Literature Review: Apparent Inebriates Needing EMS Care

Flower K, Post A, Sussman J, et al. Validation of triage criteria for deciding which apparently inebriated persons require emergency department care. Emerg Med J, Jul 8, 2010 [e-pub ahead of print].

Abstract

Objectives--The sensitivity and specificity of consensus triage criteria for identifying which apparently inebriated patients could be triaged to care in a sobering centre were determined. Sensitivity and specificity for modifications to these criteria were also investigated.

Methods--Paramedics prospectively collected data on apparently inebriated persons en route to the emergency department (ED). Ninety-nine of these patients' ED charts were retrospectively reviewed to assess who actually required ED care.

Results--Of 99 subjects with both paramedic and ED chart data available, most were male (89%), homeless (57%) and found on the street (81%). Five were admitted and 13 others appeared to require ED care. Per consensus criteria, only 40 were eligible for triage to a sobering centre, but among those were five who appeared to require ED care (sensitivity 72%, specificity 43%). Paramedic opinion alone was specific (80%) but not very sensitive (39%). Lowering the pulse exclusion threshold from 130 to 83 would increase sensitivity to 100%, but decrease specificity to 22%. A simple post hoc rule excluding those with age greater than 55 or pulse greater than 83 from non-ED care had high sensitivity (94%) and fair specificity (61%). The consensus criteria’s sensitivity and specificity varied (65%–83% and 44%–49%, respectively) depending on which ED services were considered optional (e.g., psychiatric consultation, ECG, intravenous fluids).

Conclusion--Most apparently inebriated individuals in this study did not require ED care, but prospective identification of these persons is difficult. A low exclusion cut-off for tachycardia may improve sensitivity.

Comment

Some of our most challenging patients are those with alcohol intoxication. The large majority of these patients are "just drunk," and it often seems like an unnecessary use of healthcare resources to transport them to emergency departments. Many systems have looked at ways to determine which of these patients can safely be redirected to sobering centers or other resources. This study is one of several that have shown us that this decision is complex and often inaccurate. Patients who appeared ill usually were, but the more important group, those who did not appear ill, often had unrecognized medical problems, sometimes requiring hospitalization.

With an incomplete history, difficult physical exam, lack of medical records, and limited tests (e.g., blood glucose, pulse oximeter), a field evaluation can easily fail to detect serious illness. For the chronically intoxicated, lack of transportation and access to primary care can complicate the decision, making it especially important not to overlook occult medical problems.

We need to recognize our limitations and maintain a healthy respect for the unobvious in this population. This study points out that the possibility of error may exceed any gain from not transporting these patients to the ED.

Angelo Salvucci, Jr., MD, FACEP, is medical director for the Santa Barbara County and Ventura County (CA) EMS agencies.