Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol‐intoxicated patients in the emergency department: A randomised controlled trial

Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department-Convenience or necessity?

BACKGROUND

Peripheral Intravenous Cannulas (PIVCs) are frequently utilised in the Emergency Department (ED) for delivery of medication and phlebotomy. They are associated with complications and have an associated cost to departmental resources. A growing body of international research suggests many of the PIVCs inserted in the ED are unnecessary.

METHODS

The objective of this study was to determine the rates of PIVC insertion and use. This was a prospective observational study conducted in one UK ED and one Italian ED. Adult ED patients with non-immediate triage categories were included over a period of three weeks in the UK ED in August 2016 and two weeks in the Italian ED in March and August 2017. Episodes of PIVC insertion and data on PIVC utilisation in adults were recorded. PIVC use was classified as necessary, unnecessary or unused. The proportion of unnecessary and unused PIVCs was calculated. PIVCs were defined as unnecessary if they were either used for phlebotomy only, or solely for IV fluids in patients that could have potentially been hydrated orally (determined against a priori defined criteria). PIVC classified as unused were not used for any purpose.

RESULTS

A total of 1,618 patients were included amongst which 977 PIVCs were inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for IV fluids in patients that could drink.

CONCLUSIONS

More than half of PIVCs placed in the ED were unnecessary in this study. This suggests that clinical decision making about the benefits and risks of PIVC insertion is not being performed on an individual basis.

The Impact of Alcohol-Related Presentations to Emergency Departments on Days with a Public Holiday or Sporting Event: A Retrospective Cohort Study

INTRODUCTION

The consumption of alcohol within the Australian community continues to rise, impacting care delivery in already over-burdened emergency departments (EDs).

STUDY OBJECTIVE

This study aimed to examine the impact of alcohol-related presentations (ARPs) to EDs on days with a public holiday or sporting event.

METHODS

A retrospective cohort study was undertaken using routinely collected health data pertaining to patient presentations diagnosed with an alcohol-related disorder (ICD-10-AM code F10) to two EDs in Queensland, Australia from January 1, 2016 - December 31, 2020. Descriptive and inferential statistics were used to describe and compare ARPs on event days versus non-event days and uncomplicated versus other ARPs on event days only.

RESULTS

Of all 5,792 ARPs, nine percent (n = 529) occurred on public holidays or sporting event days. When compared by day type, type of presentation, mode of arrival, and day of week differed between event and non-event days. On event days, uncomplicated ARPs differed to other ARPs, with uncomplicated ARPs being younger, having shorter median length-of-stay (LOS), and less likely to be admitted to hospital.

CONCLUSIONS

In this multi-site study, public holidays and sporting events had a noteworthy impact on ARPs to EDs. Focused refinement on the clinical management of uncomplicated ARPs is warranted to inform future resource allocation, including on event days.

Effect of intravenous fluid therapy for acute alcohol intoxication on length of time from arrival at the emergency department until awakening: A prospective observational cohort study

Aim

To evaluate the association of intravenous fluid (IVF) therapy on the length of time from arrival at the emergency department (ED) until awakening in cases of acute alcohol intoxication.

Methods

This single-center, prospective, observational study was conducted in the ED of the Self-Defense Forces Central Hospital during October 1, 2018 to July 31, 2019. Patients with 1,000 mL bolus of lactated Ringer's solution and those without bolus were compared. The primary outcome was the length of time until awakening. Secondary outcomes were the length of stay in the ED and occurrence of conditions requiring extra care. Predictors of the occurrence of any event requiring extra care were identified.

Results

We included 201 patients, of whom 109 received IVF and 92 did not. No significant difference existed in the baseline characteristics between the groups. The median length of time until awakening did not significantly differ between the groups (P = 0.77). Multivariable regression analysis adjusted by age, sex, hemoglobin, blood alcohol concentration, and initial Glasgow Coma Scale (GCS) score demonstrated that the regression coefficient of IVF for length of time until awakening was -9.55 (95% confidence interval [CI], -36.2 to 17.2). Hemoglobin (regression coefficient, 10.1; 95% CI, 0.38-19.9) and initial GCS score (regression coefficient, -7.51; 95% CI, -10.8 to -4.21) were significantly associated with length of time.

Conclusion

IVF therapy was not associated with the length of time until awakening in patients with acute alcohol intoxication in the ED. Routine IVF administration was unnecessary.

Longitudinal description and evaluation of an emergency department avoidance strategy for a youth mass gathering (Schoolies) in Australia

OBJECTIVE

ED avoidance strategies including In-Event Health Service (IEHS) processes during mass gathering events (MGEs), such as 'Schoolies week', may be important for EDs, ambulance services, the local population, and attendees. The aim of the present study was to provide a longitudinal description of emergency care requirements for young adults (16-18 years old); focussing on the impact of the Schoolies MGEs.

METHODS

This retrospective observational study included youth (16-18 years) presentations made (i) to local public EDs during Schoolies week in 2008-2014 and (ii) to local EDs over a 3-week period (pre, during, post-Schoolies week) and the IEHS in 2015 and 2016. Descriptive and inferential statistics were undertaken.

RESULTS

Youth presentations (n = 4256) were included. Presentation rates/1000 fluctuated over time (range 6.2-21.2). The IEHS provided care for 167 and 288 youth during 2015 and 2016 Schoolies week, respectively. Demographic factors (gender, age, region domiciled) and episode of care factors (time of presentation, mode of arrival, urgency, time to triage, time to be seen by a clinician and length of stay) between 2008 and 2016 varied by year. Toxicology (alcohol and other drugs), trauma, and mental health concerns were the most common diagnoses.

CONCLUSIONS

The IEHS, operational during Schoolies, appeared to reduce pressures on local EDs by offering rapid, targeted care for potentially vulnerable youth; decrease requirements for hospital transport and minimise impacts on care provision for the local community. Given increases in ED crowding and pressures on ambulance services, such care models may be worth considering for other types of MGEs and in other locations.

A nationwide randomized, double-blind, placebo-controlled physicians' trial of loxoprofen for the treatment of fatigue, headache, and nausea after hangovers

Hangovers are associated with negative economic consequences due to decreased job performance or frequent visits to physicians. Thus, a new strategy for the alleviation of hangover-related symptoms is needed to avoid this detriment to society. The purpose of this nationwide randomized, double-blind, placebo-controlled physicians' trial was to evaluate the efficacy of loxoprofen sodium for the alleviation of fatigue, headache, and nausea after hangover. A total of 229 participants were randomized to receive loxoprofen sodium (60 mg once orally) or placebo. The study was closed when the first 150 participants (n = 74 in the loxoprofen vs. n = 76 in the placebo groups) experienced hangovers. The primary endpoint was set as the difference in severity of general fatigue before and 3 h after taking the test drugs and was evaluated using a visual analogue scale. Secondary endpoints included difference in severity of headache, nausea, and incidence of adverse events. The study participants were 34 (interquartile range; 30-39) years old, 92.0% were men, and both groups were comparable for baseline characteristics. The alleviation of general fatigue did not differ statistically between the loxoprofen and placebo groups (24 [14-49] vs. 19 [9-35], p = 0.07). However, the alleviation of headache was statistically greater in the loxoprofen group (25 [10-50] vs. 10 [2-30], adjusted difference 14, 95% confidence interval 8-21, p < 0.001), whereas, there was no difference in nausea (7 [0-27] vs. 10 [0-24], p = 0.68). The incidence of adverse symptoms such as epigastric discomfort was also comparable between groups (2.7% vs. 3.9%, p = 0.25). Loxoprofen sodium was effective for relieving headaches after hangovers but did not alleviate general fatigue or nausea.

Drug and Alcohol Related Patient Presentations to Emergency Departments during Sporting Mass-Gathering Events: An Integrative Review

BACKGROUND

Drug and alcohol consumption at sporting mass-gathering events (MGEs) has become part of the spectator culture in some countries. The direct and indirect effects of drug and alcohol intoxication at such MGEs has proven problematic to in-event health services as well as local emergency departments (EDs). With EDs already under significant strain from increasing patient presentations, resulting in access block, it is important to understand the impact of sporting and other MGEs on local health services to better inform future planning and provision of health care delivery.

AIM

The aim of this review was to explore the impact of sporting MGEs on local health services with a particular focus on drug and alcohol related presentations.

METHOD

A well-established integrative literature review methodology was undertaken. Six electronic databases and the Prehospital and Disaster Medicine (PDM) journal were searched to identify primary articles related to the aim of the review. Articles were included if published in English, from January 2008 through July 2019, and focused on a sporting MGE, mass-gathering health, EDs, as well as drug and alcohol related presentations.

RESULTS

Seven papers met the criteria for inclusion with eight individual sporting MGEs reported. The patient presentation rate (PPR) to in-event health services ranged from 0.18/1,000 at a rugby game to 41.9/1,000 at a recreational bicycle ride. The transport to hospital rate (TTHR) ranged from 0.02/1,000 to 19/1,000 at the same events. Drug and alcohol related presentations from sporting MGEs contributed up to 10% of ED presentations. Alcohol was a contributing factor in up to 25% of cases of ambulance transfers.

CONCLUSIONS

Drug and alcohol intoxication has varying levels of impact on PPR, TTHR, and ED presentation numbers depending on the type of sporting MGE. More research is needed to understand if drug and alcohol intoxication alone influences PPR, TTHR, and ED presentations or if it is multifactorial. Inconsistent data collection and reporting methods make it challenging to compare different sporting MGEs and propose generalizations. It is imperative that future studies adopt more consistent methods and report drug and alcohol data to better inform resource allocation and care provision.

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.

IV crystalloid fluid for acute alcoholic intoxication prolongs ED length of stay

OBJECTIVES

Acute alcohol intoxication is often treated in emergency departments by intravenous crystalloid fluid (IVF), but it is not clear that this shortens the time to achieving sobriety. The study aim was to investigate the association of IVF infusion and length of stay in the ED.

METHODS

This single-center retrospective cohort study was conducted in Japan and included patients aged ≥20years of age and treated for acute alcohol intoxication without or with IVF. The primary outcome was the length of the ED stay and the treatments were compared by time-to-event analysis.

RESULTS

A total of 106 patients, 42 treated without IVF and 64 with IVF. The baseline characteristics of the two groups were similar. Kaplan-Meier analysis and the generalized Wilcoxon test found no significant difference between the two treatments in the time to ED discharge. The median time was 189 (IQR 160-230) minutes without IVF and 254.5 (203-267 minutes with IVF; p=0.052). A Cox proportional hazards regression model adjusted for potential confounding variables found that patients treated with IVF were less likely to be discharged earlier than those treated without IVF (HR 0.54, 95% CI: 0.35-0.84, p=0.006).

CONCLUSIONS

IVF for treatment of acute alcoholic intoxication prolonged ED length of stay even after adjustment for potential confounders. Patients given IVF for acute alcohol intoxication should be selected with care.

Additional Conditions Amenable to Observation Care

ED observation units (EDOUs) are designed for patients who require diagnostics or therapeutics beyond the initial ED visit to determine the need for hospital admission. Best evidence is that this care be delivered via ordersets or protocols. Occasionally, patients present with conditions that are amenable to EDOU care but fall outside the commonly used protocols. This article details a few of these conditions: abnormal uterine bleeding, allergic reaction, alcohol intoxication, acetaminophen overdose and sickle cell vaso-occlusive crisis. It is not meant to be exhaustive as patient care needs can vary hospital to hospital.

Alcohol-Related Visits to US Emergency Departments, 2001-2011

AIMS

Alcohol intoxication is a source of significant illness and injury commonly resulting in emergency department (ED) visits. We characterize recent trends in alcohol-related visits to US EDs using nationally representative data.

METHODS

We conducted a retrospective review of data on national ED visits among patients aged 18 years or older with alcohol intoxication between 2001 and 2011 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Demographic and resource utilization trends in alcohol-related visits were examined. We also assessed ED length of stay (LOS) across the study period, as well as the total hours spent on ED care for alcohol-related complaints.

RESULTS

Between 2001-2002 and 2010-2011, alcohol-related visits increased from 2,459,748 to 3,856,346 (P = 0.049). Utilization of resources such as laboratory tests, medications and radiography increased, with the use of advanced imaging (i.e. computed tomography and magnetic resonance imaging) increasing 232.2% (P < 0.001) from 2001-2002 to 2010-2011. Overall LOS increased 16.1% (P = 0.028), while LOS among patients admitted to the hospital increased 24.9% (P = 0.076). Total alcohol-related hours spent in EDs nationwide increased from 5.6 million in 2001 to 11.6 million in 2011, an increase of 108.5% (P < 0.001) compared with an increase in overall ED hours of 54.0% (P < 0.001).

CONCLUSION

Alcohol-related ED visits are increasing at a greater rate than overall ED visits and represent a growing burden on hospital resources.