When should you obtain alcohol levels, tox screens?

If you suspect a patient has a substance abuse problem, what do you do next? A first step may be to obtain blood alcohol levels or toxicology screens, says Darlene Matsuoka, RN, BSN, CEN, CCRN, clinical nurse educator for the ED at Seattle-based Harborview Medical Center.

As an ED nurse, you always should consider drug and alcohol abuse as part of the patient picture, advises Matsuoka. "Its presence can dictate treatment, require further observation time, and warrants a red flag’ for follow-up," she says.

Consider obtaining an alcohol and toxicology screen for the following patients:

• Patients with a possible alcohol and/or drug problem.

In addition to routinely asking about a patient’s drug history, look for signs such as slurred speech, unsteady gait, and appearance of pupil size, advises Stephen Brown, RN, BSN, MHN, CEN, an ED nurse at University of California-Irvine Medical Center.

You must determine if drugs or alcohol are contributing to the patient’s reason for being in the ED, says Brown. "For example, if the patient has abscesses due to injection of street drugs, a plan can be made to address this issue," he says.

Some patients may deny having a problem, yet give responses such as "I only drink five beers a day," or "I just use cocaine once a week," notes Brown. In this case, you should provide information on follow-up care or a referral for outpatient treatment services, he says.

If you suspect drug or alcohol abuse, but the patient denies it, obtaining blood or urine specimens can confirm the presence of certain drugs or the alcohol level in the blood, explains Matsuoka.

New ED nurses may question why it’s necessary to obtain alcohol levels and toxicology screens, especially if the patient does not seem impaired, says Matsuoka. "They may see it as a punitive measure, somehow linked to the police or the employer getting a hold of the information," she says.

At Harborview Medical Center, none of the results or medical information is released unless the patient consents, in accordance with requirements of the Health Insurance Portability and Accountability Act (HIPAA), stresses Matsuoka.

Since alcohol levels are part of the medical exam and are not legal blood alcohol levels, the results would not be available to police, she explains. "Police can present at the bedside and request a blood alcohol level be drawn for forensics, but it would be done only with the patient’s consent," she says. "In Washington state, if a patient refuses, his [driver’s] license may be suspended."

Even if there were a fatality from a drunk-driving accident, a confirmation of drug or alcohol use would be done by the medical examiner, adds Matsuoka.

Matsuoka explains to staff that the tests are done to ascertain causes of changes in level of consciousness or behavior, or to identify a substance abuse problem for a patient in denial. "These patients can then be referred to our social workers or chemical dependency counselors for counseling and referral," she says.

• Patients admitted to an inpatient psychiatric unit.

ED patients being admitted to the facility’s psychiatric unit always are screened for substance abuse, says Brown. "The only time this is not done is when a patient cannot urinate or the patient refuses to comply with our request for the sample," he says.

In this scenario, the fact that the patient refused is documented, or if the patient is unable to urinate, hydration is started. "If the patient still is unable and no medical emergency exists, the patient continues to be monitored," says Brown.

If a substance abuse problem is identified, nurses will be aware of potential withdrawal symptoms such as tremors, explains Brown.

"If the patient is on heroin for example, we can inform the doctors and methadone might be ordered," he says. "Or, if the patient has a history of alcohol abuse, we can anticipate the need for librium."

• Obtunded patients.

"Several of our patients come in obtunded, and it is important to have a thorough work-up to decide if the problem is inebriation, a subdural, or an overdose," says Matsuoka.

Many of these patients have conditions caused by chronic alcoholism, such as pancreatitis, hepatic encepalopathy, or alcohol withdrawal seizures, she adds.

• Patients with altered mental status.

Urine toxicology screens always are done for patients with altered level of consciousness and irrational or out-of-control behavior, says Matsuoka. "We see the gambit of ecstasy, GHB [gamma hydroxybutyrate], methamphetamines, cocaine, heroin, LSD, and marijuana in our ED," she reports.

"If a patient is acting in a bizarre manner and we confirm that drugs are on board, it can save an unnecessary computed tomography scan or other test," adds Brown.

• Trauma patients.

Research has documented 50% of all trauma admits had alcohol in their systems, notes Matsuoka.1 In light of these statistics, trauma patients should have alcohol levels drawn as part of their workup, she recommends.

• Overdose or suicidal patients.

If a patient has made an overdose attempt, a toxicology screen and an alcohol level should always be done, says Brown.

"A suicidal patient who comes to the ED and states that they took 100 Tylenol has a high possibility of a coingestion of other potentially lethal drugs and alcohol," he explains.

Reference

1. Gentillelo LM, Rivara, Donovan, et al. Alcohol interventions as a means of reducing risk of injury recurrence. Ann Surg 1999; 230:473-480.

Sources

For more information on alcohol levels and toxicology screens, contact:

  • Stephen Brown, RN, BSN, MHN, Emergency Department, University of California-Irvine Medical Center, P.O. Box 2463, Orange, CA 92859. Telephone: (714) 329-6699. E-mail: sjbrown@msx.ndc.mc.uci.edu.
  • Darlene Matsuoka, RN, BSN, CEN, CCRN, Clinical Nurse Educator, Emergency Department, Harborview Medical Center, Mail Stop 359875, 325 Ninth Ave., Seattle, WA 98104. Telephone: (206) 731-2646. Fax: (206) 731-8671. E-mail: dmatsuok@u.washington.edu.