Epidemiology of alcohol-related emergency department visits

Emergency department visits at Veterans Health Administration hospitals related to alcohol intoxication: A ten-year retrospective

We sought to quantify and describe the volume of emergency department visits related to alcohol intoxication at the Veterans Health Administration (VHA), the largest healthcare system in the United States. This is a retrospective cohort study of patients with VHA emergency department visits for alcohol intoxication from 2010 to 2019 as identified via ICD-9/10 code and/or serum ethanol concentration >50 mg/dL. Encounters were identified and demographic and clinical data were acquired by automated query of the VHA Corporate Data Warehouse. Descriptive statistics and univariate analysis were performed. We identified 95,123 patients with a total of 251,310 emergency department visits. The annual number of visits increased over the study period, reaching 32,333 in 2019. Men aged 40-60 were the most common demographic group in the cohort (48% of all patients), and men made up a higher proportion of patients in the database (94%) than the VHA population overall (90%). A disproportionate number of visits (32%) came from the top 4.4% of most frequent visitors. Most of the emergency department visits in the database (68%) were associated with medical or psychiatric admission, or interfacility transfer for admission elsewhere. Patients in the cohort accounted for 1.3% of all VHA emergency department visits during the study period, a proportion that is somewhat smaller than what has been reported at non-VHA facilities, despite the high prevalence of addiction disorders in the VHA patient population. We submit that this lower-than-expected proportion of alcohol-related emergency department visits may be due to the access to primary and mental care which is afforded by VHA patient benefits.

Acute injury mortality and all-cause mortality following emergency department presentation for alcohol use disorder

BACKGROUND

Alcohol-related morbidity and mortality have increased substantially in the U.S. Understanding the population health implications of these concerning trends, including by identifying clinical subgroups of alcohol users at increased risk for potentially preventable acute causes of mortality, is of critical importance.

METHODS

This retrospective cohort study used statewide, all-payer, longitudinally-linked ED patient record and mortality data from California. Participants comprised all residents presenting to a licensed ED at least once in 2009-2011 with a diagnosis of alcohol use disorder (AUD). Participants were followed for one year after index ED visit to assess acute injury (unintentional poisoning, suicide, homicide, motor vehicle crash, and fall- or fire-related injury) and all-cause mortality rates per 100,000 person-years. Age-, sex-, race/ethnicity-adjusted standardized mortality rates (SMRs) for acute injury causes of death were determined using statewide mortality data.

RESULTS

Among 437,855 patients with index non-fatal ED visits for AUD, the 12-month acute injury mortality rate was 608.6 per 100,000 (SMR=8.0; 95% CI=7.7, 8.3), and all-cause mortality was 5700.7 per 100,000 (SMR=6.5; 95% CI=6.4, 6.6). Unintentional poisoning accounted for 46.5%, and suicide for 19.7%, of acute-injury deaths. Acute injury deaths comprised 71.7% of all-cause mortality among patients aged 10-24 years, but much lower proportions among older patients. Female AUD patients had lower rates for all mortality outcomes.

CONCLUSIONS

Emergency department patients with a recognized AUD comprise a population at persistently elevated risk for mortality. Age-related AUD patient differences in common causes of death, including drug overdose and suicide, can inform the structure of future clinical interventions.

Emergency department presentations of alcohol and other substance misuse: first cross-sectional national study in Qatar

OBJECTIVES

This study attempts the first in a series of investigations into the misuse of alcohol and substances in Qatar. This study explores the emergency presentations of alcohol and substance abuse to all the state funded emergency departments (EDs) in the country which serve around 90% of the population over a 22-month period. Due to legal penalties for alcohol and substance use, and lack of subsidised community-based facilities, ED presentations are a good starting point to explore this burden.

DESIGN AND PARTICIPANTS

A retrospective population-based, cross-sectional study, analysing electronic patient records of all state funded EDs spanning a period of 22 months, from 1 January 2019 to 31 October 2020 was carried out. The study included all eligible individuals aged 18 or over. Primary reason/diagnosis for presentation containing any of the alcohol or substance use key words were included in the study using composite data capture forms by trained clinicians.

RESULTS

An overwhelming majority (95.5%) of the total 1495 cases presenting to the EDs with substance abuse were using alcohol. Only 2.1% of the cases were females. Those of Asian (non-Arab) constituted 70% of this group. Qatari citizens presented with highest proportion of substance abuse other than alcohol (23%). Overall, 2.26% of all presentations to the EDs were related to alcohol and substance abuse and this amounted to 3 ED visits per 10 000 of population per year. 56.6% of the cases presented over the weekend. Less than 1% were referred to psychiatry and no other meaningful rehabilitative interventions were offered to others.

CONCLUSION

As Qatar moves towards establishing community-based rehabilitative resources for alcohol and substances abuse, the findings from this study will help in shaping these developments. These can include ED-based routine screening for alcohol abuse and referral to rehabilitation services without fear of legal penalties.

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

•

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

•

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.

•

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

•

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.

•

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

•

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)

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.

Identification and medical utilization of incident cases of alcohol dependence: A population-based case-control study

BACKGROUND

Patients with alcohol dependence (AD) often seek help from medical professionals due to alcohol-related diseases, but the overall distribution of medical specialties identifying new AD cases is unclear. We investigated how such cases were identified and how medical resources were utilized before the identification of AD in a nationwide cohort.

METHODS

We enrolled a population-based cohort (N = 1,000,000) using the National Health Insurance Research Database of Taiwan; 8181 cases with incident AD were retrieved between January 1, 2000, and December 31, 2010. For this nested case-control study, four controls were matched for age and sex with each case based on risk-set sampling. We measured various dimensions of medical utilization before AD was diagnosed, including department visited, physical comorbidity, and medication used. Conditional logistic regression was used for estimating the variables associated with AD.

RESULTS

Patients living in less urbanized areas who were unemployed were more likely to develop AD. The highest proportions (34.2%) of AD cases were identified in the internal medicine department, followed by the emergency (22.3%) and psychiatry (18.7%) departments. AD patients had a higher risk of comorbid chronic hepatic disease (adjusted RR = 2.72, p < 0.001) before identification of AD than controls. AD patients also had greater numbers of hospital admissions than controls, including non-psychiatric and psychiatric hospitalizations. Outpatient visit numbers were similar for AD patients and controls.

CONCLUSIONS

The findings indicate that clinicians providing care in diverse medical settings should be prepared to screen for unhealthy alcohol use and to mitigate its detrimental effects.

Visits for alcohol-related problems in a large urban Emergency Department. Results of a 15-year survey

Alcohol abuse is associated with a high burden of morbidity and mortality. Nevertheless, definitive epidemiological data on alcohol-related visits in the emergency department (ED) is substantially lacking. This study was aimed to analyze the epidemiological patterns and temporal trends of alcohol-related visits in the local ED, and assessing the healthcare burden of cases needing hospital admission. All patients visited for alcohol-related problems between the years 2002-2016 were anonymously identified from the hospital database. All cases were classified according to the main cause leading to ED, age and gender, time of presentation, disposition. Overall, 8014 cases were identified (2249 women and 5765 men). Women were younger than men. The overall trend during the study period was characterized by a constant increase in the number of alcohol-related ED admissions. A significant number of subjects had multiple alcohol-related visits. A total number of 747 patients were visited twice, 259 three times and 107 four times. A mostly nocturnal pattern of ED presentation was observed in both genders, peaking between midnight and 2 AM, and an increased number of visits was recorded during the weekends. The vast majority of patients (64%) could be discharged within 6 hours, but a considerable number needed longer observation and treatment in the ED. Overall, 7551 patients were discharged from the ED, whilst 462 patients needed hospital admission, 179 for traumatic injuries and 283 for non-traumatic causes. The decreasing age of subjects admitted to the ED with alcohol-related problems should now be regarded as a public healthcare issue.

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.

The impact of educational interventions on attitudes of emergency department staff towards patients with substance-related presentations: a quantitative systematic review

BACKGROUND

Visits to emergency departments for substance use/abuse are common worldwide. However, emergency department health care providers perceive substance-using patients as a challenging group to manage which can lead to negative attitudes. Providing education or experience-based exercises may impact positively on behaviors towards this patient population. Whether staff attitudes are similarly impacted by knowledge acquired through educational interventions remains unknown.

OBJECTIVES

To synthesize available evidence on the relationship between new knowledge gained through substance use educational interventions and emergency department health care providers' attitudes towards patients with substance-related presentations.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Health care providers working in urban and rural emergency departments of healthcare facilities worldwide providing care to adult patients with substance-related presentations.

TYPE OF INTERVENTION

Quantitative papers examining the impact of substance use educational interventions on health care providers' attitudes towards substance using patients.

TYPES OF STUDIES

Experimental and non-experimental study designs.

OUTCOMES

Emergency department staff attitudes towards patients presenting with substance use/abuse.

SEARCH STRATEGY

A three-step search strategy was conducted in August 2015 with a search update in March 2017. Studies published since 1995 in English, French or Spanish were considered for inclusion.

METHODOLOGICAL QUALITY

Two reviewers assessed studies for methodological quality using critical appraisal checklists from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Reviewers agreed on JBI-MAStARI methodological criteria a study must meet in order to be included in the review (e.g. appropriate use of statistical analysis).

DATA EXTRACTION AND SYNTHESIS

The data extraction instrument from JBI-MAStARI was used. As statistical pooling of the data was not possible, the findings are presented in narrative form.

RESULTS

A total of 900 articles were identified as relevant for this review. Following abstract and full text screening, four articles were selected and assessed for methodological quality. One article met methodological criteria for inclusion in the review: use of random assignment and comparable study groups and measurement outcomes in a reliable and consistent manner. The included study was a cluster randomized controlled trial. Participants were emergency medicine residents with a mean age of 30 years. The study assessed the impact of a skills-based educational intervention on residents' attitudes, knowledge and practice towards patients with alcohol problems. While knowledge and practice behaviors improved one year following the intervention, there were no significant differences between groups on attitudinal measures.

CONCLUSIONS

Employing educational interventions to improve the attitudes of emergency department staff towards individuals with drug and alcohol related presentations is not supported by evidence.

Emergency department syndromic surveillance to investigate the health impact and factors associated with alcohol intoxication in Reunion Island

In Reunion Island, alcohol is the most tried out psychoactive substance. To our knowledge, few indicators measuring the health burden of alcohol use exist on the island. In this context, an exploratory analysis based on syndromic surveillance data was implemented in order to describe the emergency department (ED) visits for alcohol intoxication (AI) and factors associated with their variations.An analysis of anonymized records routinely collected by the syndromic surveillance system was carried out. A daily indicator of ED visits for AI was built from a selection of ICD-10 codes between 2010 and 2012. Health impact of AI was first described comparing this indicator to all causes ED visits. Then, AI visits were analyzed with time-series methods using generalized additive Poisson regression models allowing for overdispersion. The following variables were included in the model: long-term trend, seasonality, day of the week, public and school holidays, days of festival and minimum social benefits payday.During the study period, 16 652 visits for AI were recorded in EDs of Reunion Island. AI visits were the second reason for ED visits (i.e. 4%) after traumatism. AI visits mainly concerned men (87%) and the age group of 25-54 years (69%). There was a significant increase in ED visits for AI during days of benefits payday, weekends and publics holidays.This study demonstrated the interest of syndromic surveillance to monitor non-infectious diseases. Time-series models showed a robust association between ED visits for AI and several factors.

Developing a standardized measurement of alcohol intoxication

INTRODUCTION

We assessed multiple examinations and assessment tools to develop a standardized measurement of alcohol intoxication to aid medical decision making in the Emergency Department.

METHODS

Volunteers underwent an alcohol challenge. Pre- and post-alcohol challenge, subjects were videotaped performing three standardized clinical examinations: (1) Standardized Field Sobriety Test (SFST) examination, (2) Hack's Impairment Index (HII) examination, and (3) Cincinnati Intoxication Examination (CIE). Emergency clinicians evaluated the level of intoxication using five standardized assessment tools in a blinded and randomized fashion: (1) SFST assessment tool (range 0-18), (2) HII assessment tool (range 0-1), (3) St. Elizabeth Alcohol Intoxication Scale (STE, range 0-17), (4) a Visual Analog Scale (VAS, range 0-100), and (5) a Binary Intoxication Question (BIQ). Construct validity was assessed along with inter- and intra-rater reliability.

RESULTS

Median scores pre- and post-alcohol challenge were: SFST 6 (interquartile range 5) and 11 (3), respectively; HII 0 (0.05), 0.1 (0.1); STE 0 (1), 1 (2); VAS 10 (22), 33 (31). For BIQ, 59% and 91% indicated intoxication, respectively. Inter-rater reliability scores were: SFST 0.71 (95% confidence interval 0.48-0.86) to 0.93 (0.88-0.97) depending on examination component; HII 0.90 (0.82-0.95); STE 0.86 (0.75-0.93); VAS 0.92 (0.88-0.94); BIQ 0.3. Intra-rater reliability scores were: SFST 0.74 (0.64-0.82) to 0.87 (0.81-0.91); HII 0.85 (0.79-0.90); STE 0.78 (0.68-0.85); VAS 0.82 (0.74-0.87); BIQ 0.71. VAS reliability was best when paired with the HII and SFST examinations.

CONCLUSIONS

HII examination, paired with either a VAS or HII assessment tool, yielded valid and reliable measurements of alcohol intoxication.

Tweet Now, See You In the ED Later? Examining the Association Between Alcohol-related Tweets and Emergency Care Visits

BACKGROUND

Alcohol use is a major and unpredictable driver of emergency department (ED) visits. Regional Twitter activity correlates ecologically with behavioral outcomes. No such correlation has been established in real time.

OBJECTIVES

The objective was to examine the correlation between real-time, alcohol-related tweets and alcohol-related ED visits.

METHODS

We developed and piloted a set of 11 keywords that identified tweets related to alcohol use. In-state tweets were identified using self-declared profile information or geographic coordinates. Using Datasift, a third-party vendor, a random sample of 1% of eligible tweets containing the keywords and originating in state were downloaded (including tweet date/time) over 3 discrete weeks in 3 different months. In the same time frame, we examined visits to an urban, high-volume, Level I trauma center that receives > 25% of the emergency care volume in the state. Alcohol-related ED visits were defined as visits with a chief complaint of alcohol use, positive blood alcohol, or alcohol-related ICD-9 code. Spearman's correlation coefficient was used to examine the hourly correlation between alcohol-related tweets, alcohol-related ED visits, and all ED visits.

RESULTS

A total of 7,820 tweets (representing 782,000 in-state alcohol-related tweets during the 3 weeks) were identified. Concurrently, 404 ED visits met criteria for being alcohol-related versus 2939 non-alcohol-related ED visits. There was a statistically significant relationship between hourly alcohol-related tweet volume and number of alcohol-related ED visits (rs = 0.31, p < 0.00001), but not between hourly alcohol-related tweet volume and number of non-alcohol-related ED visits (rs = -0.07, p = 0.11).

CONCLUSION

In a single state, a statistically significant relationship was observed between the hourly number of alcohol-related tweets and the hourly number of alcohol-related ED visits. Real-time Twitter monitoring may help predict alcohol-related surges in ED visits. Future studies should include larger numbers of EDs and natural language processing.

The continuing care model of substance use treatment: what works, and when is "enough," "enough?"

There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.

Alcohol and trauma--in every age group

BACKGROUND

The purpose was to determine the proportion of alcohol-positive (AlcPos) trauma patients in different age groups and any association with mortality using the National Trauma Data Bank.

METHODS

Several variables were extracted from the National Trauma Data Bank (version 6.2) using MS Access 2007: age, alcohol presence, Injury Severity Score (ISS), and discharge status (alive vs dead). Age groups for logistic regression were arbitrarily defined as follows: 0 to 10, 11 to 20, 21 to 39, 40 to 64, and older than 64 years.

RESULTS

Approximately 47% of all trauma survivors were tested for alcohol (621,174 of a total of 1,311,137), and 28% of those were AlcPos (176,107/621,174). The proportion of AlcPos patients gradually increased to maximum at 22 years, when 46% (6797/14,732) tested were AlcPos. The proportion AlcPos gradually declined to 35% by age 50 years, then to 15% (2516/16,244) by age 66 to 70 years. The ISSs were significantly higher in AlcPos patients in all age groups (P < .01). Mortality rates were higher in AlcPos children (up to age 20 years) and in adults older than 40 years. The AlcPos patients who were 21 to 39 years old had lower mortality compared with alcohol-negative patients. Logistic regression analysis (controlling for ISSs) revealed that being AlcPos did not play a role in mortality until age 21 to 39 years (AlcPos lower mortality) and in age 40 to 64 years and older than 65 years (AlcPos higher mortality).

CONCLUSIONS

Trauma patients of all ages may be AlcPos. Being AlcPos is a marker for greater injury in all age groups. After controlling for ISSs, trauma patients 40 years and older who were AlcPos have increased mortality. This study suggests a role for alcohol testing in all age groups.

Epidemiological study of acute poisoning in children: a 5-year retrospective study in the Paediatric University Hospital in Białystok, Poland

BACKGROUND

Poisoning among children and youths in the northeastern part of Poland accounted for 25% of the total number of patients admitted to the Hospital Emergency Department of the Paediatric University Hospital of Białystok. We hypothesise that the epidemiology of poisoned paediatric patients admitted is related to increase in 'designer drugs' (mainly amphetamine- and ecstasy-like psychostimulants, hallucinogens and synthetic cannabinoids ('spice') intake, which became popular 5 years ago in our country.

METHODS

A retrospective chart review of medical records of 489 patients admitted due to poisoning in the 5-year period (2006-2010). The data included: age, sex, place of residence, nature of the substance, causes of poisoning, former use of psychoactive stimulants, accompanying self-mutilation and injuries and length of hospitalisation. Categorical variables were expressed as percentages, and continuous variables as mean and SD. The data were collected in a Microsoft Excel database. Statistical analysis was performed using the Statistical Programme for Social Sciences.

RESULTS

Out of 2176 hospitalised children, 489 were admitted because of poisoning. Out of these, 244 (49.9%) were hospitalised due to intoxication by alcohol. Only eight children used designer drugs. The mean age of all patients in our group was 12.86±5.04 years, of which 52.4% were male. Poisoning was intentional in 75.5%, and accidental in 24.5% of cases. Appearance of 'designer drugs' had no significant impact on the number and epidemiology of poisonings in our group.

A descriptive comparison of alcohol-related presentations at a large urban hospital center from 1902 to 2009

Although alcohol use has long been a significant cause of hospital presentations, little is published regarding the long-term demographic changes that have occurred at a single hospital site. To address this deficit, we prospectively studied all acute alcohol-related presentations to Bellevue Hospital Center (New York, NY) and compared this contemporary data set with one from the same institution from 1902 to 1935. We prospectively identified all patients presenting to the emergency department because of acute alcohol use over an 8-week period in 2009. We described the basic attributes of patients presenting currently because of alcohol and compared these data to those previously described between 1902 and 1935. We also compared our census data with contemporaneous data from all patients presenting to this hospital site. During the study period, 560 patients presented because of acute alcohol use which extrapolated to an estimated 3,800 patients over the calendar year. This compares to 7,600 presentations recorded annually early in the twentieth century. Twelve percent of patients in 2009 were female as compared to 18 % of patients between 1934 and 1935. Patients with alcohol-related presentations in 2009 were more likely to be admitted than contemporaneous patients without an alcohol-related presentation (30 vs. 19 % admitted; p < 0.001). Since first measured 110 years ago at one large New York City hospital, alcohol-related presentations remain common representing 5 % of all emergency department visits. This demonstrates alcoholism's continuing toll on society's limited medical resources and on public health as a whole.

Emergency physicians' and nurses' attitudes towards alcohol-intoxicated patients

BACKGROUND

Emergency physicians and nurses are frequently dissatisfied professionally when treating alcohol-intoxicated patients, and have negative attitudes towards this patient population and alcohol rehabilitation.

STUDY OBJECTIVES

The goal of this study is to examine differences in attitudes between emergency physicians and nurses towards alcohol-intoxicated patients.

METHODS

This single-site survey study evaluated emergency physicians' and nurses': 1) attitudes of personal professional satisfaction and dissatisfaction when caring for intoxicated patients; 2) attitudes towards the difficulty in caring for alcohol-intoxicated patients; 3) attitudes towards respect of the alcohol-intoxicated patient; 4) attitudes towards the adequacy of training in caring for intoxicated patients; 5) attitudes towards rehabilitation and counseling of alcohol-intoxicated patients.

RESULTS

Physicians were less satisfied and more dissatisfied than nurses when caring for alcohol-intoxicated patients. Physicians found treating alcohol-intoxicated patients more difficult than nurses did. Physicians were more likely to agree that alcohol-intoxicated patients should be treated with respect. Physicians felt more adequately trained than nurses in caring for alcohol-intoxicated patients. Nurses were more likely to believe that alcohol-related rehabilitation is ineffective compared with physicians. Both nurses and physicians refer alcohol-intoxicated patients to rehabilitation to a similar extent.

CONCLUSIONS

Emergency physicians and nurses have similar attitudes but significant differences in the extent of these attitudes towards the care of the alcohol-intoxicated patient.

Twenty per hour: altered mental state due to ethanol abuse and withdrawal

This article discusses the physiology and clinical syndromes involved in ethanol absorption, intoxication, and withdrawal, with special emphasis on the evidentiary backing for common treatments, as well as some discussion of the medicolegal sequelae of treatment of ethanol abusers in the emergency department.

Can the blood alcohol concentration be a predictor for increased hospital complications in trauma patients involved in motor vehicle crashes?

The goal of this report is to assess the relationship of varying levels of blood alcohol concentration (BAC) and hospital complications in patients admitted after motor vehicle crashes. Data for the study was collected by a retrospective review of the University of Wisconsin Hospital trauma registry between 1999 and 2007 using the National Trauma Registry of the American College of Surgeons (NTRACS). Of 3729 patients, 2210 (59%) had a negative BAC, 338 (9%) <100 mg/dL, 538 (14%) 100-199 mg/dL, and 643 (17%) >200 mg/dL. Forty-six percent of patients had one or more hospital related complications. The odds ratio (OR) for the occurrence of alcohol withdrawal in the three alcohol groups compared to the no alcohol group was 12.02 (CI 7.0-20.7), 16.81 (CI 10.4-27.2), and 30.96 (CI 19.5-49.2) as BAC increased with a clear dose response effect. While there were no significant differences in the frequency of the total hospital events following trauma across the four groups, rates of infections, coagulopathies, central nervous system events and renal complications were lower in the high BAC group. Prospective studies are needed to more precisely estimate the frequency of hospital complications in patients with alcohol use disorders and in persons intoxicated at the time of the motor vehicle accident. The study supports the use of routine BAC to predict patients at high risk for alcohol withdrawal and the early initiation of alcohol detoxification.

Alcohol-related visits to the emergency department by injured adolescents: a national perspective

PURPOSE

Alcohol use is a risk factor for injury in adolescents. Many injured adolescents require treatment in emergency departments (EDs). The present study was intended to explore this association between adolescent alcohol use and injury-related ED visits using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative probability sample of visits to EDs.

METHODS

This was a retrospective, cross-sectional study using data from NHAMCS for 2001 through 2004. ED visits by injured adolescents aged 13-20 years whose visits were determined by NHAMCS coders to be related to alcohol were compared with visits by those whose visits were determined not related to alcohol. Specific variables of interest included demographic and medical characteristics of visits.

RESULTS

Our analyses indicated that there were several visit-related characteristics that were associated with alcohol-related ED visits, including time of visit, type of health insurance, and geographic location of the ED. Similarly, there were a number of patient-related characteristics that were also associated with alcohol-related visits to the ED, including patient acuity and injury intentionality.

CONCLUSIONS

Our findings suggest that injured adolescents are more likely to present to the ED with an alcohol-related visit during the early hours of the morning, that the injury is more likely to be assault related and of higher acuity than non-alcohol-related visits. These findings suggest the ED as a potential site for alcohol prevention interventions with younger adolescents. However, these interventions will need to take into account when such adolescents will present to the ED and will need also to recognize that factors such as violence and aggression, in addition to alcohol use, may be important issues to address in the intervention.

An evaluation of alcohol attendances to an inner city emergency department before and after the introduction of the UK Licensing Act 2003

Background

The Licensing Act 2003 (The Act) was implemented on the 24th November 2005 across England and Wales. The Act allowed more flexible and longer opening hours for licensed premises. We investigated the effect of The Act on alcohol related attendances to an inner city emergency department in Birmingham, UK.

Methods

We compared the proportion and time of alcohol related emergency department attendances in one week periods in January 2005 and 2006, before and after the implementation of The Licensing Act 2003. An alcohol related attendance was defined as any attendance where there was any documentation of the patient having consumed alcohol before presenting to the emergency department, if they appeared intoxicated on examination, or if alcohol attributed to their final diagnosis.

Results

The total weekly attendances increased slightly from 1,912 in 2005 to 2,146 in 2006.

There was non-significant reduction in the proportion of alcohol related attendances between 2005 (3.6%) and 2006 (2.9%). A significantly greater proportion of attendances occurred at the weekend between 18.00 and 23.59 in 2005 (61.4%) than in 2006 (17.2%). There was a corresponding significant increase in the weekend proportion of attendances occurring between 03.00 to 05.59 in 2006.

Conclusion

Our findings show that there was a change in the pattern of alcohol related attendances to the emergency department around the time of implementation of the Licensing Act 2003, which has implications for delivery of emergency department services.

Brief alcohol intervention in the emergency department: moderators of effectiveness

OBJECTIVE

Prior research supports the effectiveness of brief interventions for reducing alcohol misuse among patients in the emergency department (ED). However, limited information is available regarding the mechanisms of change, which could assist clinicians in streamlining or amplifying these interventions. This article examines moderators of outcomes among ED patients, ages 19 and older, who participated in a randomized controlled trial of a brief intervention for alcohol misuse.

METHOD

Injured patients (N= 4,476) completed a computerized survey; 575 at-risk drinkers were randomly assigned to one of four brief intervention conditions, and 85% were interviewed again at 3-month and 12-month follow-ups.

RESULTS

Regression models using the generalized estimating equations approach examined interaction effects between intervention condition (advice/no advice) and hypothesized moderator variables (stage of change, self-efficacy, acute alcohol use, attribution of injury to alcohol) on alcohol outcomes over time. Overall, participants who reported higher levels of self-efficacy had lower weekly consumption and consequences, whereas those with higher readiness to change had greater weekly consumption and consequences. Furthermore, individuals who attributed their injury to alcohol and received advice had significantly lower levels of average weekly alcohol consumption and less frequent heavy drinking from baseline to 12-month follow-up compared with those who attributed their injury to alcohol but did not receive advice.

CONCLUSIONS

This study provides novel data regarding attribution for alcohol-related injury as an important moderator of change and suggests that highlighting the alcohol/injury connection in brief, ED-based alcohol interventions can augment their effectiveness.

Alcohol misuse and report of recent depressive symptoms among ED patients

OBJECTIVE

This study examined the magnitude of association between alcohol misuse and recent depressive symptoms.

METHODS

We conducted a cross-sectional study of 412 randomly selected patients at least 18 years old and seeking emergency department (ED) care.

RESULTS

Of the patients, 51.0% reported depressive symptoms. At-risk drinking was reported by 26.0%, and 28.2% scored positive on the Rapid Alcohol Problems Screen 4. Alcohol abuse and binge drinking were reported by 25.1% and 28%, respectively, of the patients. According to our results, at-risk drinking (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.47-4.20, P < or = .001), problem drinking (OR = 2.11, 95% CI = 1.27-3.51, P < or = .004), drinking abuse (OR = 2.58, 95% CI = 1.51-4.40, P < .001), and binge drinking (OR = 1.89, 95% CI = 1.13-3.15, P < .001) were all related to the manifestation of depressive symptoms.

CONCLUSIONS

The findings of this study yield information that could be used by ED health care practitioners and health educators to educate ED patients at risk for alcohol misuse and depression.

[Screening and brief intervention for alcoholic patients treated at emergency rooms: prospects and challenges]

The purpose of this article was to present the general principles, concepts, and main elements of brief intervention, with a literature review on its use for alcoholic patients treated at emergency rooms. It also presents the applicability of screening as a first step to the brief intervention process and the use of validated standard instruments that allow useful information for consistent feedback. Finally, it highlights the challenges associated with screening in emergency rooms due to insufficient time, inadequate professional training, fear of annoying the patient, and common beliefs that alcoholics do not respond to such interventions. Meanwhile, it emphasizes the relevancy of brief emergency intervention, which is both feasible and efficient, and the need for research to define the relevant adjustments by professionals and the health care system.

The effects of alcohol consumption, psychological distress and smoking status on emergency department presentations in New South Wales, Australia

BACKGROUND

Despite clear links between risky alcohol consumption, mental health problems and smoking with increased morbidity and mortality, there is inconclusive evidence about how these risk factors combine and if they are associated with increased attendance at emergency departments. This paper examines the population-level associations and interactions between alcohol consumption, psychological distress and smoking status with having presented to an emergency department in the last 12 months.

METHODS

This study uses data from a representative sample of 34,974 participants aged 16 years and over from the New South Wales Population Health Survey, administered between 2002 and 2004. Statistical analysis included univariate statistics, cross-tabulations, and the estimation of prevalence rate ratios using Cox's proportional hazard regression model.

RESULTS

Results show that high-risk alcohol consumption, high psychological distress and current smoking were all significantly and independently associated with a greater likelihood of presenting to an emergency department in the last year. Presenting to an emergency department was found to be three times more likely for women aged 30 to 59 years with all three risk factors and ten times more likely for women aged 60 years or more who reported high risk alcohol consumption and high psychological distress than women of these age groups without these risk factors. For persons aged 16 to 29 years, having high-risk alcohol consumption and being a current smoker doubles the risk of presenting to an emergency department.

CONCLUSION

The combination of being a high-risk consumer of alcohol, having high psychological distress, and being a current smoker are associated with increased presentations to emergency departments, independent of age and sex. Further research is needed to enhance recognition of and intervention for these symptoms in an emergency department setting in order to improve patient health and reduce future re-presentations to emergency departments.

A survey on alcohol and illicit drug abuse among emergency department patients

Alcohol and illicit drug abuse are major health care problems frequently leading to emergency department admission. The aims of this survey were (1) to determine for the Ghent University Hospital how frequently substance abuse contributed to emergency department admissions, (2) to describe the most important clinical features of these patients and (3) to determine how frequently these patients were referred to appropriate psychiatric services. All 1,941 patients attending the emergency department during the month of September 2003 were registered by the attending emergency department personnel. After exclusion of 8 cases, 1,933 patients were included: 198 (10%) with substance abuse leading to the emergency department admission (= INTOX group) and 1,735 (90%) in the NON-INTOX group. Males and the 21-50 years age group were overrepresented in the INTOX group. Patients with substance abuse were also overrepresented during the night, but not during the weekend. Among the patients from the INTOX group the most frequent reason for the emergency department visit was a psychiatric problem (102/198; 51%). Traumatic lesions related to a fight (n= 19), to a traffic accident (n= 17) and to leisure time activities (n=30) were also frequent. In most patients, only alcohol was abused (144/198; 73%), most frequently chronically (102/144; 71%). In 13% (26/198), there was only illicit drug use, and in 14% (28/198) alcohol abuse was combined with illicit drug use. Among the 54 patients with illicit drug use (with or without alcohol abuse) the most frequently reported drugs were cannabis (54%), cocaine (41%), amphetamines (39%) and opiates (39%). With regard to referral to appropriate psychosocial services it was striking that 53% (19/36) of trauma patients with chronic substance abuse were not offered that type of help. We conclude that abuse of alcohol--and to a much lesser degree illicit drugs--is a frequent cause of emergency department admissions. Our data may help to convince and/or reinforce health care policy makers, emergency department medical directors and the public that alcohol consumption (much more than illicit drugs) is responsible for avoidable morbidity and mortality, and that well-co-ordinated strategies against unhealthy alcohol use are urgently needed. In this respect, the importance of detection and referral of emergency department patients with unhealthy alcohol use should be stressed.

Consequences of alcohol-induced early dysregulation of responses to trauma/hemorrhage

Acute alcohol intoxication is a frequent underlying condition associated with traumatic injury. Studies from our laboratory have been designed to examine the early hemodynamic, proinflammatory, and neuroendocrine alterations in responses to hemorrhagic shock in surgically catheterized, conscious, unrestrained, male Sprague-Dawley rats during acute alcohol intoxication (1.75-g/kg bolus, followed by a constant 15-h infusion at a rate of 250-300 mg/kg/h). With both fixed-pressure (40 mm Hg) and fixed-volume (50%) hemorrhagic shock, followed by fluid resuscitation with Ringer's lactate, acute (15 h) alcohol intoxication has been shown to impair significantly the immediate hemodynamic, metabolic, and inflammatory counterregulatory responses to hemorrhagic shock. Alcohol intoxication enhanced hemodynamic instability during blood loss and impaired the recovery of mean arterial blood pressure during fluid resuscitation. Activation of neuroendocrine pathways involved in restoring hemodynamic stability was significantly attenuated in alcohol-intoxicated hemorrhaged animals. The hemodynamic and neuroendocrine impairment is associated with enhanced expression of lung and spleen tumor necrosis factor, and it suppressed circulating neutrophil function. In addition, neuroimmune regulation of cytokine production by spleen-derived macrophages obtained from alcohol-intoxicated hemorrhaged animals was impaired when examined in vitro. We hypothesize that impaired neuroendocrine activation contributes to hemodynamic instability, which, in turn, prolongs tissue hypoperfusion and enhances risk for tissue injury. Specifically, the early dysregulation in counterregulatory responses is hypothesized to affect host defense mechanisms during the recovery period. We examined host response to systemic (cecal ligation and puncture) and localized (pneumonia) infectious challenge in animals recovering from hemorrhage during acute alcohol intoxication. Increased morbidity and mortality from infection were observed in alcohol-intoxicated hemorrhaged animals. Our results indicate that alcohol-induced alterations in early hemodynamic and neuroimmune responses to shock have an impact on susceptibility to an infectious challenge during the early recovery period.

Improving emergency medicine residents' approach to patients with alcohol problems: a controlled educational trial

STUDY OBJECTIVE

We determine whether training using a structured skills-based intervention would improve emergency medicine residents' knowledge and practice in screening and intervening with patients presenting to the emergency department with alcohol problems.

METHODS

In a controlled trial conducted at 2 similar emergency medicine residency programs associated with urban, Level I trauma centers, a 4-hour didactic, video, and skills-based workshop was conducted. Main outcome measures included (1) scores on changes in self-reported knowledge, current practice, self-efficacy, role-responsibility, attitudes and beliefs, and provider readiness to change from baseline to 1 year after intervention and (2) change in practice as measured by record review before and after intervention.

RESULTS

The intervention group (n=17) had a significant increase in knowledge scores (P <.001) and practice with regard to percent of medical records with evidence of screening and intervention (17% before versus 58% after; 95% confidence interval [CI] 31 to 50; P <.001); no change was observed in the control group (n=19). These increases were significantly different between groups (95% CI 30 to 54; P <.001). There were no significant differences within or between groups for composite scores derived for current practice, self-efficacy, role responsibility, or readiness to change.

CONCLUSION

A brief, structured, educational intervention for residents contributed to significant improvement in knowledge and practice with regard to patients with alcohol problems.

Improving detection of alcohol misuse in patients presenting to an accident and emergency department

OBJECTIVES

To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT). Design-Prospective study of the effects of audit feedback.

SETTING

An urban accident and emergency department.

SUBJECTS

Senior house officers (SHO) (n = 13).

OUTCOME MEASUREMENTS

PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT.

RESULTS

1062 of 1737 patients (61.1%) were defined as PAT possible-that is, presented with > or = one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p<0.0001). The response to audit and feedback showed marked inter-SHO variation. When feedback was withdrawn (month 4), there was a significant reduction in PAT use (p=0.003). Three other indices of detection followed this trend: (a) number of PAT positive patients identified, (b) proportion of PAT possible patients identified as PAT positive, and (c) number of PAT positive patients referred to the alcoholic health worker. The 10 most common PAT positive categories, accounting for 77% of all PAT positive complaints were: fall > collapse (including "fit", "blackout") > head injury (including "facial injury") > assault (including "domestic violence" and 'other') > nonspecific gastrointestinal problem > "unwell" > psychiatric (including "depression", "overdose", "confusion") > cardiac (including "chest pain" and "palpitations") > self neglect > repeat attendance.

CONCLUSIONS

Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.

Reliability of clinical decisions regarding alcohol influence

In Jordan, pursuing legal procedures related to alcohol intake usually depends on the physicians' clinical judgment. A study was carried out on 825 medico-legal cases over a 2 year period to evaluate the extent of physicians' clinical decisions on patients suspected to be under the influence of alcohol. A significant number of cases (12.6%, n = 104) were found to be positive for alcohol. The study showed that the clinical examination failed to diagnose a large number of cases (78.9%, n = 82). Also, the majority of diagnosed cases (50%, n = 11) had a blood alcohol concentration (BAC) range of 50-100 mg/dl. 32% (n = 33) of the cases with positive BAC were admitted to hospital. A high admission rate was observed when BAC was <50 mg/dl and >150 mg/dl, which constituted 39.3% (n = 13) and 48.5% (n = 16) of the admitted cases respectively. A large number of the admitted cases had either simple or no trauma (48.4%, n = 16) as compared with the control group of cases (21.8%, n = 10). The admission rate of positive BAC cases in traffic accidents was double that of control group. These findings may reflect the unreliability of the clinical decision in positive BAC. Implementing a certain BAC level locally for both clinical and a jurisdiction purposes is strongly recommended.