Thursday, January 26, 2006

So here's an interesting, at least to me, issue. Many of my colleagues, and most of the nurses, will check a blood alcohol on patients who have been drinking. Why?

If they have an altered mental status, the BA may help explain it, but you are going to have to work the patient up anyway. Why not do your work-up without checking the BA? What does the BA add? I would be concerned that an elevated BA might make you less aggressive about your work-up and you could miss something.

The other problem is the disposition problem. If you discharge a patient with documentation of safe gait, an understanding of his situation and an understanding of his discharge instructions, but without a BA, that should be sufficient. If he gets in a problem later, you don't have a pesky BA to explain.

If you discharge that exact same patient with a BA of 150 and then anything bad happens, you have to explain the BA. So the tendency in the ER is to keep the patient until the BA is less than 100. Why 100? Well, that has traditionally been the "legal BA." I often here referrence to "legally drunk."

Help me, Curious JD, but what exactly does legally drunk mean? It isn't against the law to be drunk, is it?

Of course, it is against the law to drive drunk. But we aren't releasing these patients to go drive. Just to walk to a car, driven by someone else, go home and go to bed.

Besides, the legal definition of DUI changes, doesn't it? Here in TN, it is now 80. But those same people feel OK about discharging a BA of 90.

Besides, we've probably all seen someone with a BA of 150 that could pass a field sobriety test, haven't we?

So my theory is this: Don't check the BA. If you think the patient is not safe to discharge, don't. If you think he is safe, document your findings that support your opinion and discharge.

If you are keeping a patient in the ER, or admit for OBS because of an elevated BA, are you suggesting that this person represents a risk to themselves or others? If not, why are you keeping them? If so, this would mean, potentially, an involuntary commital/admission.

What if the patient wants to leave, but you have a BA of 200 on the chart? Let's say that this is a chronic drinker, a frequent-flyer who is always drunk. Someone who comes to the ER, asks for a dinner tray and then wants to leave after he eats. His speech is fluent, maybe his gait is slightly antalgic. He knows where he is, what day it is and understands your instructions.

Do you let him leave? Do you call the police/security to keep him in the hospital?

Do you have a locked ward?

If you have admitted/kept in the ER a patient with the goal of discharging when the BA is less than 100, are you substituting this lab for your clinical judgement? What happens when you go in the room and the patient has eloped?

Give me your opinions about this situation. Under which circumstance would an ER doc be at greater risk if a patient leaves the ER and causes someone else to be injured:
  • A patient is discharged with careful documentation of the ER doc's findings of an apparently safe condition, but without any BA

  • A patient has a BA of 150, but the ER doc has documented findings of an apparently safe condition

  • A patient has a BA of 90, but the ER doc has not documented specific findings of an apparently safe condition

  • A patient has a BA of 150 and the ER doc has felt it necessary to keep the patient until the BA is less than 100, but the patient left without discharge

In the last situation, is the ER doc/hospital liable for not protecting the patient/community from this "legally drunk" patient?