Admitting Alcohol Intoxication

[suckstobeme]

Do you guys ever admit alcohol intoxication? Like nothing else, just EtOH. Is there a certain level or anything that would trigger an admission for you? Are there CMS admission criteria for it?

I'm asking because my group has an incentive linked goal of reducing time to discharge. My personal longest dispo times are for EtOH because they check in around 2AM and are ready to go 6a-12p. I generally don't check levels and rely on "clinical sobriety". I place them in "ED Observation" but that does not really help in terms of our statistics, though putting them in our CDU or Admitting them would make them fall out of our statistics. Based on the realities of our CDU, putting them there would be kind of a disaster.

---

Members don't see this ad.

 

[WilcoWorld]

The only pure EtOH intoxication patients that I admit are those who I intubate for airway protection, and that is exceedingly rare (I think I've done it twice in 10 years).

Your post seems like a good example of metrics pushing us to do the wrong thing, but I digress.

Would it be possible to get your group to exclude EtOH intoxication diagnoses from your stats?

 

[suckstobeme]

Wilco-
I had the same thoughts about the metrics causing us to do the wrong thing for the patient. But then I thought about. The only reason it's the wrong thing for the patient is because the ED staff is more experienced and we have developed systems to deal with the intoxicated patient. I think with time, the floor staff can develop the same expeirence and systems to deal with them. I think it's still a safe disposition. As far as patients getting a charge for a hospitalization, I kinda don't care.

 

[WilcoWorld]

Wilco-
I had the same thoughts about the metrics causing us to do the wrong thing for the patient. But then I thought about. The only reason it's the wrong thing for the patient is because the ED staff is more experienced and we have developed systems to deal with the intoxicated patient. I think with time, the floor staff can develop the same expeirence and systems to deal with them. I think it's still a safe disposition. As far as patients getting a charge for a hospitalization, I kinda don't care.

No disagreement here. I should have been clear that I'm coming at this from my current situation of boarding lots of admits. I'd much rather get my neutropenic fever patients upstairs than the drunks who can snooze safely in the hallway. If I were working in a system where all admits went straight up, and ED beds were at the highest premium, than admitting EtOH intoxication would probably be the better way to go.

 

[Daiphon]

Do you guys ever admit alcohol intoxication? Like nothing else, just EtOH. Is there a certain level or anything that would trigger an admission for you? Are there CMS admission criteria for it?

I'm asking because my group has an incentive linked goal of reducing time to discharge. My personal longest dispo times are for EtOH because they check in around 2AM and are ready to go 6a-12p. I generally don't check levels and rely on "clinical sobriety". I place them in "ED Observation" but that does not really help in terms of our statistics, though putting them in our CDU or Admitting them would make them fall out of our statistics. Based on the realities of our CDU, putting them there would be kind of a disaster.

Yes, I do. Intubated patients obviously. Otherwise, for 3 reasons:

1) drunk + suicidal with EtOH > 6h to sobriety.
2) drunk > 10h to sobriety.
3) drunk & I need the ED bed.

This is, of course, for pure EtOH intoxication. Other stuff, with EtOH found surreptitiously (such as AKA or CP, polysubstance ingestion, etc), depends on the problem.

-d

Semper Brunneis Pallium

 

[deleted547339]

Yes, I do. Intubated patients obviously. Otherwise, for 3 reasons:

1) drunk + suicidal with EtOH > 6h to sobriety.
2) drunk > 10h to sobriety.
3) drunk & I need the ED bed.

This is, of course, for pure EtOH intoxication. Other stuff, with EtOH found surreptitiously (such as AKA or CP, polysubstance ingestion, etc), depends on the problem.

-d

Semper Brunneis Pallium

#2 = med student dials every number available through EMR or patients cell phone to get a sober ride.

 

[Daiphon]

#2 = med student dials every number available through EMR or patients cell phone to get a sober ride.

Of course. Was implied. d=)

This is also assuming we have a name or cell phone... when you show up drunk from Lollapalooza wearing nothing but some strategically placed bandaids & a shower curtain, then it becomes moot.

-d

Semper Brunneis Pallium

 

[WilcoWorld]

Of course. Was implied. d=)

This is also assuming we have a name or cell phone... when you show up drunk from Lollapalooza wearing nothing but some strategically placed bandaids & a shower curtain, then it becomes moot.

-d

Semper Brunneis Pallium

Hey! I thought we were discussing pure EtOH intoxication - this patient clearly has something(s) else on-board.

 

[gman33]

Some payers will reimburse an Etoh level of 400 as a full inpatient admission.
In residency it was standard practice to admit anyone above 400. As a result nearly everyone got a level and you hoped it wasn't 399.

Where I work now people go crazy if you try to admit a pure Etoh pt.

 

[Janders]

Typically patients placed in observation are removed from ED Door-to-Discharge statistics (for obvious reasons).

You may want to remind those creating the statistics that the only reasonable alternative to placing these patients into ED observation is to place them on ward/floor observation, which will really gum up the works.

As well, using median TAT numbers helps reduce the effects of your 1-2 drunks a day (being optimistic).

 

[RustedFox]

Some payers will reimburse an Etoh level of 400 as a full inpatient admission.
In residency it was standard practice to admit anyone above 400. As a result nearly everyone got a level and you hoped it wasn't 399.

Where I work now people go crazy if you try to admit a pure Etoh pt.

Big bucks, big bucks, no whammies... STOP!

STOP.... At 399... Womp-womp.

 

[Siggy]

Just do what my hospital does... and put them on a psych hold. I've had a night where 6 of the 7 patients the ED admitted to me was EtOH intoxications on psych holds...

 

[ERDude]

Just do what my hospital does... and put them on a psych hold. I've had a night where 6 of the 7 patients the ED admitted to me was EtOH intoxications on psych holds...

I guess that is lame (and I get it's extra work for you either way) and is not my experience in a community ED practice but as a physician you would be able to revoke the hold and discharge the patient if you felt it wasn't clinically indicated.

 

[RustedFox]

I had one the other day that I have to share.


Gal comes in via EMS after having FALLEN ASLEEP in the pub (right across the street from the hospital). I check her records, and sure - she's a regular for ETOH-related stuff. Here's the kicker... she was seen there YESTERDAY for ETOH intox... found a ride, went home.

But wait... she was in the ED yesterday for ETOH, then comes back THE NEXT DAY after falling asleep in the pub ?

EtOH = 346. Safety concerns. Marchmann acted.

So she goes upstairs. Sobers up. Signs out AMA.

I come to work the next day.

Guess who's back.... back again... shady's back... ETOH = 501.

Admitted.

 

[WilcoWorld]

Guess who's back.... back again... shady's back...

I've created a monster...cuz nobody wantsta see Marshal no more...they want Shady, I'm chopped liver....well if you want Shady this's what I'll give ya...

Very appropriate reference, as the next stanza finds Shady getting cardioverted in the ER. Plus it's a great song. Eminem was fantastic, but, moreover, Dr. Dre was the King Midas of Hip Hop for a while there - everything he touched went gold (or platinum).

 

[gman33]

I had one the other day that I have to share.


Gal comes in via EMS after having FALLEN ASLEEP in the pub (right across the street from the hospital). I check her records, and sure - she's a regular for ETOH-related stuff. Here's the kicker... she was seen there YESTERDAY for ETOH intox... found a ride, went home.

But wait... she was in the ED yesterday for ETOH, then comes back THE NEXT DAY after falling asleep in the pub ?

EtOH = 346. Safety concerns. Marchmann acted.

So she goes upstairs. Sobers up. Signs out AMA.

I come to work the next day.

Guess who's back.... back again... shady's back... ETOH = 501.

Admitted.

Is this unusual?
I see our regulars more than my family.

 

[shookwell]

I've never seen someone admitted just for being drunk. Although, in our ED, I can watch someone sober up all night, and sign it out to the next shift, without any pushback. Benzo overdose without respiratory depression gets the same thing. No one checks alcohol levels unless there's trauma involved or diagnostic uncertainty.

 

[RustedFox]

I worked today, and during my social history....

Me: "Do you drink alcohol?"
Patient: "Ohhh, yeahhh."
Me: "Okay, how much?"

Patient proceeds to reach into her rather large purse, and hands me a near-full 750ml handle of vodka. Tells me that I can have a nip... She won't tell.

Several hours later, I had a guy spark up his bowl in fast track (no joke). Police were called, and he was arrested... For not passing to the left. Zzzing!

 

[Arcan57]

I'll admit if it's going to tie up a bed for >6hrs and they have beds upstairs (ends up being about 10% of drunks in a shop with relatively few pure ETOH presentations). The morbidity and mortality for ETOH or drug OD probably isn't any better than for cellulitis or asthma, which get routinely obs'ed in some systems.

 

[Cerberus]

I initially get laughed at, then yelled at, if I tried to admit a drunk solely for being drunk

 

[RustedFox]

I initially get laughed at, then yelled at, if I tried to admit a drunk solely for being drunk

This kinda amazes me. If I have a drunk that I can't sober up in a few hours, or find a responsible party for... they get admitted. I get no pushback. Better on the floor than taking up an ED bed.

EDIT: Maybe there's inconsistency regarding use of the term "obs". I can choose to "obs" patients upstairs, and the IM team is then responsible for them.

 

[Vandalia]

This kinda amazes me. If I have a drunk that I can't sober up in a few hours, or find a responsible party for... they get admitted. I get no pushback. Better on the floor than taking up an ED bed.

EDIT: Maybe there's inconsistency regarding use of the term "obs". I can choose to "obs" patients upstairs, and the IM team is then responsible for them.

Exactly. As soon as they set foot on hospital property, they are the hospital's problem. You can't just make them disappear. (Hmmm. I have a vision of a stereotypical mob guy visiting a hospital CEO and offering his company's unique "services.") You have to tuck them in somewhere. The vast majority of the time EM beds are more valuable than on the floor.

This may be the ONLY time when "patient satisfaction" works to our benefit. The admin folks do not want their "mobile customers" being verbally assaulted by the drunk guy next to them in the ED, and are usually fairly quick to get them somewhere out of sight and out of mind.

 

[shoal]

we have detox. if they have no evidence of injury. we send them to detox.

Sent from my VS986 using Tapatalk

 

[Siggy]

Remember a time when being drunk in public was a crime?

 

[n2b8me]

fortunately, or not depending on how you look at it being drunk in public is illegal depending on the state you live in. In the state I work it is illegal. Furthermore, in our county the police that bring people to the ER after public intoxication for medical eval are also responsible for picking them up afterwards when they can stand up again. It helps some length of stay for the etohers.
But no... we don't admit people for being too drunk.

 

[Vandalia]

fortunately, or not depending on how you look at it being drunk in public is illegal depending on the state you live in. In the state I work it is illegal. Furthermore, in our county the police that bring people to the ER after public intoxication for medical eval are also responsible for picking them up afterwards when they can stand up again. It helps some length of stay for the etohers.
But no... we don't admit people for being too drunk.

It is illegal in every state that I know of. It is also illegal to not have a man walking in front of your car with a red flag if you are driving within the limits of a city. The question is what the police feel willing to spend their time and/or their jail space on. Also, at least here, if they are in the ED, it is very unlikely that the jail will accept them. It is a game of musical chairs and the jail is perfectly happy to have these people here rather than taking up some of their bed space. (Which is in one place fixed under a federal consent decree.)

 

[TheBlueBlazer]

give some benzos because they "looked kinda shaky and withdraw-y" and you're set.