Do you admit drunk patients?

[Merely]

If a pt has alcohol level more than legal limit (let’s say double), can you do a psych evaluation on him and potentially admit him to inpatient unit if he meets criteria in the ED? People around here are saying you wait until level becomes under legal limit then you do evaluation and decide. He is pretty coherent even while 2x or 3x legal limit.

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[futuredo32]

wait until the patient is sober

 

[Ironspy]

I wait until alcohol levels drop. Lots of these folks stop being suicidal when they sober up. Seems like a waste to admit and immediately DC when they can sober up in the ED prior to reassessment

 

[tr]

In general I agree it is not good practice to admit someone who is actively intoxicated to inpt psych.

Are you getting pressure to admit from the ED? At our institution the ED is under pressure to dispo people quickly because their performance metrics suffer when patients spend extended amounts of time in the ED. If this is the case, sometimes the patient can go to an observation unit to sober up instead of staying in the main ED.

 

[Merely]

In general I agree it is not good practice to admit someone who is actively intoxicated to inpt psych.

Are you getting pressure to admit from the ED? At our institution the ED is under pressure to dispo people quickly because their performance metrics suffer when patients spend extended amounts of time in the ED. If this is the case, sometimes the patient can go to an observation unit to sober up instead of staying in the main ED.

Thanks for your insight. That’s a good idea. I was also wondering about like the people who are very chronic drinkers that are very sober at a alcohol level of 0.2, should we be waiting to get the level below like 0.1 (or whatever the legal driving limit is) before evaluating or is it ok to go ahead and admit a person with a 0.2 level who is coherent as he has a very high tolerance. Thx

 

[downwithDTB]

I would only ever admit an intoxicated person (> 0.05 ish, obviously higher if they are likely to start to withdraw at that level) if the collateral/circumstances suggest involuntary admission regardless of what they say (left a suicide note while sober then started drinking and went to get their gun before family happened across them). Statistically, very, very few people suicide while drunk (via case series of autopsy BAC), suggesting that the drunk suicidal patient is actually very low risk to complete and not at acute need of admission. Get 'em low but not too low and wait till the bars open or they sober up and want to go to detox.

*This may be different if you local law requires admission for alcohol abuse.

Metrics are no excuse for bad medicine.

 

[Bartelby]

I have to disagree with the idea that very few people commit suicide when drunk, for instance see Use of alcohol before suicide in the United States. - PubMed - NCBI. For people who come in drunk and suicidal but deny suicidal thinking the next day, I think they are at elevated (but not likely imminent) longer-term risk. A key factor in reducing risk is often reducing substance use and engaging in treatment for affective or other disorders. Since risk is not typically imminent in these situations, addiction is a chronic disorder, and issues like depression take more than a three-day inpatient stay to address, outpatient follow up is the way to go. Sending someone out this way, however, presumes that they have been allowed to sober up and do not appear to pose an imminent risk once sober.

By sober, they should be clinically sober. As you mentioned, some chronic drinkers will be clinically sober with alcohol levels that are still modestly high. Sometimes the ER will not let the person stay for a sober re-eval and insists on admission or discharge. I think that is inappropriate, but if that is the situation and I am not confident the patient is safe to leave I will admit them. They can be discharged the next day if low-risk. The psychiatry department should then discuss the systems issue with the ER: will it be a typical approach in this situation to observe in the ER, admit to medicine, or admit to psychiatry? Once a standard approach has been set, you are then probably stuck using it (which may mean some admissions that are basically a waste of time). It's better than sending someone out who is expressing suicidal thinking without a proper (sober) examination.

 

[Stagg737]

At our academic center it depends on the extent of the SI. If they've got a solid plan and an ability to actually complete or someone brought them in and can give good reason, they'd likely get admitted at least for obs. If they made an actual attempt, they'll get admitted regardless though. If it's at the VA we rotate through, they'll typically get admitted regardless of how drunk they are (depending on extent of SI) and just get sorted out in the morning once they sober up. If they're not suicidal anymore and don't want detox they get cut loose. Just because they're drunk doesn't mean they're at lower risk either. Most of the highest risk/most serious cases I've had were from attempts while people were intoxicated. I'm not saying that everyone with SI while intoxicated should be admitted. However, for many of them I don't have a problem admitting them for observation until they're sober so we can get a safety plan and follow-up in place assuming there's space on the unit to do so.

If they're asking for detox and they've got enough use that they'd potentially go into DTs or severe withdrawal we'll admit regardless as long as they're medically stable (otherwise they go to medicine).

 

[thoffen]

Intoxication and alcohol use are absolutely very serious risk factors for suicide. Someone shouldn't be discharged from the ED before they are sober, but that's not the same as evaluating/admitting to psych while currently intoxicated.

 

[downwithDTB]

Alcohol abuse is a chronic risk factor for suicide. I'm not aware of anyone who debates that. All things equal, person with AUD is more likely than person without to lifetime suicide. This partially explains why suicide decedents are more likely than the average person to have a BAC. The majority of people who suicide (including in the study cited above) still do not have a BAC at death.

The question of when those who drink suicide is a separate question from how many people have a BAC at time of death. A BAC of 0.08 is not something I want in my Uber driver but also not close to the modal "drunk suicidal" ED patient. When you start to threshold BAC above 0.2 or 0.3, you'll find a surprisingly low number of completed suicides. That's why I too am advocating for an intoxication hold: they are probably unlikely to suicide with a very high BAC when they present and likely would not do so immediately if discharged but might actually do so when closer to clinical sobriety several hours down the road, hence the reeval.

Another thing to be considered is secondary gain and the reinforcement of maladaptive coping. When patients are admitted on a revolving door due to SI and have very brief stays (< 2 days) over and over (as at some VAs) I highly doubt that this modifies chronic suicide risk at all and instead becomes an extremely expensive way to perpetuate substance use... but I'm certainly open to reading some data on this.

The following paper, easily found on search engine discusses some but not all of this.
The modal suicide decedent did not consume alcohol just prior to the time of death: An analysis with implications for understanding suicidal behavior.

 

[FlowRate]

I wait until people are "clinically sober." If they're a heavy using chronic alcoholic, they don't need to clear all the alcohol in their blood for that to be true. "Clinically sober" in my opinion is almost never "clinically sober" (arousable by sternal rub) in the ED's opinion.

 

[clausewitz2]

Alcohol abuse is a chronic risk factor for suicide. I'm not aware of anyone who debates that. All things equal, person with AUD is more likely than person without to lifetime suicide. This partially explains why suicide decedents are more likely than the average person to have a BAC. The majority of people who suicide (including in the study cited above) still do not have a BAC at death.

The question of when those who drink suicide is a separate question from how many people have a BAC at time of death. A BAC of 0.08 is not something I want in my Uber driver but also not close to the modal "drunk suicidal" ED patient. When you start to threshold BAC above 0.2 or 0.3, you'll find a surprisingly low number of completed suicides. That's why I too am advocating for an intoxication hold: they are probably unlikely to suicide with a very high BAC when they present and likely would not do so immediately if discharged but might actually do so when closer to clinical sobriety several hours down the road, hence the reeval.

Another thing to be considered is secondary gain and the reinforcement of maladaptive coping. When patients are admitted on a revolving door due to SI and have very brief stays (< 2 days) over and over (as at some VAs) I highly doubt that this modifies chronic suicide risk at all and instead becomes an extremely expensive way to perpetuate substance use... but I'm certainly open to reading some data on this.

The following paper, easily found on search engine discusses some but not all of this.
The modal suicide decedent did not consume alcohol just prior to the time of death: An analysis with implications for understanding suicidal behavior.

I think finding any evidence demonstrating a positive impact on suicide completion attributable to inpatient hospitalization in the short stay era is going to be very difficult.

 

[Merely]

I think finding any evidence demonstrating a positive impact on suicide completion attributable to inpatient hospitalization in the short stay era is going to be very difficult.

Are you suggesting we should be keeping people longer

 

[clausewitz2]

Are you suggesting we should be keeping people longer

Not as 99% of inpatient psych units are currently configured. Also probably not ever involuntarily primarily for SI/SA in the absence of delirium, acute psychosis and/or an actual mixed manic episode; in other words, unless there is a good chance that in a week of meds the patient is going to say "what was I thinking, that's not at all me" it probably doesn't help anyone.

It does address medicolegal mandates and makes us/society feel better that we are doing something, so I guess there's that.

 

[whopper]

Metrics are no excuse for bad medicine.

Absolutely.

If the ER is putting pressure to discharge cause of metrics alone and not based on good treatment the issue then is likely higher up than your shoulders and the people running the ER need to make an observational unit to hold these people.

As attendings, we have a responsibility to show leadership and to take these issues up ourselves, talk to the our partners in the ER, the department heads, the administration, what have you to come up with better solutions. Residents often times can't do this themselves although some institutions and residents are big enough to make this effort.

I wouldn't discharge until legally sober, unless as an exception clinically sober and they had someone that could pick them up and attest to their safety. If they get ticked off cause they're clinically sober and no one can pick them up, oh well, that's just going to add to the behavioral therapy of realizing they got a drinking problem that was bad enough to put them to these measures.

 

[Duloxetini]

Most of the inpatient units I've heard of would never take a person that could withdraw from alcohol in a psych facility.... Unless it's a med psych floor and even then it's a stretch since things can go south pretty quickly.

 

[whopper]

The issue of withdrawal and lack of inpatient treatment is frustrating. Do you really want to give an alcoholic bad enough to go to the hospital a benzo? I don't.

But here are the options for their withdrawal. No medication treatment (not good), a benzo (not good without supervision), or outpatient referal to an inpatient rehab where the patient likely won't take you up on the offer.

 

[FlowRate]

Most of the inpatient units I've heard of would never take a person that could withdraw from alcohol in a psych facility.... Unless it's a med psych floor and even then it's a stretch since things can go south pretty quickly.

Our units aren't "med psych" the way true med psych units are (rounding internist, more medicine than psych ward). That said, at our psych units located in general medical hospitals, we take uncomplicated withdrawal.

 

[Stagg737]

Most of the inpatient units I've heard of would never take a person that could withdraw from alcohol in a psych facility.... Unless it's a med psych floor and even then it's a stretch since things can go south pretty quickly.

Really? In the city I went to med school in most of the psych units would take patients asking for detox who weren't complicated and do a 3-5 day benzo taper and both psych hospitals in my residency program will take uncomplicated detoxers as long as they carry a psych diagnosis.

The question of when those who drink suicide is a separate question from how many people have a BAC at time of death. A BAC of 0.08 is not something I want in my Uber driver but also not close to the modal "drunk suicidal" ED patient. When you start to threshold BAC above 0.2 or 0.3, you'll find a surprisingly low number of completed suicides. That's why I too am advocating for an intoxication hold: they are probably unlikely to suicide with a very high BAC when they present and likely would not do so immediately if discharged but might actually do so when closer to clinical sobriety several hours down the road, hence the reeval.

I'd actually be interested in any literature which looked at the BAL/impairment levels of patients who actually attempt. I'd be curious if there'd be a bell curve with rates dropping off after a certain point.

 

[downwithDTB]

I'm having trouble finding the direct citation from Thomas Joiner's work that supports that statement but I did see him show the data in public and it was quite convincing ... of course... hard to trust anonymous person on website, but you could ask him. There was no bell curve, fewer suicides at no then low than high BAC. Very few at very high BAC. Will report back if I can find it.

 

[Evidence Based]

Most of the inpatient units I've heard of would never take a person that could withdraw from alcohol in a psych facility.... Unless it's a med psych floor and even then it's a stretch since things can go south pretty quickly.

Yeah this is surprising to me, we take folks to our adult general unit all the time for either symptom triggered or fix dose bento taper, unless they have a history of really bad withdrawals (DTs, ICU admission, etc). We're also in a general hospital so maybe that has something to do with it?

In regards to the thread question, our PES has a policy of not evaluating someone until they're "clinically sober," and our medical ED is apparently fine with it. Means people can board here for several hours, but I think that resolves in better clinical care and better disposition decisions.

 

[Duloxetini]

Maybe it's just an institution specific thing because it always seemed a bit odd to me. But patients where I am need to be medically cleared before SW even starts looking for a bed placement.

Most of these units are free standing psych units though.

But yeah... Managing uncomplicated withdrawal isn't really a big deal. I'm guessing it's due to the liability the free standing psych units just don't want to deal with.

It's also totally possible that this is bias from my end since I'm on consults and seeing the folks that we're on the fence about sending to the ICU and are evaluating patients both on the floor and in the ICU. The need for medical clearance here appears pretty high especially if there was anything acute in the history.

I went to medical school in MA and I honestly can't remember what we did there. I never rotated through inpatient psych at my institution (did consult and was elsewhere for IP), but I feel like I've seen more DTs in a week here than in a month of consult where I was a student.

 

[thoffen]

We are free standing and will take a person who is not currently in withdrawal and (almost exclusively) use symptom triggered management and ship to ED if withdrawal becomes complicated. We will deny patients if their substance abuse is too severe or known history of complicated withdrawal. We're not a licensed detox facility. Problem is from an outside ED you're at the mercy of whatever history they bother to collect or record and whatever they say a person's mental status is. Sometimes they try to hide abnormal vitals. That said, it's rare that we end up with someone actually needing transfer or in active withdrawal when they show up. Maybe part of that is it's usually easier to place these patients elsewhere so we don't receive the bulk of the referrals.

 

[Armadillos]

As an aside, not sure if this is true but ER docs tell me from a liability standpoint if a patient comes to an ER for any reason and you actually check BAL then you essentially have to wait until zero to let them leave or else your potentially on hook for literally anything that happens or they do next couple hours after they go. However if you don’t check the BAL and document they were drinking but after observation now they are clinically sober based on exam then you can make whatever decision you want as far as discharging w/o waiting as long.

This isn’t really related to SI specifically, just this perception (true or not, no idea) explains why a lot of ER docs seem to like to avoid checking BALs

 

[thoffen]

As an aside, not sure if this is true but ER docs tell me from a liability standpoint if a patient comes to an ER for any reason and you actually check BAL then you essentially have to wait until zero to let them leave or else your potentially on hook for literally anything that happens or they do next couple hours after they go. However if you don’t check the BAL and document they were drinking but after observation now they are clinically sober based on exam then you can make whatever decision you want as far as discharging w/o waiting as long.

This isn’t really related to SI specifically, just this perception (true or not, no idea) explains why a lot of ER docs seem to like to avoid checking BALs

I'm sure one of the forensic folks here has a better idea on this, but it sounds like pure crap to me. Regardless, making decisions which aren't in the interest of a patient purely out of concern for your own liability is bad medicine.

 

[Armadillos]

I'm sure one of the forensic folks here has a better idea on this, but it sounds like pure crap to me. Regardless, making decisions which aren't in the interest of a patient purely out of concern for your own liability is bad medicine.

Yeah, just so nobody is confused I’m not saying I agree with what I posted. Just that knowing the rumors of folks on the other side can help understand better when they do things that confuse us

 

[Merely]

Yeah this is surprising to me, we take folks to our adult general unit all the time for either symptom triggered or fix dose bento taper, unless they have a history of really bad withdrawals (DTs, ICU admission, etc). We're also in a general hospital so maybe that has something to do with it?

In regards to the thread question, our PES has a policy of not evaluating someone until they're "clinically sober," and our medical ED is apparently fine with it. Means people can board here for several hours, but I think that resolves in better clinical care and better disposition decisions.

What is the definition of clinically sober

 

[Shufflin]

I'm sure one of the forensic folks here has a better idea on this, but it sounds like pure crap to me. Regardless, making decisions which aren't in the interest of a patient purely out of concern for your own liability is bad medicine.

The experienced doctors will have one foot on the looking-out-for-one-liability side while doing what's best for the patient.

 

[NickNaylor]

What is the definition of clinically sober

No clinical evidence of intoxication - slurred speech, unsteady gait, disinhibited behavior, etc. - irrespective of BAL.

 

[whopper]

Maybe it's just an institution specific thing because it always seemed a bit odd to me.

Very true.

How you treat in one hospital vs another can highly differ.

The biggest reason why I'd be against admitting people just for detox is several substance abusers use to to enable their substance abuse or other bad agendas. E.g. they want to be in the hospital and all they got to do is get rip-roaring drunk and say they have withdrawal when they don't drink?

I've seen several substance abusers when they go through withdrawal want to go to the hospital simply because someone will make meals for them and be coddled. E.g. in the hospital you got air-conditioning, meals made to order, a clean room, etc. Also almost all of these people I mention had no financial consequences as a result of their hospital stay. Of course these people should get treatment for their substance abuse but hospitalization will not affect that success rate. Admitting these patient in effect was enabling their substance use.

But if you compare the hospital where I worked at vs a different one where hardly any malingerers come in the hospital may have a different mindset.