American Journal of Emergency Medicine (2012) 30, 1224-1228

Brief Report

A pilot study of emergency medical technicians’ field assessment of Intoxicated patients‘ need for ED care^?

Alexandra H. Cornwall BA ^a, Nickolas Zaller PhD ^a,?, Otis Warren MD ^b,c, Kenneth Williams MD ^b,c, Nina Karlsen-Ayala ScB ^c, Brian Zink MD ^b,c

^aDivision of Infectious Diseases, The Miriam Hospital, Providence, RI 02906, USA ^bDepartment of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA ^cWarren Alpert Medical School of Brown University, Providence, RI, USA

Received 29 April 2011; accepted 3 June 2011

Abstract

Objective: Alcohol-intoxicated individuals account for a significant proportion of emergency department care and may be eligible for care at alternative sobering facilities. This pilot study sought to examine intermediate-level emergency medical technician (EMT) ability to identify intoxicated individuals who may be eligible for diversion to an alternative sobering facility.

Methods: Intermediate-level EMTs in an urban fire department completed patient assessment surveys for individual intoxicated patients between May and August 2010. Corresponding patient medical records were retrospectively reviewed for diagnosis, disposition, and blood alcohol content. Statistical analysis was conducted to determine correlates of survey response, diagnosis, and disposition; and survey sensitivity and specificity were calculated.

Results: One hundred ninety-seven Patient transports and medical records were analyzed. Emergency medical technicians indicated 139 patients (71%) needed hospital-based care, and 155 patients (79%) had a primary ethanol diagnosis. Fourteen patients (7%) were admitted to the hospital, and EMTs identified 93% of admitted patients as requiring hospital-based care. Overall sensitivity and specificity of the survey were 93% (95% confidence interval, 66.1-99.8) and 40% (95% confidence interval, 33.3-

47.9), respectively.

Conclusion: Intermediate-level EMTs may be able to play an important role in facilitating triage of intoxicated patients to alternate sobering facilities.

(C) 2012

^? Sources of support: This work was supported in part by the Closing the Addiction Treatment Gap Initiative, Open Society Foundations (grant no. 20023067).

* Corresponding author. Division of Infectious Diseases, Nikolas Zaller,

The Miriam Hospital, Providence, RI 02906, USA.

E-mail address: [email protected] (N. Zaller).

Introduction

Background

Alcohol-related incidents account for a significant proportion of emergency medical services and emergency department (ED) use [1,2]. Whether the intoxicated patient requires Acute medical care or “sobering” with rehabilitation

0735-6757/$ - see front matter (C) 2012 doi:10.1016/j.ajem.2011.06.004

referral is often a difficult determination [3]. Many communities have developed or are developing alcohol- and drug-related intoxication ED diversion programs or Sobering centers, where publicly intoxicated patients can be taken to sober up in lieu of transport to the ED [4-7]. Prehospital identification of patients who may benefit from diversionary sobering care vs hospital-based emergency care is an opportunity to reduce health care costs and improve resource use.

Importance

Inherent in ED diversion processes is the ability of the field medical evaluation performed by paramedics, emer- gency medical technicians (EMTs), police, and fire person- nel to distinguish between patients who are in need of hospital-based medical evaluation from those who are intoxicated without emergent concerns. The ability of EMTs to accurately perform prehospital diagnosis and triage of other medical conditions, such as trauma and stroke, has been shown [8]. However, limited data exist on whether EMTs can accurately predict if an intoxicated patient is in need of a hospital-based medical evaluation or can be safely triaged to an alternative sobering center [3].

Goals of this investigation

The goal of this pilot study was to determine EMT abilities to recognize an intoxicated patient’s need or lack thereof for hospital-based medical attention. A 14-point survey was developed to test EMT alcohol-triaging abilities, and the sensitivity and specificity of this survey were analyzed.

Table 1 Emergency medical technician responses to survey questions

Methods

Design and setting

This was a prospective survey study performed on a convenience sample of city fire department EMT-Cardiacs (an advanced life support EMT level unique to certain states but similar to the Department of Transportation EMT- Intermediate 99 curriculum) transporting patients with a chief complaint of alcohol intoxication to an urban ED in Rhode Island. Currently, there is no local alcohol diversion program in Rhode Island; and all publicly intoxicated patients are transported by ambulance to area hospitals. Between 2007 and 2010, EMTs in our sample population responded to approximately 3000 alcohol-related calls per year.

Implementation

A 14-point survey, including 10 objective and 4 subjective yes/no questions, was developed (Table 1). There is no validated clinical evaluation tool for prehospital evaluation of intoxicated patients, and the survey was developed based on the authors’ clinical experience and in accordance with standard EMT practice. All EMTs in the city fire department attended a 2.5-hour training session about the survey and the study. Informed consent was obtained from EMTs at this training session. Research staff administered the survey in the ED triage area to EMTs arriving with patients with a chief compliant of alcohol intoxication. Emergency medical technicians responded to the survey questions with a verbal “yes” or “no.” The ED medical record was then reviewed retrospectively for patients transported during the study for diagnosis,

Yes (%)		No	(%), n (%)	Sensitivity (95% CI)	Specificity (95% CI)
Objective variables
Complaint other than alcohol intoxication	52 (26)	145	(74)	64.3 (35.1-87.2)	76.5 (69.7-82.4)
Age younger than 16 years	0	100	(100)	0	100
Abnormal vital signs	38 (19)	159	(81)	50.0 (23.0-77.0)	83.1 (76.8-88.2)
Abnormal pulse oximetry	25 (13)	172	(87)	7.14 (0.18-33.9)	86.9 (81.1-91.4)
Any sign of trauma	23 (12)	174	(88)	7.14 (0.18-33.9)	88.0 (82.4-92.3)
Any sign of illness	7 (4)	190	(96)	0 (0-23.2)	96.2 (92.3-98.4)
Any sign of environmental emergency	2 (1)	195	(99)	7.14 (0.18-33.9)	99.5 (97.0-100)
Abnormal Blood sugar	51 (26)	146	(74)	35.7 (12.8-64.9)	74.9 (67.9-81.0)
Aggressive/confrontational	45 (23)	152	(77)	28.6 (8.39-58.1)	77.6 (70.9-83.4)
Other finding of concern	4 (2)	193	(98)	0 (0-23.2)	97.8 (94.5-99.4)
Subjective variables
Speech impaired	20 (10)	177	(90)	7.14 (0.18-33.9)	89.6 (84.3-93.6)
Impaired ability to sit	27 (14)	170	(86)	7.14 (0.18-33.9)	87.8 (79.9-90.5)
Impaired ability to stand	52 (26)	145	(74)	14.3 (1.78-42.8)	72.7 (65.6-79.0)
Impaired ability to walk	65 (33)	132	(67)	21.4 (4.66-50.8)	66.1 (58.8-72.9)

disposition, and blood alcohol content (BAC). Because of intoxication, patient consent could not be obtained and a more detailed medical record review and data collection of patient diagnosis and treatment were not conducted. This study was implemented between May 1, 2010, and August 31, 2010, and was approved by the institution’s institutional review board.

Data analysis

Survey questions were categorized as either subjective or objective to further elucidate the abilities of the survey (Table 1). Sensitivity and specificity analyses were per- formed using STATA 10 (STATA Corporation, College Station, TX). Emergency department care was considered to be indicated if any 1 of the 14 survey questions received a “yes” response. For analysis purposes, questions that were left blank were assumed to be a “yes” response so that bias, if any, was in favor of ED care.

Results

Patient population

Survey and hospital admission data were available for 197 transports, representing 132 unique patients; 5 patients had greater than 10 transports each. Blood alcohol content data were available for 189 patients; mean BAC was 272 mg/dL (95% confidence interval [CI], 259.2-285.4).

One hundred fifty-five patients (79%) had a primary ED diagnosis of alcohol intoxication, dependence, abuse, or withdrawal (ethanol [ETOH]). One hundred seventeen did not have any additional diagnoses. Forty-one patients (21%) had a primary diagnosis other than ETOH, of whom 12 had a secondary or tertiary ETOH diagnosis. Thirty patients (15%) had no ETOH diagnosis at all, and diagnosis information was not available for 1 patient.

In total, 14 patients (7%) were admitted to the hospital; 5 had a primary diagnosis of ETOH. Of the remaining 9 admitted patients, 4 had a secondary or tertiary diagnosis of ETOH. Of the 183 who were not admitted to any hospital or nonhospital facility, 150 (83%) had a primary diagnosis of ETOH.

Table 2 Sensitivity and specificity of survey, by question type

Emergency medical technician survey responses

Results of individual survey questions are listed in Table

1. Emergency medical technicians answered “no” to all questions for 58 patients (29%), indicating there was no medical or traumatic presentation or concern beyond that of ETOH intoxication. Of these 58 patients, 57 (98%) had a primary diagnosis of ETOH, 1 had a primary diagnosis of hypoglycemia and 1 was admitted to the hospital. Forty-five patients (78%) did not have a secondary diagnosis, 9 (16%) had a secondary diagnosis of ETOH, and 4 (7%) had a secondary diagnosis that was not alcohol related.

Emergency medical technicians answered “yes” to at least 1 question or left at least 1 question blank on the survey for 139 patients (71%), indicating either a concern other than ETOH intoxication or intoxication too severe for diversion- ary sobering care. The most common “yes” responses were to “impaired ability to walk” (33%), “impaired ability to stand” (26%), “complaint other than alcohol intoxication” (26%), “abnormal blood sugar” (26%), and “aggressive/ confrontational” (23%). Of those patients with a “yes” response to any question, 98 (71%) had a primary diagnosis of ETOH; and 11 (8%) had a secondary diagnosis of ETOH.

Of the 30 patients who did not have any ETOH diagnosis at all, 29 (97%) had a “yes” response on their corresponding survey, indicating that EMTs identified them as having a condition that required ED care; and 5 were admitted.

Survey validity

Of the 58 patients for whom the EMTs responded “no” to all survey questions, 1 (2%) was admitted to the hospital (Table 2). Of the 139 patients with a “yes” response to at least 1 question on the survey, 13 were admitted to the hospital (9%); all 13 had a “yes” response to at least 1 objective question, indicating the patient required ED evaluation. Seventeen patients (12%) had “yes” responses to only subjective questions, none of whom were admitted. The overall sensitivity and specificity of the full survey (both objective and subjective questions) were 93% (95% CI, 66.1- 99.8) and 40% (95% CI, 33.3-47.9), respectively. Among the objective survey questions only, the sensitivity and speci- ficity were 93% (95% CI, 66.1-99.8) and 40.4% (95% CI,

33.3-47.9), respectively.

Variable	n	Admitted	Sensitivity (95% CI)	Specificity (95% CI)
All “no”	58	1	7.14 (0.18-33.9)	68.9 (61.6-75.5)
Objective “yes” to any question	122	13	92.9 (66.1-99.8)	40.4 (33.3-47.9)
Subjective “yes” only	17	0	0 (0-23.2)	90.7 (85.5-94.5)
Any yes	139	13	92.9 (66.1-99.8)	31.1 (24.5-38.4)

Discussion

The results of this pilot study suggest that intermediate- level EMTs are able to accurately identify intoxicated patients who require hospital-based medical attention and admission via a routine assessment using a clinical prediction rule. Using this survey, EMTs identified 13 of the 14 patients who were admitted to the hospital as having an objective medical concern that warranted emergency attention. Emergency medical technicians were also able to accurately identify more than 25% of intoxicated patients who did not require hospital admission, representing a group of individuals who may be eligible for diversion to another nonhospital facility for sobering. Furthermore, EMTs were conservative in their estimation of patients in need of medical care, indicating that, with additional training and screening guidelines, EMTs may accurately triage an even larger number of intoxicated patients to alternate sobering facilities.

Many patients with intoxication do indeed require ED evaluation. However, there is a large subset of intoxicated patients who only need a safe place to sober up and do not need to use Hospital resources to do so. Sobering facilities as alternates to EDs have opened in numerous cities around the country [6,7]. In some cities, EMTs play a triaging role in facilitating transport of the intoxicated individual to either a sobering facility or hospital as deemed appropriate through a patient assessment process [7,9]. Although previous research has examined the ability of paramedics to assess medical necessity for intoxicated patients, to the authors’ knowledge, our study is the first to examine the feasibility of using intermediate-level EMTs in this role [3]. The findings from this study and from our prospective pilot study suggest that EMTs, using a clinical decision rule, may be able to safely implement earlier alcohol triaging away from EDs to alternative sobering centers for some intoxicated patients and can accurately identify patients presenting with a complaint of intoxication who do require ED care. This supports other literature suggesting that EMTs may be underused in the prehospital arena of alcohol intervention [10].

Careful consideration must also be given to the implications of inappropriate triaging or missing injuries or illnesses in diversion cases. In our study, 1 patient who was triaged on the survey by EMTs as not having any medical concerns had to be admitted to the hospital. However, many established sobering programs that use EMTs in the triaging process, in particular, the McMillan Stabilization center in San Francisco, CA, and the Central City Concern in Portland, OR, have had few reported instances of concern, suggesting that additional alcohol-specific training and appropriate clinical assessment protocols may be able to prevent most instances of mistaken diagnosis [4,7]. In addition, once at these centers, ongoing observation, care, and diagnostics can be performed, albeit in a more limitED capacity that at an ED; and patients can always be

transported to an ED from this location should concerns arise. Additional research is also needed to examine the impact of intoxicated patient diversion on patient health outcomes, quality of care, ED population changes, and cost- effectiveness [5,6].

This study has several limitations. Some survey questions were subjective in nature, which may have allowed for EMT misinterpretation and bias. Analyses of primary and secondary ETOH diagnoses were subject to physician bias in assigning order of diagnoses. In addition, our data were unable to account for vital signs not taken due to short transport times, patient refusal, or other reasons. Analysis was intentionally conservative, with all survey questions left blank for a variety of these situations considered a “yes” response to capture all potentially ill patients. Therefore, results may actually underestimate the true validity of the survey tool and abilities of the EMTs to make an accurate assessment. Our data collection also did not include ED treatment information. Therefore, our outcome measure of hospital admission may not capture those patients who received emergent or urgent interventions in the ED followed by discharge. However, it is feasible that many Treatment interventions performed in the ED setting may also be performed in a sobering center, such as oral fluids, glucose administration, and basic wound care. Finally, because all patients were intoxicated and, thus, not able to provide informed consent, patient information beyond that of diagnosis, disposition, and BAC level was not collected, preventing analysis of demographics and correlates to health outcomes.

Conclusion

The findings from this pilot study suggest that interme- diate-level EMTs may be able to play an important role in facilitating triaging of intoxicated patients to EDs or alternative sobering centers. Further research should inves- tigate refinement of a clinical decision-making tool capable of assisting EMTs in making the proper clinical transport decision for intoxicated patients.

Acknowledgments

The authors owe a debt of gratitude to Benjamin Schnapp from the Warren Alpert Medical School of Brown University for his assistance with the collection of data for this study.

References

1. Pletcher MJ, Maselli J, Gonzales R. Uncomplicated alcohol intoxication in the emergency department: an analysis of the National

Hospital Ambulatory Medical Care Survey. Am J Med 2004;117(11): 863-7.

1. McDonald AJ, Wang N, Camargo Jr CA. US emergency department visits for alcohol-relatED diseases and injuries between 1992 and 2000. Arch Intern Med 2004;164(5):531-7.
2. 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 2010.
3. Liu W. McMillan stabilization pilot project: 6-month interim report. San Francisco (Calif): City and County of San Francisco; 2004 http:// www.sfdph.org/dph/files/reports/StudiesData/McMillan/6MonRpt. pdf. Accessed February 15, 2011.
4. Dunford JV, Castillo EM, Chan TC, et al. Impact of the San Diego serial inebriate program on use of emergency medical resources. Ann Emerg Med 2006;47(4):328-36.
5. McClure CJ, Mello MJ, Zink B. Community based programs for chronic inebriate as an alternative to the emergency department. Med Health R I 2009;92(6):204-6.
6. Wood D. Central city concern: 25 years of changing lives. Portland: Central City Concern; 2004.
7. Richards JR, Ferrall SJ. Triage ability of emergency medical services providers and patient disposition: a prospective study. Prehosp Disaster Med 1999;14(3):174-9.
8. Safe House and Transport Van Program. Almeida County Behavioral health care services. Oakland, CA. Available at: http://www. acbhcs.org/sobering_svcs/sobering_ctr.htm. Accessed February 23, 2011.
9. Lynagh M, Sanson-Fisher R, Shakeshaft A. Reducing alcohol-related harm: the untapped potential of pre-hospital care workers. Int J Emerg Med 2009;2(4):237-40.