Imaging of Frequent Emergency Department Users with Alcohol Use Disorders

Abstract

Background Patients with altered level of consciousness secondary to alcohol use disorders (AUDs) often undergo imaging in the emergency department (ED), although the frequency and yield of this practice over time are unknown. Study Objectives We describe the use of imaging, the associated ionizing radiation exposure, cumulative costs, and identified acute and chronic injuries and abnormalities among frequent users of the ED with AUDs. Methods This is a retrospective case series of individuals identified through an administrative database having 10 or more annual ED visits in 2 consecutive years who were prospectively followed for a third year. International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology codes were used to select individuals with alcohol-related diagnoses, track imaging procedures, and calculate cost. Diagnoses, imaging results, and radiation exposure per computed tomography (CT) study were abstracted from the medical record. Results Fifty-one individuals met inclusion criteria and had a total of 1648 imaging studies over the 3-year period. Subjects had a median of 5 (interquartile range [IQR] 2–10) CT scans, 20 (IQR 10–33) radiographs, 28.3 mSv (IQR 8.97–61.71) ionizing radiation, 0.2% (IQR 0.07–0.4) attributable risk of cancer, and $2979 (IQR 1560–5440) in charges using a national rate. The incidence of acute fracture or intracranial head injury was 55%, and 39% of the cohort had a history of moderate or severe traumatic brain injury. Conclusion The remarkable use of imaging and occurrence of injury among these highly vulnerable and frequently encountered individuals compels further study to refine clinical practices through the development of evidence-based, effective interventions.

Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes

“…Studies from Western countries on time-critical conditions in OOH services are dominated by time-to-treatment and components-of-delay studies – especially regarding AMI, closely followed by sepsis and stroke [5, 6, 11, 31, 36, 37]. However, some of these earlier studies have also investigated the patient pathway for certain time-critical conditions.…”

Voices of Homeless Alcoholics Who Frequent Bellevue Hospital: A Qualitative Study

“…45 However, the exceptionally high morbidity and mortality of this population should give us pause. 8,12,37,51,52 Because the success of treatment for addiction is highly correlated with internal motivation, these individuals in their current state of indifference have little chance of recovery. 12,53,54 How, then, do we engage these individuals who, despite repeated presentation to EDs, are in fact not seeking help and are often refusing it?…”

Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

“…Further, the large variation in the frequency with which intoxicated individuals receive neuroimaging indicates considerable differences in our approaches. [1][2][3] Our ability to use existing guidelines to aid in decisions about whether or not to image these patients is hindered by limitations in the quality of the history and physical examination due to intoxication. The authors of "Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma" 4 showed that many significant intracranial injuries would be missed by translating exiting clinical guidelines to intoxicated patients, a finding that highlights the need to further research this understudied, commonly encountered, patient population and clinical scenario.…”

“…Although the radiation exposure associated with a single head CT scan is relatively low, cumulative exposure from repeated CT scans for patients who are frequently brought to the ED for intoxication is of potential significance. 2,3,5 On the other hand, the practice of serial examinations has its own less tangible costs. It requires vigilance to ensure that patients are not simply left unattended, may prolong length of stay, and may place patients at risk of delayed diagnosis.…”

“…In a retrospective series of 51 alcohol-dependent patients having more than nine annual ED visits each for 2 consecutive years, almost half had evidence of prior focal brain injury, and a quarter had acute intracranial injuries in the 3 years they were followed. 3 The lack of consistency in our approach to this common problem, the risk for consequential occult injury, and the inadequate sensitivity of established clinical decision rules demands further attention. Additional study is needed to determine the prevalence and indicators of serious injury in this population and to compare the clinical and cost-effectiveness of differing approaches.…”