Frequent Monitoring and Behavioral Assessment: Keys to the Care of the Intoxicated Patient

REVIEWS & ANALYSES

Mary C. Magee, MSN, RN, CPHQ, CPPS INTRODUCTION Senior Patient Safety/Quality Analyst Pennsylvania Patient Safety Authority Intoxicated patients and those under the influence of alcohol, regardless of care setting, pose unique challenges to healthcare providers, who must manage patient Timothy Horine, BSN, RN Staff Nurse, Neuro-Cardiac ICU aggression, gain cooperation with treatments, and monitor the patient for changes in Main Line Health-Bryn Mawr Hospital condition, including gradual or acute deterioration. The World Health Organization (WHO) estimates that 38.3% of the world’s popula- ABSTRACT tion drinks alcohol. Individuals older than 15 years drink 6.2 liters on average per Worldwide, harmful use of alcohol year, and globally, harmful use of alcohol causes about 3.3 million (5.9%) deaths every causes more than 3 million deaths per year.1 Two-thirds of American adults consume alcohol, up to 10% abuse it, and acute year. Two-thirds of American adults intoxication is associated with traffic accidents, domestic violence, homicide, and sui- consume alcohol and up to 10% cide.2 A 2014 survey conducted by the Substance Abuse and Mental Health Services abuse it. In the United States every Administration (SAMHSA) noted that “24.7% of people ages 18 or older reported year, more than 600,000 emergency that they engaged in binge drinking* in the past month; 6.7% reported they engaged department visits are related to alco- in heavy drinking in the past month.”4 In the United States, it is estimated that hol intoxication. Pennsylvania ranks more than 600,000 emergency department (ED) visits are directly related to alcohol in the top third for binge drinking in intoxication.5 the United States. Between January 1, The Centers for Disease Control and Prevention reports that excessive alcohol use is 2005, and December 31, 2015, more responsible for an annual average of 88,000 deaths and 2.5 million years of potential than 9,500 alcohol-related events life lost. More than half of these deaths and three-quarters of the years of potential life were reported to the Pennsylvania lost were due to binge drinking.6

Patient Safety Authority through its † Pennsylvania Patient Safety Reporting Nationally, Pennsylvania ranks in the top tertile at 18.5% for age-adjusted prevalence System. Review of narratives revealed of binge drinking among adults age 18 years or older and in the middle tertile at 7 drinks per occasion for the average largest number of drinks consumed by binge drink- 1,327 event reports involving acute 3 alcohol intoxication in adults; 69 were ers on any occasion in the past month. identified as Serious Events, including Pennsylvania Patient Safety Authority analysts analyzed Serious Events associated with deaths. Most events occurred in the alcohol use, abuse, and intoxication in all care areas and found that failures or inade- emergency department. A majority of quacies of assessing and monitoring were associated with patient harm. Analysts sought Serious Events involved patient falls. to describe the evidence-based best practices for the assessment and management of Other findings, such as seizures, com- intoxicated patients. bativeness, suicide-related, and leaving against medical advice occurred. METHODS Failures or inadequacies of assessing Analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) data- and monitoring intoxicated patients base for event reports related to alcohol intoxication, including reports that described were identified as factors contributing patients under the influence or abuse of alcohol in all acute level facilities, includ- to harm. Assessment and management ing hospitals, birthing centers, abortion clinics, and ambulatory surgical facilities in of these patients—including screening Pennsylvania submitted between January 1, 2005, and December 31, 2015. The follow- and brief intervention—and behavioral ing search terms were used to identify applicable events: alcohol, intoxicated, inebriate, assessment are key elements to the ETOH, drunk, under the influence, unconscious, police, blood alcohol content, BAC, care and prevention of harm of the Narcan, sleep off, banana bag, and detox. The initial query resulted in 9,536 reports. intoxicated patient. (PA Patient Saf Advis 2017 Jun;14[2]:45-54.) The query was re-run to exclude patients age 0 to 17 years (n = 349) because of the unique needs and different treatment approaches for this population, events occur- Corresponding Author ring more than 24 hours after admission (n = 2,888), and events unrelated to alcohol Mary C. Magee

* Binge drinking is defined as four or more drinks for a woman or five or more drinks for a man on an occasion during the past 30 days.3 † Tertile: Any of the two points that divide an ordered distribution into three parts, each containing a third of the population.7

intoxication (n = 3,975; e.g., events classi- were classified as Incidents (i.e., events, computer system within the expected fied as skin integrity or transfusion, events occurrences, or situations that could have time frame. involving staff or visitors, and events injured the patient but did not) and 5.2% reporting only a past medical history of (n = 69) of the reports represented Serious Serious Events alcohol use). The revised query resulted Events (i.e., events causing temporary or Of the 5.2% (n = 69 of 1,327) events in 2,324 reports. Analysts individually permanent harm or death).* that were reported as Serious Events, reviewed the event report narratives and the majority 72.5% (n = 50) as shown in excluded an additional 95 events unre- Care Area Figure 2, were reported as harm score E lated to alcohol intoxication. Of the three As seen in Figure 1, most intoxicated (i.e., an event occurred resulting in tem- main “direct mechanisms of harm caused patients presented to the ED. Of the porary harm and required treatment or by alcohol consumption in an individual” 926 ED patients, 7.3% (n = 68) were intervention). presented in the WHO report, the ana- admitted to the hospital and more than Of the 69 Serious Events reported, lysts focused on “intoxication, leading to a third (34.8%, n = 322) eloped, left impairment of physical coordination, con- 55.1% (n = 38) described delay or failure before treatment was completed, or left to observe, assess, or recognize change sciousness, cognition, perception, affect against medical advice. In certain ancil- or behavior,”1 because this mechanism in condition as factors contributing to lary departments (i.e., surgical services, the harmful event. Reports of patient of harm was the most prevalent in the imaging, and outpatient clinics), instances PA-PSRS database. deaths accounted for 7.2% (n = 5 of were noted in which testing, treatments, 69) of the Serious Events and three of Patients presenting for detoxification or surgeries were cancelled because of the five deaths were attributable to the (n = 544) and those in withdrawal patients arriving under the influence of aforementioned factors. The following are (n = 358; i.e., beyond the intoxication alcohol or intoxicated. examples of Serious Events mentioning phase) were excluded unless the event nar- The following is an example of a those factors: rative mentioned both intoxication and † cancellation : ‡ detoxification or withdrawal. The final Patient admitted to [unit] as a 302 . sample size analyzed was 1,327 alcohol Upon arrival to the pre-op area for a Nurse returned to room after checking intoxication-related events. scheduled surgical procedure, nursing lab results to find patient [had eloped]. staff noticed that the patient had Authorities notified. Analysts conducted a review of the lit- an odor of alcohol. Upon further The patient was being evaluated for erature and an Internet search to obtain evaluation by anesthesia, the patient epidemiological data and information possible drug and alcohol overdose. admitted to ingesting alcohol prior to When nurse came back into room, on alcohol use and abuse and to identify the procedure. Surgeon notified and assessment and care management strate- he noticed an empty pill bottle at the surgery was cancelled in the inter- the bedside. The patient [allegedly] gies to reduce the likelihood of patient est of patient safety. harm. Interviews with addiction special- ingested more than 30 benzodiaz- ists were conducted to clarify and refine Ancillary departments comprised 7.4% epine tablets. the approach to data analysis. (n = 98) of the care areas noted. Of the The patient, who was under the influ- 98 ancillary department events, 82.6% ence of alcohol, was being evaluated for reports originated from the laboratory. RESULTS right sided pain. The patient was in CT Failure to document or properly report [unattended] and upon return to the Harm critical alcohol serum lab results led ED the patient’s condition deteriorated, The Authority uses the harm level defini- to delays in care. The following is an requiring intubation. tions as defined by the MCARE Act.8 example of an improperly reported critical Most events, 94.8% (n = 1,258) value event: Patient admitted to a monitored unit with alcohol intoxication and other medi- A critical value for serum alcohol was cal co-morbidities. The patient went into * Serious Events are events, occurrences, not called and/or documented in the a lethal cardiac arrhythmia and was or situations involving the clinical care of a patient in a medical facility that either: (a) resulted in death, or (b) compromises patient † The details of the PA-PSRS event narratives ‡ safety and results in an unanticipated injury in this article have been modified to preserve A 302 commitment in Pennsylvania is an requiring the delivery of additional health care confidentiality. None of these event narratives involuntary commitment into a mental health 9 services to the patient.8 came from the co-author’s facility. institute for emergency psychiatric evaluation.

1,000 926

800

600

400

200 98 92 88 56 48 15 4 0 MS17123 Emergency Ancillary General and Critical Surgical Psychiatric/ Imaging Outpatient department department specialty care/ services/ rehabilitation clinic unit intermediate labor and unit unit delivery A AA

Note: Data reported through the Pennsylvania Patient Safety Reporting System, January 2005 through December 2015.

found unresponsive a couple of hours Both patients had comorbid behavioral a dislocation or actual or probable frac- later. The patient later died. health diagnoses. The other patients sus- ture, two of which occurred as a result of tained harm ranging from self-inflicted physical restraint and the others sustained Associated findings. As seen in Figure 3, wounds to cardiac and respiratory arrest; findings associated with intoxication men- harm including lacerations; seven injuries Most suicide-related events occurred in tioned in some events are consistent with occurred in the ED and one on an inpa- non-psychiatric EDs. The following is an characteristics and behaviors of intoxicated tient rehabilitation unit. example of a suicide-related event: patients.10-13 Seizure activity, including Patients who took sedative-hypnotics, delirium tremens, was the most frequently The patient was brought to the ED opioids, or other drugs; ingested hand mentioned finding. All of the patients with alcohol intoxication after a sui- sanitizer or mouthwash; plus those who experiencing seizure sustained a fall, with cide attempt. Patient had been acting eloped account for 14.5% (n = 10) of the harm ranging from abrasion to fracture; cooperatively until staff found patient other findings mentioned. The majority eight occurred in non-psychiatric EDs and with [equipment] cables [wrapped] of these 10 were ED patients. two on intermediate/specialty units. around neck. Staff intervened and Event type. As seen in Figure 4, the major- patient was placed on one-to-one Suicide, including suicide attempts and ity, 61% (n = 42 of 69), of Serious Events observation. suicidal ideation, was the second most were falls; 64.3% (n = 27) of the 42 falls frequently mentioned finding. Of the Combativeness was the third most were unobserved. Of the 35.7% (n = 15) two completed suicides, one followed an frequently mentioned finding. Half of that were observed, staff attempted, inpatient admission and subsequent ED the combative patients attempted to unsuccessfully, to prevent the fall. Patients visit; the other occurred in the facility. physically harm staff and half sustained experiencing seizure activity accounted for

Figure 2. Intoxication Events Reported as Serious Events By Harm Score (N = 69) 23.8% (n = 10) of the 42 falls. Of the 27 unobserved falls, 7 patients experienced N seizure activity, and of the 15 observed 60 falls, 3 patients experienced seizure activity. 50 50 The following are examples of reported falls with harm events: 40 Patient was intoxicated, climbed over 30 the side rails, fell to the floor, and landed on the left hip. X-ray con- 20 firmed a fracture and patient went 13 to surgery. 10 5 0 1 While standing for additional x-rays,

0 MS17124 the patient fell forward, landing E F G H I on [her] face. The fall resulted in a laceration and a probable [cervical] A S fracture. Note: Data reported through the Pennsylvania Patient Safety Reporting System, January 2005 through December 2015. Patient was intoxicated upon arrival to ED and sustained a scalp laceration. CT showed an epidural hematoma. While waiting to be transferred to [an inpatient unit], the Figure 3. Serious Events with Associated Findings (N = 69) patient fell out of bed. A repeat CT showed an [increasing hematoma]. N The patient was then admitted to a VNS [critical care unit]. 12 Reports of other/miscellaneous events 10 accounted for 27.5% (n = 19 of 69) of 10 9 the Serious Events. The following are 8 examples of reported other/miscellaneous 8 events that show a range of care chal- 6 5 lenges with this patient population: Patient was [intoxicated and violent] 4 3 upon arrival to ED. The patient 2 2 was placed in restraints and later found to have deep lacerations to

0 MS17125 torso. Broken glass was used by the patient to [self-inflict these injuries]. The patient was taken to the OR for Seizure exploratory surgery and there was no permanent injury sustained. Suicide-related Combativeness Ingestion of hand medical advice An [intoxicated] patient became Controlled substance sanitizer/mouthwashElopement/left against [extremely violent]. Staff was unable to [verbally] de-escalate the situation NN and the patient began kicking and Note: Data Reported through the Pennsylvania Patient Safety Reporting System, January 2005 through December 2015; data is not mutually exclusive.

Page 48 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority Figure 4. Intoxication-Related Serious Events by Event Type (N = 69) a person who has been drinking have proved effective in accurately determining VN P alcohol intoxication, and the BAC can verify a patient’s report of intoxication.16 Patient self-harm 1.4 Teplin and Lutz’s Alcohol Symptom Checklist (ASC) is an observational measure of intoxication and is used in Medication error 1.4 situations in which objective measures of alcohol are unavailable.17 The ASC is a reliable, easy, and efficient tool that Error related to 2.9 procedure/test/treatment can be used in lieu of a BAC when, for example, an intoxicated patient refuses diagnostic testing.17 Complication related to 5.8 procedure/test/treatment In a 2013 study by Volz et al., the authors measured the effectiveness of a behavior- Other/miscellaneous 27.5 ally-based alcohol intoxication scale for assessing a patient’s readiness for transfer from the ED to the behavioral health Fall 61.0 unit “rather than relying solely on a BAC level.”14 Patients who met specific criteria MS17126 in this behavioral scale were found to be 10 20 30 40 50 60 70 80 0 medically stable after transfer.14 PNA Failure to observe, assess, or recognize Note: Reported through the Pennsylvania Patient Safety Reporting System, January 2005 changes in patient condition were associ- through December 2015. ated with harmful events and deaths as identified and reported through PA-PSRS. Alcohol intoxication causes changes to several organ systems, including cardio- punching staff and police officer DISCUSSION vascular, neurological, endocrine, and used a Taser [to gain control of the Acute Symptom Assessment pulmonary; and the degree of impact patient]. depends on the amount of alcohol “A person is said to suffer from alcohol consumed and the patient’s tolerance A patient with a history of a psy- intoxication when the quantity of alcohol level.2,18,19 Care of the patient is aimed at chiatric disorder was brought to the the person consumes produces behavioral managing the intoxication symptomology, ED intoxicated. Patient was kept or physical abnormalities. overnight for observation. During comorbidities, and acute injuries. In other words, the person’s mental and morning assessment patient denied Treatment interventions include physi- physical abilities are impaired.”1 that [her binge drinking] was a sui- ologic monitoring, frequent observation cide attempt. Patient contracted for In addition to observable impaired physi- and rounding, supportive care, and safety and was [agreeable to inpatient cal and mental abilities, alcohol levels prevention of harm or injury.18 Frequent treatment]. [Several hours later,] the can be measured in the breath or blood. rounding and direct observation, patient began yelling and started Studies have found, however, that the including waking sleeping patients to to vomit. [She] lost consciousness, level of blood alcohol concentration assess responsiveness, is associated with [stopped breathing], and required (BAC) correlates poorly with physical and decreases in secondary harm.18,20 intubation. A repeat ETOH [ethyl mental impairments depending on the alcohol] level was elevated. Staff alcohol tolerance of the individual.10,14,15 Reoccurrence Prevention – noticed an empty bag of hand sani- An overreliance on these concentrations Screening and Brief Intervention may hinder healthcare providers’ abil- tizer in the trash. The patient was Implementing screening for alcohol- ity to protect these patients from harm. admitted to a [telemetry] bed. dependent drinkers and providing brief Assessment of signs and symptoms in

intervention for those who screen posi- Understanding the patient’s perception Provide reminders to patient and tive or at-risk for alcohol dependency is of drinking helps enhance motivation to family, maintain communication. shown to reduce the quantity of alcohol promote change in drinking habits.16,33 Intoxicated patients should be consumed and re-visits to the ED.16,21-24 Giving advice and negotiating helps the assessed as high fall risk and those Varying levels of screening, brief interven- patient take steps and commit to change.16 with gait disturbances shall have staff tion, and follow up may be incorporated Following up reinforces the intervention in attendance. into interactions with the intoxicated and can include various forms of contact Patients who leave against medical advice patient. Initial screening serves as such as phone calls, appointments with (AMA) pose unique considerations for the basis for determining appropriate primary care physicians, and referral to staff. As shown in these examples, facility 21,33 intervention. Alcoholics Anonymous. ED DIRECT staff feel obligated or are required to dis- is a mnemonic that helps providers charge these patients under supervision: Screening and brief intervention is remember components of this brief supported by the American College intervention.25 Supported by ACEP, ED The patient was [insistent on leaving of Emergency Physicians (ACEP), the DIRECT is administered in the ED to AMA]. [The patient was taken] into Emergency Nurses Association, and “at-risk” or “harmful” drinkers with a goal police custody to ensure [she] would the American College of Surgeons’ of speaking with a counselor while in the not be a danger to [herself] or others. Committee on Trauma, which “recom- ED or referral to primary care or special- The local police provided the [inebri- mends that all trauma centers incorporate ized treatment program.25 ated] patient transportation home. alcohol screening and brief intervention as part of routine trauma care” and those Healthcare providers’ attitudes, biases, and The patient [was discharged] AMA perceptions of alcohol-intoxicated patients with “sufficient resources” discuss or offer accompanied by a friend. are associated with inadequate assessment follow-up options.16,25,26 Facility staff also note the need for fre- and the lack of frequent monitoring and quent communication, closer observation, Several screening tools are advocated, use of behavioral assessment scales.34-36 and follow-up phone calls as indicated in including a single alcohol screening ques- Ongoing staff education on the rationale these examples: tion (SASQ), the Alcohol Use Disorders and use of objective assessment scales and Identification Test (AUDIT), the Cutting screening tools; in conjunction with edu- When there is a delay, commu- down, Annoyance by criticism, Guilty cation regarding their own attitudes and nicating with the patient and feeling, and Eye openers (CAGE) ques- perceptions, are keys to successful imple- family frequently may help decrease tionnaire, the CRAFFT Substance Abuse mentation of these useful strategies.34-36 frustration. Screening Test, and the Paddington Frequently monitor patients who have Alcohol Test.21,27-32 These evidence-based Facility Recommendations to mentioned the desire to leave. screening tools are tailored for time- Improve Patient Safety A follow up phone call was made pressed environments such as the ED and A number of recommendations were to ensure the patient arrived at the take into account the possibility of patient submitted in event reports specific to treatment facility. underreporting of alcohol intake. reported challenges. The ingestion of hand sanitizer is Brief interventions are short counseling These recommendation examples are typi- on the rise nationally,37 although sessions. The goal of brief intervention is cal of those proposed by facility staff for not prevalent in the reported events to help patients make decisions to lower patients who fell: submitted through PA-PSRS, where their risk for alcohol-related incidents. Use fall precautions including a bed 1.6% of all events (n = 21 of 1,327) Giving information and feedback about alarm and place patient on continu- and 4.3% of Serious Events (n = 3 of screening results helps point out the ous observation. 69) involved the ingestion of hand danger and educate patients on accept- sanitizer or other ethanol-containing Notify family. Perform neurologic able limits of alcohol intake. The Table products. Intoxicated patients and assessments frequently, closer monitor- identifies alcohol use screening tools and those with alcohol use disorders are ing of patients who are at increased brief intervention resources found in the more likely to consume this product fall risk, and place the patient in a literature, the predictive trait of the tool, while in the hospital because of its room closer to the nurse’s station. and which population they have been availability. Although most instances used to evaluate. (continued on page 52)

Page 50 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority Table: Alcohol Use Screening and Brief Intervention Resources RESOURCE DESCRIPTION POPULATION ADDRESSED Single Alcohol Screening A single screening question for The study focused on adult patients Question (SASQ)1 identifying hazardous drinking and presenting to emergency departments within alcohol use disorders. 48 hours of an injury. Alcohol Use Disorders A screening instrument for proactive The 1993 study focused on subjects recruited Identification Test (AUDIT)2,3 identification of hazardous and harmful from representative primary health care alcohol consumption. The instrument facilities in six countries (age not specified). is a 10-item questionnaire that covers The 2005 study focused on patients 18 years the domains of alcohol consumption, or older presenting to one of three hospital drinking behavior, and alcohol-related emergency departments within 48 hours of problems. an injury. Cutting down, Annoyance by A screening instrument for identifying The 1984 study focused on male patients in criticism, Guilty feeling, and Eye- a high likelihood of the presence of an alcoholism rehabilitation facility. 3,4 openers questionnaire (CAGE) alcoholism. The 2005 study focused on patients 18 years or older presenting to one of three hospital emergency departments within 48 hours of an injury. Car, Relax, Alone, Forget, Friends, A screening instrument for identifying The study focused on adolescents, age 14 to Trouble questionnaire (CRAFFT)5 substance-related problems and 18 years, coming for routine medical care disorders. to an adolescent and young adult medical practice. Paddington Alcohol Test (PAT) and A screening instrument for identifying The May 2004 study focused on adult brief intervention6,7 alcohol-related problems. patients presenting to the emergency A referral to an alcohol health worker department. made while the patient is still in the The October 2004 study focused on adult emergency department. patients 18 years or older presenting to an emergency department and having a positive PAT screen. Screening and brief intervention A review of four studies that offered brief The studies focused on adolescent and adult (BI) in the emergency interventions to patients, while still in the patients 13 years or older admitted to an department8 emergency department, whose injuries emergency department or trauma center. were alcohol-related. The effect of the BI was generally positive (i.e., patients decreased their alcohol consumption and alcohol-related negative consequences after the BI when assessed 3 to 12 months after their initial emergency department visit). Notes 1. Williams R, Vinson DC. Validation of a single screening question for problem drinking. J Fam Pract. 2001 Apr;50(4):307-12. PMID: 11300981. 2. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption--II. Addiction. 1993 Jun;88(6):791-804. PMID: 8329970. 3. Canagasaby A, Vinson DC. Screening for hazardous or harmful drinking using one or two quantity-frequency questions. Alcohol Alcohol. 2005 May- Jun;40(3):208-13. Also available: http://dx.doi.org/10.1093/alcalc/agh156. PMID: 15797883. 4. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984 Oct 12;252(14):1905-7. PMID: 6471323. 5. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002 Jun;156(6):607-14. PMID: 12038895. 6. Patton R, Hilton C, Crawford MJ, Touquet R. The Paddington Alcohol Test: a short report. Alcohol Alcohol. 2004 May-Jun;39(3):266-8. PMID: 15082467. 7. Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, Reece B, Brown A, Henry JA. Screening and referral for brief intervention of alcohol- misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet. 2004 Oct 9-15;364(9442):1334-9. PMID: 15474136. 8. D’Onofrio G, Degutis LC. Screening and brief intervention in the emergency department. Alcohol Res Health. 2004-2005;28(2):63-72. PMID: 19006993.

(continued from page 50) be familiar with the care and management CONCLUSION of alcohol withdrawal, including symptom Caring for and safeguarding intoxi- of intentional hand sanitizer inges- recognition, medication regimens, and cated patients poses unique challenges, tion result in little or no harm to supportive care such as frequent monitor- including managing patient aggression, the patient, a literature review of ing, limiting sensory stimulation, and monitoring patients for deterioration, and published cases and a query of the 19,39,40 providing reassurance. gaining cooperation with treatments. National Poison Data System iden- About 5% of the intoxication-related tified cases of moderate to severe LIMITATIONS harm.38 The study suggests increasing events reported to the Authority were awareness by healthcare providers of Relevant information is derived from the Serious Events (i.e., events in which this growing problem and taking steps event type taxonomy and from free-text patients sustained harm). Pennsylvania such as removing hand sanitizers from narratives; categorization and narra- acute level facilities reported that among at-risk patients’ rooms and frequent tive detail were provided by PA-PSRS intoxicated patients, the occurrence of patient monitoring.38 reporters. falls, seizures, suicide attempts, combativeness, and patients leaving against medical Although it was beyond the scope of this Reporters may have used the terms advice were common. Failure to adequately article to address the management of alco- “intoxication,” “detoxification,” and monitor and assess intoxicated patients hol withdrawal, the possibility cannot be “withdrawal” interchangeably and in com- contributed to the majority of harm ignored that an alcohol-dependent patient bination when providing the narrative experienced by these patients and in rare may remain in the ED or hospital long detail. Analysts sorted the events based instances resulted in death. Behavioral enough to be at high risk for develop- on the use of these terms as described in assessments and frequent or continuous ing withdrawal even if presenting for an the methods section and every effort was monitoring, supplemented by objective unrelated complaint.39 Researchers recom- made to classify events into these catego- measurements such as blood alcohol con- mend that healthcare providers ries accurately. centration in combination with symptom management, are key to avoiding harm and caring for these patients.

NOTES

1. Global status report on alcohol and health persons aged 18 or older, by demographic Available: http://www.yourdictionary. 2014. Geneva: World Health Organiza- characteristics: percentages, 2013 and com/tertile. tion (WHO); 2014. 86 p. Also available: 2014. Also available: http://www.samhsa. 8. Medical Care Availability and Reduc- http://www.who.int/substance_abuse/ gov/data/sites/default/files/NSDUH- tion of Error (MCARE) Act of March publications/global_alcohol_report/ DetTabs2014/NSDUH-DetTabs2014. 20, 2002, P.L. 154, No. 13, Cl. msb_gsr_2014_1.pdf?ua=1. htm#tab2-46b. 40.;Available: http://www.legis.state. 2. Cowan E, Su M. Ethanol intoxication in 5. Pletcher MJ, Maselli J, Gonzales R. pa.us/cfdocs/legis/li/uconsCheck. adults. In: UpToDate [internet]. Waltham Uncomplicated alcohol intoxication in cfm?yr=2002&sessInd=0&act=13. (MA): UpToDate; 2014 [accessed 2014 the emergency department: an analysis 9. Q: What is a 302 commitment in May 07]. [8 p]. Available: http://www. of the National Hospital Ambulatory Pennsylvania? [internet]. Reference. uptodate.com. Medical Care Survey. Am. J. Med. com; [accessed 2016 Dec 28]. [1 p]. 3. Data and maps: Excessive drinking. [inter- 2004 Dec 1;117(11):863-7. Also avail- Available: https://www.reference.com/ net]. Atlanta (GA): Centers for Disease able: http://dx.doi.org/10.1016/j. government-politics/302-commitment- Control and Prevention (CDC); 2016 Sep amjmed.2004.07.042. PMID: 15589492 pennsylvania-a2780351abbc9039. 6 [accessed 2016 Oct 25]. Available: http:// 6. Centers for Disease Control and Preven- 10. Olson KN, Smith SW, Kloss JS, Ho www.cdc.gov/alcohol/data-stats.htm. tion (CDC). Alcohol-related disease JD, Apple FS. Relationship between 4. National Survey on Drug Use and impact (ARDI). [internet application]. blood alcohol concentration and Health, 2013 and 2014. Rockville (MD): Atlanta (GA): Centers for Disease Control observable symptoms of intoxication Substance Abuse and Mental Health and Prevention (CDC); [accessed 2016 in patients presenting to an emergency Services Administration (SAMHSA), Nov 09]. Available: https://nccd.cdc.gov/ department. Alcohol Alcohol. 2013 Jul- Center for Behavioral Health Statistics DPH_ARDI/default/default.aspx. Aug;48(4):386-9. Also available: http:// and Quality; 2015 Sep 10. Table 2.46B - 7. Tertile. [internet]. Burlingame (CA): Your dx.doi.org/10.1093/alcalc/agt042. PMID: Alcohol use, binge alcohol use, and heavy Dictionary; [accessed 2016 Nov 09]. [1 p]. 23690233 alcohol use in the past month among

Page 52 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority 11. Ambrosius RG, Vroegop MP, Jansman 19. Sutton LJ, Jutel A. Alcohol withdrawal 26. Substance abuse (alcohol/drug) and the FG, Hoedemaekers CW, Aarnoutse syndrome in critically ill patients: identifi- emergency care setting. Emergency Nurses RE, van der Wilt GJ, Kramers C. Acute cation, assessment, and management. Crit Association; 2010. Also available: http:// intoxication patients presenting to an Care Nurse. 2016 Feb;36(1):28-38. Also www.apna.org/files/public/substance_ emergency department in The Nether- available: http://dx.doi.org/10.4037/ abuse_and_the_emergency_care_ lands: admit or not? Prospective testing ccn2016420. PMID: 26830178 setting.pdf. of two algorithms. Emerg Med J. 2012 20. Gardner B. Intoxication guideline. Der- 27. Williams R, Vinson DC. Validation Jun;29(6):467-72. Also available: http:// byshire Healthcare NHS Foundation of a single screening question for dx.doi.org/10.1136/emj.2010.106500. Trust; 2012 Feb. 12 p. Also available: problem drinking. J Fam Pract. 2001 PMID: 21546510 www.derbyshirehealthcareft.nhs.uk/Easy- Apr;50(4):307-12. PMID: 11300981 12. Alcohol intoxication. [internet]. eMedi- SiteWeb/GatewayLink.aspx?alId=4291. 28. Canagasaby A, Vinson DC. Screen- cine.com; 2016 [accessed 2016 Nov 09]. [6 21. Crawford MJ, Patton R, Touquet R, ing for hazardous or harmful drinking p]. Available: http://www.emedicine Drummond C, Byford S, Barrett B, using one or two quantity-frequency health.com/alcohol_intoxication/article_ Reece B, Brown A, Henry JA. Screen- questions. Alcohol Alcohol.. 2005 May- em.htm#alcohol_intoxication_facts. ing and referral for brief intervention of Jun;40(3):208-13. Also available: http:// 13. Berger JT. Discharge against medical alcohol-misusing patients in an emergency dx.doi.org/10.1093/alcalc/agh156. advice: ethical considerations and profes- department: a pragmatic randomised PMID: 15797883 sional obligations. J Hosp Med. 2008 controlled trial. Lancet. 2004 Oct 29. Saunders JB, Aasland OG, Babor TF, de Sep;3(5):403-8. Also available: http:// 9-15;364(9442):1334-9. PMID: 15474136 la Fuente JR, Grant M. Development of dx.doi.org/10.1002/jhm.362. PMID: 22. Bernstein E, Bernstein JA. Chapter 12. the alcohol use disorders identification 18951403 Implementing brief interventions: a series test (AUDIT): WHO collaborative project 14. Volz TM, Boyer KS. The development of of five papers. In: Cherpitel CJ, Borges on early detection of persons with harm- a behaviorally-based alcohol intoxication G, Giesbrecht N, Hungerford D, Peden ful alcohol consumption--II. Addiction. scale. J Emerg Nurs. 2014 Jul;40(4):330- M, Poznyak V, Room R, Stockwell T, 1993 Jun;88(6):791-804. PMID: 8329970 5. Also available: http://dx.doi. editors. Alcohol and injuries: emergency 30. Ewing JA. Detecting alcoholism. The org/10.1016/j.jen.2013.09.008. PMID: department studies in an international CAGE questionnaire. JAMA. 1984 Oct 24182893 perspective. Geneva: World Health Orga- 12;252(14):1905-7. PMID: 6471323 15. Roberts JR, Dollard D. Alcohol levels do nization (WHO); 2009. p. 175-80. Also 31. Knight JR, Sherritt L, Shrier LA, Harris not accurately predict physical or mental available: http://www.bu.edu/bniart/ SK, Chang G. Validity of the CRAFFT impairment in ethanol-tolerant subjects: files/2011/02/SBIRT-implementing- substance abuse screening test among relevance to emergency medicine and intervention.pdf. adolescent clinic patients. Arch Pediatr dram shop laws. J Med Toxicol. 2010 23. Verelst S, Moonen PJ, Desruelles D, Gil- Adolesc Med. 2002 Jun;156(6):607-14. Dec;6(4):438-42. Also available: http:// let JB. Emergency department visits due PMID: 12038895 dx.doi.org/10.1007/s13181-010-0048-z. to alcohol intoxication: characteristics of 32. Patton R, Hilton C, Crawford MJ, Tou- PMID: 20358415 patients and impact on the emergency quet R. The Paddington Alcohol Test: a 16. American College of Surgeons Com- room. Alcohol Alcohol. 2012 Jul- short report. Alcohol Alcohol. 2004 May- mittee on Trauma. Alcohol screening Aug;47(4):433-8. Also available: http:// Jun;39(3):266-8. PMID: 15082467 and brief intervention (SBI) for trauma dx.doi.org/10.1093/alcalc/ags035. PMID: 22493048 33. D’Onofrio G, Degutis LC. Screening patients. Chicago (IL): American College and brief intervention in the emergency of Surgeons; 16 p. Also available: https:// 24. Johnson JA, Woychek A, Vaughan D, department. Alcohol Res Health. 2004- www.facs.org/~/media/files/quality%20 Seale JP. Screening for at-risk alcohol use 2005;28(2):63-72. PMID: 19006993 programs/trauma/publications/sbirt- and drug use in an emergency depart- guide.ashx. ment: integration of screening questions 34. Brosinski C, Riddell A. Mitigating Nurs- ing Biases in Management of Intoxicated 17. Teplin LA, Lutz GW. Measuring alcohol into electronic triage forms achieves high screening rates. Ann Emerg Med. and Suicidal Patients. J Emerg Nurs. 2015 intoxication: the development, reli- Jul;41(4):296-9. Also available: http:// ability and validity of an observational 2013 Sep;62(3):262-6. Also available: http://dx.doi.org/10.1016/j.annemerg- dx.doi.org/10.1016/j.jen.2014.11.002. instrument. J Stud Alcohol. 1985 PMID: 25583427 Nov;46(6):459-66. PMID: 4087907 med.2013.04.011. PMID: 23688769 35. Kabale BM, Nkombua L, Matthews P, 18. Johnson JM. Last call: ethanol metabo- 25. Alcohol screening and brief intervention in the emergency department. Irving (TX): Offiong BE. Healthcare professionals’ lism and the implications for emergency perceptions of alcohol-intoxicated trauma department clinicians managing patients American College of Emergency Physi- cians; 3 p. Also available: https://www. patients: implecations for healthcare with extreme ethanol intoxication. Adv delivery at South Rand Hospital emer- Emerg Nurs J. 2009 Jul-Sep;31(3):221-7. acep.org/Clinical---Practice-Management/ Alcohol-Screening-and-Brief-Intervention- gency department. S Afr Fam Pract. Also available: http://dx.doi. 2013;55(4):398-402. org/10.1097/TME.0b013e3181afbf3a. in-the-ED/. PMID: 20118874

36. Warren OU, Sena V, Choo E, 38. Gormley NJ, Bronstein AC, Rasimas 40. Zerhouni O, Bègue L, Brousse G, Carpen- Machan J. Emergency physicians’ JJ, Pao M, Wratney AT, Sun J, Aus- tier F, Dematteis M, Pennel L, Swendsen and nurses’ attitudes towards alcohol- tin HA, Suffredini AF. The rising J, Cherpitel C. Alcohol and violence in intoxicated patients. J Emerg Med. incidence of intentional ingestion of the emergency room: a review and per- 2012 Dec;43(6):1167-74. Also avail- ethanol-containing hand sanitizers. Crit spectives from psychological and social able: http://dx.doi.org/10.1016/j. Care Med. 2012 Jan;40(1):290-4. Also sciences. Int J Environ Res Public Health. jemermed.2012.02.018. PMID: 22525698 available: http://dx.doi.org/10.1097/ 2013 Sep 27;10(10):4584-606. Also 37. Hand sanitizer. [internet]. Alexandria CCM.0b013e31822f09c0. PMID: available: http://dx.doi.org/10.3390/ (VA): American Association of Poison 21926580 ijerph10104584. PMID: 24084671 Control Centers (AAPCC); [accessed 39. Stehman CR, Mycyk MB. A rational 2017 Apr 03]. [4 p]. Available: http:// approach to the treatment of alcohol www.aapcc.org/alerts/hand-sanitizer/. withdrawal in the ED. Am J Emerg Med. 2013 Apr;31(4):734-42. Also available: http://dx.doi.org/10.1016/j. ajem.2012.12.029. PMID: 23399338

This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 14, No. 2—June 2017. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2017 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://patientsafety.pa.gov.

THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS

The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://patientsafety.pa.gov.

ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.

The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.

Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.