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Are blood alcohol levels needed for intoxicated patients?
Good clinical judgment lowers liability risks
Many ED physicians do not get blood alcohol levels on intoxicated patients because levels do not correlate well with the patient's mental status or competence, while others say this practice is legally risky. So should blood alcohol levels be obtained?
There is no evidence-based answer to this question, says Robert Shesser, MD, professor and chair of the department of emergency medicine at George Washington University in Washington, D.C. Many EDs use breathalyzers to get a simple, fast, repeatable quantitative ethanol determination, which doesn't have as much accuracy as a blood determination, says Shesser.
As ethanol is associated with many other medical conditions, and is also seen in patients who have been traumatized, the clinical setting and totality of the patient's evaluation is more important than the actual ethanol level, says Shesser.
Very few clinical indications exist for serum alcohol determinations, but they may be useful in the differential diagnosis of delirium, says Larry D. Weiss, MD, JD, professor of emergency medicine at the University of Maryland School of Medicine in Baltimore. For example, if a patient presents with head trauma, apparent alcohol intoxication, and delirium, the serum alcohol level may raise the suspicion of a serious closed head injury.
As a general clinical standard of care, intoxicated patients may be safely discharged when the clinical syndrome of intoxication has resolved, but this does not correlate well with serum alcohol levels, says Weiss. "Evidence and logic does not support drawing serial serum alcohol levels to determine the time of discharge from an emergency department," he says. "A careless plaintiff attorney may allege anything, but an honest expert witness would not claim that serum alcohol levels determine competency to leave an ED."
However, over the course of a career, emergency physicians would accumulate risk if they made disposition decisions based on serum alcohol levels rather than on their clinical judgment regarding the resolution of clinical intoxication, adds Weiss.
Physician should make decision
EDs should not have policies requiring that alcohol levels be obtained in particular circumstances, says Weiss. "Clinical practice should not be dictated by hospital policy, but should be a result of autonomous physician decision making in accordance with national standards of practice," he says.
Not all ED patients will fit into any one policy, says James Hubler, MD, JD, assistant clinical professor of emergency medicine at the University of Illinois College of Medicine at Peoria. "And if the ED physician uses his clinical judgment, which may conflict with the policy and there is a bad outcome, then there will be more ammunition for the plaintiff's attorney," says Hubler.
Obtaining an ethanol level is medically important when the diagnosis of ethanol intoxication is in question, says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL. When the clinical diagnosis of acute intoxication is clear, then levels are not absolutely necessary as long as the patient is steadily improving over time, he says.
"As long as ethanol intoxication was not a misdiagnosis, I think that the legal issues come up more at the point of discharge," says Scaletta.
If the patient has a reliable family member or friend, he or she may be taken home once they are cooperative and able to stand and walk without assistance, says Scaletta. On the other hand, if the patient is leaving on his/her own, the patient must be "functionally" sober. This means that they can walk and talk, will avoid self-injury, and have a plan of where to go and how to get there. "And if the patient insists on driving home, the blood alcohol level must be under the legal limit," says Scaletta.
When discharging a patient who has been sobering up in the ED, be sure there are no safety concerns, such as the ability of the patient to cross a street or find food or shelter. "If the patient is competent to refuse the blood test or breathalyzer, but may be over the legal limit, I would summon the police who will often make sure the patient does not drive while under the influence of alcohol," says Scaletta.
Lawsuits are prevented with good documentation more so than ethanol levels, says Scaletta. "I am not a fan of policies that dictate clinical care. I prefer that board-certified or emergency medicine residency trained physicians are making these types of decisions on a case-by-case basis."
Don't miss emergency conditions
The determination of a patient's blood alcohol level has been a two-edged sword in determining physician liability in a claim of medical malpractice, says Edward Monico, MD, JD, assistant professor in the section of emergency medicine at Yale University School of Medicine in New Haven, CT. On one hand, levels above the legal limit have bolstered claims of incapacity made by patients who were injured as a result of inadequate monitoring.1
On the other hand, when intoxication is assumed without objective proof and patients are injured as a result of a wrongful assumption, the absence of a blood level can work against physicians in malpractice cases, says Monico.2
When confronted with a patient who appears intoxicated, keep in mind that your suspicion of limited capacity should be primarily a clinical decision supported by laboratory evidence such as blood alcohol levels, says Monico.
Physician actions, followed by appropriate documentation, should resonate with the clinical and objective determinations of capacity. "For instance, adequate monitoring to prevent injury should be instituted once a patient's capacity is called into question," says Monico. "Also, emergency physicians should seek alternative etiologies for impairment if the clinical suspicion is not supported by the blood alcohol level."
If you fail to get an alcohol level, you could potentially miss a life-threatening problem, warns Frank Peacock, MD, vice chief of emergency medicine at The Cleveland (OH) Clinic Foundation. When a patient appears to be intoxicated and the blood alcohol level comes back at 400, that fits—the lab result reflects that the patient is intoxicated, and they should wake up over the next six hours and be fine, says Peacock.
"And as long as that happens, it's okay," says Peacock. "But what is the surprise is when somebody comes in, looks drunk, and the level comes back and it's zero. If you didn't get the level, you wouldn't know that. Then you have a problem. You have a significant legal risk."
Alcohol levels do not correlate with sobriety, notes Peacock. "There are people walking around with a level of 200 who look pretty darn sober. They would still be considered drunk drivers, but that is a different animal," he says. "We are talking about doing the right thing medically. You need to get the level so you know that the altered mental status is because they are drunk."
For example, Peacock believed that one patient was intoxicated, but when the level came back as zero, it was determined that the man was poisoned with antifreeze. "Then we knew he had to go to dialysis, which we arranged and it saved his life—but you wouldn't know that without the alcohol level," says Peacock.
1. Scott v. Uljanov, 74 N.Y.2d 673.
2. Scott v. Dauterine Hospital Corp., 851 So. 2d 1152.
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