Analysis of Alcohol Use Clusters among Subcritically Injured Emergency Department Patients

Objectives : 1) To cluster patients according to self-reported drinking patterns using cluster analysis; 2) to externally validate clustered groups on variables related to drinking but not used in the cluster analysis; and 3) to use the clustered patients' responses to alcohol consumption questions to develop a brief screening tool emergency physicians can use to identify patients in need of referral or intervention related to potentially hazardous alcohol consumption. Methods : A self-report battery was administered to 95 subcritically injured patients. Patients also were saliva alcohol-tested upon arrival to the ED. Using the patients' self-reported quantity, frequency of alcohol consumption, and frequency of having ≥6 drinks on a drinking occasion, patients were categorized into 3 groups using cluster analysis. The 3 clusters were externally validated using injury-related variables, alcohol-related consequences, and the patients' reported readiness to change drinking. A screening tool was developed using cutoff values reported by the patients' answers to drinking pattern questions. Results : Fifty-nine patients were alcohol-negative, and 36 tested alcohol-positive (i.e., >4 mmol/L [>20 mg/ dL]) or had elevated scores on an alcohol problem screening instrument. Three distinct drinking pattern clusters were found. Clusters were validated using discriminant function analysis and multivariate analyses of variance to confirm cluster classifications. Steady and high-intensity drinkers reported more alcohol-related negative consequences, and high-intensity drinkers indicated they would consider changing their drinking. The screening tool correctly classified 97% of the patient sample into their respective clusters. Conclusions : Using the drinking pattern questions in the clustering procedure was effective for grouping injured patients into clusters that could be differentiated on other drinking-related variables. The resulting screening tool can be used in the ED setting to screen patients for further assessment and intervention. The readiness-to-change results support the assertion that the injury event provides a “teachable moment” for subcritically injured patients whose injury may be related to their alcohol consumption.     

Identification of Hazardous/Harmful Drinking among Subcritically Injured Patients

Objectives: To examine the relationship between a saliva alcohol test (SAT) and hazardous/harmful drinking, as measured by the Alcohol Use Disorders Identification Test (AUDIT), among a sample of subcritically injured patients.
Methods: Patients ( n = 78) seeking treatment for a subcritical injury were saliva-tested for alcohol and interviewed regarding their drinking behaviors and related difficulties. Associations of SAT values with AUDIT results were determined.
Results: SAT results and hazardous/harmful drinking were not independent events (p < 0. 001). Estimates of sensitivity and specificity (using a dichotomous SAT result [≥ 4 mmol/L] to identify positive AUDIT patients) were 65. 2% and 83. 6%, respectively. SAT-positive people had significantly higher AUDIT scores than did SAT-negative individuals (p < 0. 0001). Patients experiencing assault-type injuries were much more likely to be SAT-positive than were patients incurring other types of injury. Discriminant function analysis suggests that AUDIT scores can successfully identify SAT-positive and SAT-negative patients; the analysis accounted for 42. 5% of the variance and correctly classified 84. 6% of the sample.
Conclusions: The use of an easy-to-administer, noninvasive, routine SAT, among patients presenting for a subcritical injury in a hospital ED, provides a mechanism for the identification of individuals with a history of hazardous/harmful drinking. However, since discrimination of hazardous/harmful drinking is imperfect, some caution is warranted when conducting such screening activities.     

Violence and Substance Use among an Injured Emergency Department Population

OBJECTIVES: This study evaluated a sample of emergency department (ED) patients for history of violence and substance abuse. METHODS: Injured patients (n = 320) completed questionnaires (14% refusal rate) during a visit to a Level 1 urban ED after an acute injury. Specific questions were asked regarding whether the injury was related to acute violence (AV), whether there was past-year violence history (VH), including violence victimization and perpetration in both partner and nonpartner relationships, as well as any substance use in the past month and any substance-related consequences in the past year. RESULTS: Fourteen percent of the participants presented with an AV-related injury, and 53% reported VH. Most AV patients (89%) reported VH. No significant differences were found between the participants with AV and VH in demographic, substance use, or substance-related consequences. The AV and VH groups were combined (V), with analyses comparing these participants with those without AV and VH. Men were significantly more likely than women to report V (odds ratio = 2.0). V was significantly related to substance use and substance-related consequences. For example, in comparison with the participants reporting no alcohol or drug use, those reporting illicit drug use were 6.2 times as likely to report V, and those drinking any alcohol only were 2.0 times as likely to report V. CONCLUSIONS: A large percentage of injured patients in this urban ED experienced violence in the past year. Alcohol and illicit drugs appear to be concomitant with violence.     

Detection of Alcohol Use in Adolescent Patients in the Emergency Department

Abstract. Objectives : To examine 3 methods of detecting alcohol use among adolescent patients visiting a Level-1 regional trauma center. Methods : Part 1 was a retrospective review of laboratory records and (13- to 19-year-old) patient medical records over the 1-year period from August 1993 to July 1994. Part 2 was a review of ICD-9 discharge diagnoses for the same age range during the same 1-year period. Part 3 involved prospective saliva alcohol testing of injured patients aged 13—17 years old. Results : Part 1: A total of 522 blood tests were conducted and 160 (30.6%) were positive for alcohol. More than one-third of the alcohol-positive sample had alcohol ingestion as the only reason for their visits, i.e., they were uninjured. The alcohol-positive group was more likely to be male and older. Part 2: A total of 99 alcohol-related discharge diagnoses were given to adolescent patients. Alcohol abuse was the most common diagnosis. With the 2 methods of detection combined, 186 patients were identified. Part 3: A total of 119 saliva alcohol tests were conducted. One patient tested positive but had been identified while in triage as having used alcohol. Conclusion : In this study population, approximately one-third of adolescent patients tested for alcohol as part of routine clinical care were alcohol-positive but were not necessarily given an alcohol-related diagnosis. Thus, studies determining rates of alcohol-positive adolescents treated in EDs should use multiple methods of detection. Universal testing does not appear to be warranted for all injured adolescent patients.     

Brief Motivational Intervention to Increase Self-reported Safety Belt Use among Emergency Department Patients

Objectives:  Brief motivational interventions have shown promise in reducing harmful behaviors. The authors tested an intervention to increase safety belt use (SBU) among emergency department (ED) patients.
Methods:  From February 2006 to May 2006, the authors conducted a randomized trial of adult ED patients at a teaching hospital in Boston. ED patients were systematically sampled for self-reported SBU. Those with SBU other than "always" were asked to participate. At baseline, participants answered a 9-item series of situational SBU questions, each scored on a 5-point Likert scale. SBU was defined as a continuous variable (9-item average) and as a dichotomous variable (response of "always" across all items). Participants were randomized to an intervention or a control group. The intervention group received a 5- to 7-minute intervention, adapted from classic motivational interviewing techniques, by a trained interventionist. Participants completed a 3-month follow-up phone survey to determine changes from baseline SBU. Continuous and dichotomous SBU were analyzed via analysis of covariance and chi-square testing.
Results:  Of 432 eligible patients, 292 enrolled (mean age 35 years, standard deviation [SD] ±11 years; 61% male). At baseline, the intervention and control groups had similar mean (±SD) SBU scores (2.8 [±1.1] vs. 2.6 [±1.1], p = 0.31) and SBU prevalence (each 0%). At 3 months, 81% completed follow-up. The intervention group had significantly greater improvement in mean (±SD) SBU scores than controls (0.76 [±0.91] vs. 0.34 [±0.88], p < 0.001). Also, SBU prevalence of "always" was higher for the intervention group than controls (14.4% vs. 5.9%, p = 0.03).
Conclusions:  Participants receiving a brief motivational intervention reported higher SBU at follow-up compared to controls. An ED-based intervention may be useful to increase SBU.     

Alcohol Use and Medical Care Utilization among Health Maintenance Organization Patients in the Emergency Department

Objective: To determine the association of an alcohol–related ED visit with medical care utilization during a two–year period surrounding the ED visit in an HMO.
Methods: A probability sample of ED patients were interviewed and underwent breath analysis in a large HMO in a Northern California county. Based on recent alcohol intake or documentation of an alcohol–related ED visit, the patients were assigned to an alcohol group ( n = 91) or a non–alcohol group ( n = 897). A 10% random sample of the health plan membership of the same county ( n = 19, 968) served as a comparison group. Utilization data were obtained from computerized files. Multiple linear regression was used to determine differences in subsequent outpatient visit rates between the alcohol and the non–alcohol groups. Logistic regression was used to compare the risks of hospitalization in the two groups.
Results: Annual outpatient visit rates were 7. 8 in the alcohol group and 8. 3 in the non–alcohol group (p = 0. 65), controlling for gender, age, and injury status, and were significantly different from the visit rate of 5. 5 for the random health plan sample (p = 0. 0001). No difference was found between the alcohol and the non–alcohol groups for risk of hospitalization; however, those in the health plan sample were less than half as likely to be hospitalized as were those in the non–alcohol group (odds ratio 0. 44, p = 0. 002).
Conclusions: No difference was found in utilization of medical services between the alcohol and the nonalcohol groups in this predominantly white, well–educated HMO ED population. However, both groups used significantly more inpatient and outpatient services than did the general HMO membership.     

Weapon Carriage among Major Trauma Victims in the Emergency Department

Objective: To determine the occurrence of weapon carriage by major trauma patients at a university/county hospital ED.
Methods: Retrospective observational study of major trauma patients seen in the ED of a major urban trauma center in Los Angeles from 1979 to 1993. All major trauma patients were searched routinely for weapons by the security police. Cases of violence in the ED caused by these weapons were reviewed.
Results: Over the 14-year period, 26.7% of the victims of major trauma presenting to ED were armed with lethal weapons. The occurrence of automatic weapon seizure increased significantly from an annual rate of only 0.2 in the first five years to an average of 17 over the last five years (p < 0.001). A total of 115 "incidents" of violence involving weapons in the ED were recorded during this period; 1.7% of the weapons brought to the ED led to violence and injury. There were four fatalities of armed and dangerous patients, but only six minor injuries to the staff. No other (unarmed) patient in the ED at the time of these incidents was injured.
Conclusions: ED major trauma patients at one urban trauma center in Los Angeles frequently carry weapons, including automatic military weapons. In addition to violence prevention measures such as weapon confiscation, plans must be made and practiced for the management of violence within the "sacrosanct" hospital doors to protect both patients and ED personnel.     

Rates of At-risk Drinking among Patients Presenting to the Emergency Department with Occupational and Nonoccupational Injury

OBJECTIVES: To compare the characteristics and rates of at-risk drinking among patients presenting to the emergency department (ED) with occupational and nonoccupational injury. METHODS: Cross-sectional survey of injured patients presenting to a university hospital ED. Injured patients were prospectively identified, and consenting patients completed a survey including questions regarding quantity/frequency of alcohol use, TWEAK, CAGE, and work-relatedness of injury. Major trauma and motor-vehicle collisions were excluded. Demographic and injury information was obtained from the medical record. Patients with a TWEAK score > or =3, CAGE score > or =2, or who exceeded NIAAA quantity/frequency guidelines were defined as at-risk drinkers. Analysis utilized the Student t-test for continuous variables, and frequency and chi-square analysis for categorical variables. RESULTS: Among 3,476 enrolled patients, 766 (22%) had work injuries and 2,710 (78%) had nonwork injuries. Patients with work injuries were as likely as patients with nonwork injuries to be at-risk drinkers; 35% of patients with an occupational injury and 36% of those with a nonoccupational injury were at-risk drinkers (odds ratio = 0.96). CONCLUSIONS: Patients presenting to the ED with an occupational injury have rates of at-risk drinking similar to other injury patients, and may be an important group in which to target brief alcohol interventions.     

Psychosocial Difficulties and Emergency Department Use

Objective: To determine whether psychosocial difficulties are more prevalent among ambulatory patients using the ED for nonemergent complaints as compared with ambulatory patients having emergent complaints.
Methods: A survey of noncritical ED patients was performed using anonymous questionnaires addressing psychosocial difficulties: psychiatric illness, educational level, homelessness, alcohol and/or drug dependency (CAGE and DAST surveys), and depression (DSM-III criteria). Three independent physicians ranked each patient's chief complaint as either emergent or appropriate for primary care. The majority ranking was used to determine whether the complaint was emergent. Groups with and without specific psychosocial difficulties were compared for their proportion of emergent vs primary care complaints.
Results: Of 700 patients, 367 (52%) met criteria for ≥1 psychosocial difficulty [acute psychosis—36 (5%), illiteracy—139 (20%), homelessness—45 (6%), alcohol dependency—111 (16%), drug dependency—66 (9%), and depression—130 (19%)]. There were 379 (54%) ED visits considered emergent. Patient groups with vs without ≥ psychosocial difficulty had similar rates of emergent visits (58% vs 50%, p = 0.04). Emergent visit rates also were similar for subgroups with vs without specific psychosocial difficulties: psychosis (56% vs 54%, p = 1.00), illiteracy (58% vs 53%, p = 0.89), homelessness (62% vs 54%, p = 0.33), alcohol dependency (62% vs 53%, p = 0.08), drug dependency (59% vs 54%, p = 0.47), or depression (58% vs 53%, p = 0.42).
Conclusion: Psychosocial difficulties are common among ED patients; however, emergent complaints are just as common in these patients as they are in those without psychosocial difficulties.     

Factors Affecting Emergency Department Opioid Administration to Severely Injured Patients

OBJECTIVES: Studies of emergency department (ED) pain management in patients with trauma have been mostly restricted to patients with fractures, yet the potential for undertreatment of more severely injured patients is great. The authors sought to identify factors associated with failure to receive ED opioid administration in patients with acute trauma who subsequently required hospitalization. METHODS: At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study of trauma team activation patients requiring hospitalization between January 1 and December 31, 1999, was conducted. The authors excluded patients receiving opioids only within ten minutes of chest tube insertion or fracture manipulation. The main outcome measure was ED opioid administration. RESULTS: A total of 540 charts of hospitalized first-tier trauma team activation patients were reviewed. A total of 258 (47.8%) received intravenous opioid analgesia within three hours of ED arrival. The median time to receiving the first dose of opioids was 95 minutes. Patients were independently less likely to receive opioids if they were younger or older, were intubated, had a lower Revised Trauma Score, or did not require fracture manipulation. Patients with these factors were less likely to receive opioids independent of the amount of time they spent in the ED. CONCLUSIONS: Many trauma activation patients requiring hospitalization do not receive opioid analgesia in the ED. Patients at particular risk for oligoanalgesia include those who are younger or older and those who are more seriously injured, as defined by a lower Revised Trauma Score, lower Glasgow Coma Scale score, and intubation.     

Use, Understanding, and Beliefs about Complementary and Alternative Medicines among Emergency Department Patients

OBJECTIVES: To describe the extent of complementary and alternative medicine (CAM) use among emergency department (ED) patients, to evaluate patients' understanding of CAMs, and to determine gender differences in beliefs about CAMs. METHODS: This study was a convenience sampling of patients seen in an urban ED. Patient demographics were recorded. A questionnaire was administered that assessed patients' knowledge and use of CAMs. Patients were also asked about their beliefs on safety, medication interactions, and conveying information about these substances to their physicians. RESULTS: A total of 350 ED patients were included in the study; 87% had heard of at least one of the CAMs. There was no difference between genders or races concerning knowledge about CAMs. The most commonly known CAMs were ginseng (75%), ginkgo biloba (55%), eucalyptus (58%), and St. John's wort (57%). Forty-three percent of the responders had used CAMs at some time and 24% were presently using CAMs. The most commonly used CAMs were ginseng (13%), St. John's wort (6%), and ginkgo biloba (9%). All CAMs were considered to be safe by 16% of the patients. Only 67% would tell their doctors they were using CAMs. Females were more likely than males to believe that CAMs do not interact with other medications (15% vs 7%, difference 8%, 95% CI = 2% to 15%). CONCLUSIONS: Complementary and alternative medicines are familiar to most patients and used by many of them. Despite this, a large percentage of patients would not tell their physicians about their use of alternative medications. Emergency medicine providers should be aware of the commonly used CAMs, and questions about their use should be routinely included in ED exams.     

A Multicenter Study of Depression among Emergency Department Patients

Objectives: The authors sought to determine the 12‐month prevalence of depression among emergency department (ED) patients using a single‐question screen. Methods: This cross‐sectional study was conducted in four Boston‐area EDs. For two 24‐hour periods, consecutive patients aged 18 years or older were interviewed, excluding those who were severely ill, potential victims of sexual assault, or emotionally disturbed. During the interview, patients were asked “Have you had any of the following problems during the past 12 months?” Patients answered “yes” or “no” to a list of health problems that included depression. In a validation study, the authors found that this simple approach correlated well with results from the validated Center for Epidemiologic Studies Depression Scale. Results: Of 752 eligible patients, 539 (72%) were interviewed. Of these patients, 30% (95% confidence interval = 26% to 34%) reported depression within the past 12 months. Compared with their nondepressed counterparts, depressed patients were more likely middle‐aged, female, and of lower socioeconomic status. Depressed patients were more likely to be smokers and to report a diagnosis of asthma or arthritis/rheumatism. In a multivariate analysis, factors that were independently associated with depression were lower level of education, smoking, and self‐reported anxiety, chronic fatigue, and back problems. Conclusions: A 30% 12‐month prevalence of depression among ED patients was found. Depressed patients had a distinct sociodemographic and health profile. In the future, awareness of risk factors for depression in the ED setting and use of simple screening instruments could aid in the recognition of depression, with subsequent referral to mental health services.     

Alcohol Use among Injured Patients Aged 12 to 18 Years

Objective : To examine the scope of alcohol use among a population of injured adolescents.
Methods : A convenience sample of injured patients aged 12–18 years seen at a pediatric ED was tested for the presence of alcohol. Injured patients seen within 6 hours of their injuries were asked to submit urine samples for testing using reagent strips. Data were collected from the patient, out-of-hospital emergency care personnel, and parents regarding the circumstances of the injury.
Results : Of the 243 injured patients who were tested during an 8-month period, 231 were included in the final analysis. Ninety patients (39%) were alcohol-positive. The mean age of the alcohol-positive group was 16.0 ± 1.64 years, compared with 15.3 ± 1.8 years for the alcohol-negative group (p < 0.003). There was no significant difference between the 2 groups based on race, gender, or injury characteristics. A positive urine alcohol test was found for 18 (33%) of the motor vehicle crash victims, 9 (38%) of the motor vehicle drivers, 10 (37%) of the patients who attempted suicide, and 49 (44%) of the assault victims.
Conclusions : A substantial percentage of injured adolescent patients were alcohol-positive. The authors recommend the use of alcohol screening when treating injured adolescents.     

Emergency Department Services for Patients with Alcohol Problems: Research Directions

This report summarizes recommendations on research directions developed from the conference "Alcohol Problems among Emergency Department Patients: Research on Identification and Intervention." The conference was developed in order to evaluate the existing state of the art research on emergency department interventions for alcohol problems, and offer further recommendations for research.     

Bispectral Electroencephalographic Analysis of head-injured Patients in the Emergency Department

OBJECTIVES: Bispectral analysis of single-lead electroencephalographs (BIS) has proven valuable in assessing the level of awareness in sedated patients. In this study, the authors sought to determine if BIS values had a predictive value in patients with traumatic brain injuries (TBIs). Therefore, the objective was to determine in emergency department (ED) patients presenting with head trauma whether BIS and Glasgow Coma Scale score (GCS) prior to sedation would be sensitive and specific in predicting TBI. METHODS: A convenience sample of patients with known or suspected head trauma presenting between June and August of both 2001 and 2002 were entered into the study by having a BIS monitor placed immediately on presentation to the ED. BIS and GCS scores were collected every 2 minutes. Head computed tomography (CT) results and discharge dictations were then evaluated to determine the presence of TBI. RESULTS: Fifty-two patients were entered into the study; 13 were excluded due to receiving sedatives prior to enrollment. Of the remaining 39 patients, 14 had intracranial hemorrhage on initial head CT. Of these 14, two had BIS scores over 95. Both of these were neurologically intact at discharge. Eleven of the 12 remaining patients died or left the hospital neurologically impaired. Of the patients with no abnormalities on initial head CT, 19 of 25 had initial BIS scores >95 and all left the hospital neurologically intact. Of the patients with normal initial head CT and initial BIS scores < 95, four of six died or were neurologically impaired at discharge. Twenty of 39 patients presented with an initial GCS of 15; four of 20 had an initial BIS score < 95, three of whom were neurologically impaired at discharge. The 16 of 20 with BIS >95 left the hospital neurologically intact. All patients with a GCS of 14 had BIS scores >95 and left the hospital neurologically intact. All patients with a GCS of 13 had initial BIS scores < 95 and were neurologically impaired at discharge. One patient with a GCS of 11 and a BIS score of 67 left the hospital neurologically intact; all other patients with a GCS < 12 had a BIS < 95 and left the hospital with a neurologic deficit. CONCLUSIONS: BIS scores obtained prior to sedative medicines in the face of trauma are predictive of TBI and neurologic outcome at discharge.     

急诊伤害事件调查分析及护理

目的通过对我院急诊科2006年～2007年诊治的急诊伤害病例的调查,使急诊护理人员了解伤害事件病因特点,分析其相关因素,解决相关的护理问题。方法研究我院急诊科2006年1月～2007年12月诊治的所有初诊伤害患者。结果共报告有效病例4735例,其中男性3138例,女性1597例,性别比1．96：1,平均年龄32．36士18岁,职业以农民（41．18％）和学生（16．75％）为主,伤害发生时间多集中在上午9～10时（14．55％）和下午16～17时（14．40％）,伤害发生的原因主要为机动车车祸（31．40％）、跌落（22．03％）,伤害死亡率为0．97％。结论在急诊护理流程、急诊护理措施方面要持续改进,急诊工作人员可以通过采取针对性和预防性的措施,为患者提供优质的服务及护理。     

Herbal Preparation Use among Urban Emergency Department Patients

Objective : To determine the prevalence of herbal preparation use among patients presenting to an urban teaching hospital ED.
Methods : A prospective anonymous survey on herbal preparation use was performed. Consecutive, acutely ill or injured adult (≥8 years old) ED patients were offered the survey over a 1-month period. The survey also asked for information related to patient age, ethnicity, gender, employment, education, cigarette smoking history, ethanol consumption, use of illicit drugs, chief complaint, and HIV status.
Results : Of 2,473 eligible subjects, 623 (25%) participated. The overall reported prevalence of herbal preparation use among the participants was 21.7%. Women were more likely to use herbal preparations than men (28.5% vs 17.2%, p = 0.013). Prevalence rates in different ethnic populations were: whites, 18.2%; Hispanics, 13.9%; blacks, 26.4%; and Asians, 36.8%. Asians had a significantly higher use rate than the other ethnic groups (p = 0.039). Neither HIV positivity, educational level, employment status, nor age was significantly associated with herbal preparation use. The most commonly reported herbal preparations were goldenseal tea, garlic, and ginger. Several of the herbal preparations reported as used by patients in this study have been associated with severe systemic toxicity in the medical literature.
Conclusion : Although the survey response rate was low, the prevalence of herbal preparation use among acutely ill or injured patients presenting to this urban ED remains significant. A directed history toward specific herbal preparation use may provide relevant pharmacologic information and uncover cases of herbal-preparation-induced toxicity.     

Injury as a Motivator to Reduce Drinking

Objectives: To identify predictors of readiness to change drinking behavior by minor-injury patients who had positive saliva alcohol tests (SATs) in the ED. To develop and test a model intended to be prognostic of readiness to change, which included predispositional and injury-event-related variables.
Methods: An on-site survey was conducted of minor-injury ED patients sampled consecutively during predesignated periods. Patients were identified as SAT-positive during their screening evaluations. After giving their consent, they were administered a self-report battery that assessed predispositional and injury-event-related variables as well as readiness to change their drinking. Predictors of readiness to change drinking were tested with regression analyses.
Results: Twenty-four SAT-positive patients participated; there were 18 men and six women (average age 34 years). Preinjury predispositional variables were by themselves unrelated to the patient's readiness to change while in the ED. Aversiveness of the injury and perception of degree of alcohol involvement were injury-event-related variables predictive of readiness to change (p <0.008). Negative consequences attributed to drinking prior to the injury event strengthened the association of injury aversiveness and alcohol involvement with readiness to change (p <0.0075).
Conclusion: Interventions to decrease drinking in this population should focus on increasing patient awareness of the association between drinking, injuries, and other alcohol-related negative consequences.