Is Intoxicated Patient ‘Just Another Drunk,’ or Someone With Unsuspected Critical Illness?
About 1% of patients who arrived to the ED for uncomplicated alcohol intoxication required critical care resources during their encounter, according to a recent study.1
“The purpose of this study was to identify the frequency at which patients who presented to the ED for uncomplicated alcohol intoxication had underlying critical illness,” says Lauren Klein, MD, MS, the study’s lead author.
Researchers analyzed 31,364 ED visits of patients from 2011 to 2016. The initial assessment for these patients was uncomplicated alcohol intoxication without other acute medical or traumatic complaints. A few factors were associated with increased odds of critical illness, including chemical sedation, hypoglycemia, and abnormal vital signs. Common diagnoses included infection or sepsis, acute hypoxic respiratory failure, intracranial hemorrhage, and alcohol withdrawal. Three patients went into cardiac arrest.
“While working in the ED, in patients who arrived to the ED ‘just intoxicated,’ we would often find additional serious pathology,” says Klein, faculty in the department of emergency medicine at Hennepin County Medical Center in Minneapolis. Sometimes, these patients would even go on to require critical care interventions, such as endotracheal intubation for respiratory failure. The findings correlated with the researchers’ clinical experience.
“This validated our concern that the population of patients presenting with alcohol intoxication is a high-risk cohort,” Klein reports. “These encounters should be treated with the utmost respect and attention to detail.”
If busy EPs see a patient on the tracking board listed as there for “alcohol intoxication,” the patient may not get their full attention compared to the other patients who seem sicker. “This study suggests that intoxicated patients need a comprehensive evaluation,” Klein offers. “Intoxicated patients can hide serious pathology, and it is our job to find this pathology.”
In the ED, “we still stigmatize people who are intoxicated. There’s a lot of frustration and skepticism, a mindset that ‘You’re just drunk, get out of my ER,’” says Andrew Lawson, MD, FACEP, acting director of quality assurance & quality improvement for the emergency physician group at Mission Hospital Regional Medical Center in Mission Viejo, CA.
EPs must overcome this bias, approaching the interaction with an open mind, Lawson says. “If you treat them as you would treat anybody else, you will order the appropriate tests and treat appropriately.”
Mindset “plays a huge factor in this,” Lawson adds. “Seeing the patient as ‘just another drunk’ vs. a patient just like any other patient is the number one cause of getting into medical/legal trouble.”
The following are issues involving intoxicated ED patients that can lead to litigation:
• ED providers may miss serious medical conditions because of a less-than-thorough evaluation. “Often, we get jaded, and go down a line where we do very little testing or do the wrong tests,” Lawson laments.
Frequent ED users who visit the ED for acute alcohol intoxication demonstrated higher rates of medical and psychiatric comorbidities compared to non-frequent users. Researchers noted that these comorbidities included liver disease, chronic kidney disease, ischemic vascular disease, dementia, COPD, history of traumatic brain injury, schizophrenia, and bipolar disorder.2
Of 32,121 patient encounters, 325 patients were defined as frequent users for alcohol intoxication, comprising 11,370 of the encounters during the study period. The number of ED visits per patient ranged from 20-169.
“Downplaying what’s going on will get you into trouble,” Lawson warns, reporting that he has seen EPs miss spinal cord injuries and broken bones in intoxicated patients. “The patient could have a broken neck and not act like they do.”
The patient’s intoxication can distract EPs from other medical conditions that require attention. Lawson says this is similar to the way an ED patient’s injury can distract the EP from noting another unrelated injury.
“You have to be very careful. We almost have to order and evaluate more aggressively than you would for somebody not intoxicated,” Lawson notes.
• ED providers may not be able to obtain an accurate history from the intoxicated patient. “We need to get information from everybody — paramedics, family members — to put together what really happened,” Lawson advises. Questions for paramedics might include “Who called 911?” or “What did you see when you arrived?” Questions for family might include “Does the patient live alone?” or “Was this a suicide attempt?”
• Staff may fail to take appropriate precautions to prevent the intoxicated patient from sustaining an injury in the ED. “You get into trouble when you allow [patients] to walk without assistance or give them a bedside urinal rather than keeping the gurney sides up and making sure they are not able to harm themselves,” Lawson explains.
• Documentation in ED charts sometimes appears judgmental. ED staff may document something like “George is drunk again.”
“You want to document exactly what transpired without any derogatory comments,” Lawson advises. “Be an objective observer rather than an invested, subjective person.”
For example, EPs might chart, “The patient moved their arm in an aggressive way to try to punch me,” or “the patient tried to attack me.”
• Intoxicated patients may be harmed because of an unsafe discharge situation. “You need to provide the patient with a safe ‘out,’” Lawson advises. Ideally, the patient is awake, alert, and able to ambulate — all while a family member is present.
“That’s a pretty good situation for discharge,” Lawson says. “But if [patients] don’t have a family member with them, or you think they are not that intoxicated, and you allow them to leave by taxi, that’s high risk.”
• The intoxicated patient who leaves the ED against medical advice (AMA) may be harmed. “You certainly don’t want to sign somebody out AMA who is intoxicated [and] who may not be competent to understand the risks and benefits of leaving,” Lawson warns.
Lawson recommends getting the family involved to help convince the patient to stay for tests, and using statement such as “I don’t blame you, I would want to get home, too. But if you can give us another hour of your time, we can get you some food to eat.”
If the patient insists on leaving, calling the police may be necessary. In such cases, Lawson says, “We don’t really want to do this, but we are concerned for your welfare, and we don’t feel you are safe to go home yet. If you insist on leaving, we will need to call the police to speak with you.”
If there’s litigation, and the intoxicated patient signed out AMA, decision-making capacity almost certainly will become an issue.
“[Plaintiffs] can potentially find a lawyer who says the patient clearly was not capable of signing such a document in their condition,” Lawson says.
REFERENCES
- Klein LR, Cole JB, Driver BE. Unsuspected critical illness among emergency department patients presenting for acute alcohol intoxication. Ann Emerg Med 2018;71:279-288.
- Klein LR, Martel ML, Driver BE, et al. Emergency department frequent users for acute alcohol intoxication. West J Emerg Med 2018;19:398-402.
SOURCES
- Lauren Klein, MD, MS, Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis. Phone: (612) 873-7448. Email: [email protected].
- Andrew Lawson, MD, FACEP, Acting Director, Quality Assurance & Quality Improvement, Emergency Physician Group, Mission Hospital Regional Medical Center, Mission Viejo, CA. Phone: (949) 400-5216. Email: [email protected].
About 1% of patients who arrived to the ED for uncomplicated alcohol intoxication required critical care resources during their encounter, according to a recent study.
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