitted to medical or psychiatric services were significantly more likely to be diagnosed than those on trauma services (P =.02). Patients on medical or psychiatric services were also more likely to be assessed for withdrawal and referred for after-care (P <.0001) than those cared for on trauma services. The delivery of care for alcohol-related disorders was deficient, particularly for patients with traumatic injuries, even among patients severely intoxicated at admission. Failure to identify such patients represented a missed opportunity to address this vital contributor to trauma. It is suggested that both the origins of this shortfall and its resolution depend not just upon trauma providers but upon the entire medical system.

Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.

Comparing two different methods of identifying alcohol related problems in the emergency department: a real chance to intervene?

OBJECTIVES

To examine the feasibility of screening for alcohol problems in a representative flow sample of patients attending a busy UK emergency department. To compare two methods of identifying alcohol related problems in the emergency department.

METHODS

Brief interview administered by the same interviewer to a representative flow sample of 429 patients attending a single accident and emergency department over a six week period. Measures included a CAGE questionnaire and assessments by the patient and staff as to whether the attendance was alcohol related.

RESULTS

413 patients (96%) were successfully screened. Of these, 115 (28%) patients were considered to have an alcohol related attendance on the basis of the CAGE questionnaire or the staff assessment. Head injuries and psychiatric presentations were particularly likely to be associated with alcohol misuse. Compared with those identified by staff, patients scoring above threshold on the CAGE were more likely to attend during routine working hours and recognise they had an alcohol problem.

CONCLUSIONS

Emergency departments may provide an opportunity for the early prevention of alcohol related difficulties. However, patients with alcohol problems who present to the emergency department are not a homogenous group. Different screening methods identify different groups of patients, who in turn may respond to different forms of intervention. Further research examining the efficacy and feasibility of different alcohol treatment approaches is needed to enable us to target specific interventions to those patients who might most benefit.

An evaluation of intravenous ethanol in hospitalized patients

Alcohol withdrawal is a serious complication of heavy alcohol use and a condition requiring patient stabilization before initiating surgery or implementing lifesaving procedures for injury. Intravenous ethanol (IVE) is used to prevent withdrawal during these maneuvers. This report explores the use and potential problems of this practice in an academic urban medical center. This study was undertaken to improve the treatment of IVE recipients in an urban, academic health system providing trauma, surgery, and general inpatient services. All 68 patients, identified by a review of the pharmacy database for the period August 1993 through January 1994, received IVE during their stay. A priori outcome measures related to the course of therapy in the selected cases. Of all patients studied, 67.6% were admitted for alcohol-related trauma; 61.8% of IVE recipients had no documented risk factors for delirium tremens (59.5% of these were oriented); 17.6% were discharged on the same day the drip was discontinued; only 17.6% were referred to the alcohol consult team; and, throughout the course of therapy in all cases, no blood alcohol level (BAL) determinations were recorded in patients' records. The use of IVE is associated with potentially serious clinical concerns. We found a high prevalence of alcohol-related admissions, inconsistent IVE administration, and a low rate of alcohol consult requests. Guidelines to improve the selection, management, and disposition of IVE recipients are suggested.

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.

Alcohol, the elderly, and motor vehicle crashes

To document the prevalence of alcohol or drug use among elderly drivers admitted to a Level 1 trauma center after motor vehicle crashes, charts from 180 drivers age 60 years or older who were admitted to an urban Level 1 trauma center after motor vehicle crashes were retrospectively reviewed. Overall, 14% of the patients had a positive blood alcohol screen; among men, 21% had a positive screen. Only 55% of the patients were discharged to home. Only one patient ( < 1%) had a toxicology screen positive for another drug abuse. Alcohol/drug abuse counselling was offered to only one patient. These results suggest a relatively of high prevalence of alcohol use in elderly drivers involved in motor vehicle crashes, particularly men. However, abuse of other drugs was uncommon. Physicians treating intoxicated drivers should consider referral for alcohol counselling.

Characteristics of repeat trauma patients, San Diego County

Data on 22,312 admissions to the San Diego County Trauma System were used to identify 185 trauma patients admitted repeatedly to trauma units. These patients were compared with the entire group of nonrepeating trauma patients admitted during the 80-month period of the study. In comparison with nonrepeaters, the repeaters were younger, were more often men, were more often Black, and were much more frequently victims of assault. Forty-eight percent of the repeaters were injured by the same general mechanism on both admissions.

The pedestrian trauma patient. Perspectives from a psychiatric consultation service

The hospital course of adult pedestrians injured by automobiles and treated by a university trauma service over a 12-month period was reviewed to evaluate the prevalence, recognition, and intervention of substance use and suicidal behavior. The study showed that the pedestrian trauma patient had a dramatically high rate of substance use and a surprisingly low index of suspicion of suicide attempt by the treatment team as a cause of the accident. Appropriate intervention might greatly reduce the financial and human cost of trauma care, but awareness and identification of these risk factors must be taught first.