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Monday, October 27, 2008

Resuscitation room blood alcohol concentrations: one-year cohort study
Emergency Medicine Journal 2008;25:752-756;

To clarify the relationship between presenting clinical condition and blood alcohol concentration (BAC) among adult patients admitted to a resuscitation room (RR) of an emergency department (ED) in order to help guide clinical practice.

291 (15%) of 1908 presentations had a positive BAC (ie, BAC >10 mg/100 ml) ranging from 11 to 574 mg/100 ml, of which almost 40% were over 240 mg/100 ml (ICD-10 code Y90.8). In addition to collapse from alcohol/drugs, almost half of those presenting following self-harm or assault had a positive BAC. Those with a positive BAC had a higher rate of ED re-attendance in the following 6 months. 10% of all presentations were due to trauma.

The following five presentations to the RR are associated with a positive BAC: collapse from alcohol/drugs, self-harm, trauma, gastrointestinal bleeding (ICD-10 code K92.2) and non-cardiac chest pain (ICD-10 code R07). Patients with a positive BAC demonstrate a very wide range of pathology, some with severe levels of misuse. This highlights the opportunity for prompt feedback when sober, to ensure all is done to encourage patients to contemplate change in order to reduce re-attendance.

This work follows directly on from our first paper: "Use of blood alcohol concentrations in resuscitation room patients",1 which covers ethical, judicial and insurance issues. Alcohol misuse is a very common problem confronting all healthcare staff working in emergency departments (ED) worldwide.2 The value of screening and brief intervention in ED by an alcohol nurse specialist is established,3 with one less return visit to the ED over 12 months for every two people referred to an alcohol nurse specialist.4 At our hospital early identification of alcohol misuse is by the Paddington alcohol test (PAT) facilitating brief advice (with possible referral for brief intervention).5

Identification of patients with alcohol problems in the ED may be by history (PAT), clinical examination or blood alcohol concentration (BAC). PAT application is usually not possible for patients who are potentially critically ill and the need is for urgent assessment and treatment. Clinical examination for possible alcohol use is limited for the obtunded patient and has variable concordance with BAC.6 A degree of tolerance, thereby camouflaging clinical signs, for the "experienced" drinker is also well recognised.7 Measurement of BAC may provide a means of assessing the influence of alcohol use on the person’s presentation and management,8–10 but our ED staff were blinded to results (BAC requests not previously being routinely available at our hospital). Requesting the BAC without prior consent is acceptable to potentially critically ill patients, provided that feedback is given when patients are in a sufficiently improved clinical state.1 11

The extent of concurrent alcohol use among all categories of patients treated specifically in the resuscitation room (RR) of an ED has not previously been reported; every ED in the UK has a specific RR, usually between two and six bays, for potentially critically ill patients.12 We therefore set out to determine which RR patients were most likely to have a positive BAC and to explore associations with clinical outcomes, now that early identification with the giving of brief advice has been shown to be effective in reducing ED re-attendance.

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