Checklist diverts inebriated from emergency department

By Eleanor McDermid, Senior medwireNews Reporter

A checklist for use by ambulance crews helps paramedics decide which drunk patients need emergency medical care and which can be diverted to a detoxification facility, say researchers.

"We believe our data suggest that paramedics with specific training and protocols can safely identify patients who can appropriately be directly transported to a detoxification center," say David Ross (American Medical Response Inc., Colorado Springs, USA) and team.

The checklist was 99% sensitive for detecting patients who needed medical assistance. In all, 19.2% of 718 inebriated cases (434 individual patients) seen by paramedics over a 2-year period (2003-2005) were sent to a detoxification center, and just four (0.6%) of these ultimately required medical care.

None of these four events were high acuity, however. One patient was sent to the emergency department (ED) after becoming difficult to arouse, one developed cellulitis for which he needed antibiotics, another required medication for postoperative pain, and the fourth was seen for chest/abdominal pain that had been ongoing for several months.

But this high sensitivity came at the price of low specificity, at just 42%, with 184 of 523 patients taken to the ED not actually requiring emergency medical care. However, the researchers note that both the sensitivity and specificity are in line with American College of Surgeons Committee on Trauma recommendations for over- and undertriage rates for trauma center transport.

The checklist contains 29 criteria, and a positive answer to just one of these precludes patients from being sent to a detoxification facility. Excluding cases where patients were taken to the ED purely because they refused to go to the detoxification facility (31 cases) improved the specificity, but only to 52%.

The item most often checked - 334 times - was "inability to ambulate with minimal assistance," and this was the most frequent single exclusion (56 times), making it primarily responsible for the low specificity of the checklist.

"There may be ways to more precisely define and potentially combine clinical findings within this criterion population that might predict a cohort of patients who can safely be directly transported to a detoxification center," say Ross et al in the Annals of Emergency Medicine.

But they stress: "Refined criteria should maintain the high sensitivity for necessary ED care observed in this study while increasing specificity."

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