Biases in the collection of blood alcohol data for adult major trauma patients in Victoria, Australia.

BACKGROUND: In-hospital alcohol testing provides an opportunity to implement prevention strategies for patients with high risk of experiencing repeated alcohol-related injuries. However, barriers to alcohol testing in emergency settings can prevent patients from being tested. In this study, we aimed to understand potential biases in current data on the completion of blood alcohol tests for major trauma patients at hospitals in Victoria, Australia. METHODS: Victorian State Trauma Registry data on all adult major trauma patients from 1 January 2018 to 31 December 2021 were used. Characteristics associated with having a blood alcohol test recorded in the registry were assessed using logistic regression models. RESULTS: This study included 14 221 major trauma patients, of which 4563 (32.1%) had a blood alcohol test recorded. Having a blood alcohol test completed was significantly associated with age, socioeconomic disadvantage level, preferred language, having pre-existing mental health or substance use conditions, smoking status, presenting during times associated with heavy community alcohol consumption, injury cause and intent, and Glasgow Coma Scale scores (p<0.05). Restricting analyses to patients from a trauma centre where blood alcohol testing was part of routine clinical care mitigated most biases. However, relative to patients injured while driving a motor vehicle/motorcycle, lower odds of testing were still observed for patients with injuries from flames/scalds/contact burns (adjusted OR (aOR)=0.33, 95% CI 0.18 to 0.61) and low falls (aOR=0.17, 95% CI 0.12 to 0.25). Higher odds of testing were associated with pre-existing mental health (aOR=1.39, 95% CI 1.02 to 1.89) or substance use conditions (aOR=2.33, 95% CI to 1.47-3.70), and living in a more disadvantaged area (most disadvantaged quintile relative to least disadvantaged quintile: aOR=2.30, 95% CI 1.52 to 3.48). CONCLUSION: Biases in the collection of blood alcohol data likely impact the surveillance of alcohol-related injuries. Routine alcohol testing after major trauma is needed to accurately inform epidemiology and the subsequent implementation of strategies for reducing alcohol-related injuries.

Asymptomatic myocarditis during clozapine re-titration, in a patient who had previously been stable on clozapine for 10 years.

OBJECTIVE: We present a case of confirmed clozapine-induced myocarditis in a patient who was not naïve to the drug. METHOD: This patient, who had been stable on clozapine for 10 years, relapsed following self-cessation. Asymptomatic throughout inpatient re-titration, serum cardiac enzymes were nonetheless routinely taken. RESULTS: Occult myocarditis was only discovered due to an elevated Troponin I, and was confirmed by cardiac imaging. CONCLUSIONS: Once thought to be the preserve of initial exposure to the medication, clozapine-induced myocarditis can occur at any re-titration point if the immunological milieu permits. We therefore recommend routine monitoring of serum cardiac enzymes with all patients undergoing titration of clozapine, regardless of whether they have previously been stable on the drug.

Prevalence of alcohol and other drug detections in non-transport injury events.

OBJECTIVE: To measure the prevalence of alcohol and/or other drug (AOD) detections in suspected major trauma patients with non-transport injuries who presented to an adult major trauma centre. METHODS: This registry-based cohort study examined the prevalence of AOD detections in patients aged ≥18 years who: (i) sustained non-transport injuries; and (ii) met predefined trauma call-out criteria and were therefore managed by an interdisciplinary trauma team between 1 July 2021 and 31 December 2022. Prevalence was measured using routine in-hospital blood alcohol and urine drug screens. RESULTS: A total of 1469 cases met the inclusion criteria. Of cases with a valid blood test (n = 1248, 85.0%), alcohol was detected in 313 (25.1%) patients. Of the 733 (49.9%) cases with urine drug screen results, cannabinoids were most commonly detected (n = 103, 14.1%), followed by benzodiazepines (n = 98, 13.4%), amphetamine-type substances (n = 80, 10.9%), opioids (n = 28, 3.8%) and cocaine (n = 17, 2.3%). Alcohol and/or at least one other drug was detected in 37.4% (n = 472) of cases with either a blood alcohol or urine drug test completed (n = 1263, 86.0%). Multiple substances were detected in 16.6% (n = 119) of cases with both blood alcohol and urine drug screens (n = 718, 48.9%). Detections were prevalent in cases of interpersonal violence (n = 123/179, 68.7%) and intentional self-harm (n = 50/106, 47.2%), and in those occurring on Friday and Saturday nights (n = 118/191, 61.8%). CONCLUSION: AOD detections were common in trauma patients with non-transport injury causes. Population-level surveillance is needed to inform prevention strategies that address AOD use as a significant risk factor for serious injury.

Alcohol-related trauma presentations among older teenagers.

OBJECTIVE: The objectives of the present study were to report the proportion of older teenagers, including the subgroup operating a motor vehicle, presenting to an adult major trauma centre after injury with a positive blood alcohol concentration (BAC) over a 12-year period. METHODS: This was a registry-based cohort study, including all patients aged 16-19 years presenting to an adult major trauma centre in Victoria, Australia from January 2008 to December 2019 and included in the trauma registry. A Poisson regression model was used to test for change in incidence of positive BAC associated trauma and summarised using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: There were 1658 patients included for analysis and alcohol was detected in 368 (22.2%; 95% CI 20.2-24.3). Most alcohol positive presentations were on weekend days (n = 207; 56.3%) and most were males (n = 307). Over the 12-year period, there was a reduction in the incidence of older teenagers presenting with a positive BAC (IRR 0.95; 95% CI 0.93-0.98; P = 0.001). Among patients presenting after trauma in the setting of operating a motor vehicle (n = 545), alcohol was detected in 80 (14.7%) with no significant change in incidence of positive BAC (IRR 0.95; 95% CI 0.89-1.02; P = 0.17). CONCLUSIONS: A substantial proportion of older teenagers included in the registry had alcohol exposure prior to trauma. Despite a modest down-trending incidence, the need for continuing preventive measures is emphasised. In particular, preventive efforts should be targeted at male, older teenagers undertaking drinking activities on weekend days and driving motor vehicles.

Security interventions for workplace violence in the emergency department.

OBJECTIVES: Despite a policy of zero tolerance towards workplace violence (WPV) in Australian public hospital EDs, the incidence of WPV continues to increase. The aim of this study was to characterise security responses to WPV within an adult level 4 ED. METHODS: A retrospective single-centre review of episodes of WPV perpetrated by adults occurring within the ED was conducted between 1 January 2013 and 31 December 2015. Cases were identified using a prospectively recorded security register that records all events of security personnel attendance. The presence of police officers on initial presentation was the primary exposure variable. RESULTS: There were 1853 violent episodes committed by 1224 patients requiring security intervention during the study period, with half the episodes (n = 916; 49%) involving perpetrators who had committed at least two or more violent acts during the study period. Most cases (n = 1057, 57%; 95% CI: 55-59) occurred in the absence of police presence. Only 144 (7.8%) cases were managed by the presence of security personnel without physical security interventions. CONCLUSIONS: EDs should not rely on police response to prevent or handle violence. The finding of a high proportion of events being perpetrated by repeat offenders indicate that data sharing between EDs for identification of perpetrators of WPV can be useful for prevention of future episodes. ACEM policy for WPV in EDs should encompass further details on security credentialing and preventive strategies towards minimisation of WPV in the Australian EDs.

Increasing workplace violence in an Australian adult emergency department.

OBJECTIVE: Workplace violence (WPV) is an increasingly concerning occupational hazard within the ED. The aim of the present study was to evaluate the incidence and characteristics of WPV in an adult ED. METHODS: A retrospective cohort study was conducted to identify the incidence of ED WPV in an adult metropolitan ED. Data were obtained from the activity records of security staff from 1 January 2013 to 31 December 2015 for all incidents of patient-perpetrated violence. Data on patients identified from these records as requiring security staff intervention for violence in the ED were collected through an explicit chart review. Data on patient illicit drug or alcohol exposure and acute psychiatric diagnoses were also collected. RESULTS: There were 1853 episodes of patient-perpetrated WPV identified over the study period. The incidence of WPV over the 3 years was 103 (95% CI: 98-108) per 10 000 of the presenting population, with a significant increase from 2013 to 2015 (IRR 1.07; 95% CI: 1.04-1.10; P < 0.01). Drug and/or alcohol exposure was observed in 1145 (61.8%) patients. Among the drug- and/or alcohol-affected violent population, three quarters (840/1145 = 73.4%) did not have a concurrent psychiatric diagnosis that required assessment during the violent presentation. CONCLUSION: The rate of WPV was increasing within this Australian ED during the study period. The majority of violent patients were affected by drugs and/or alcohol in the absence of a psychiatric diagnosis. Interventions to reduce access to and misuse of alcohol and illicit drugs could have a substantial impact on the concerning increase of violence in the ED.

Review article: Workplace violence in the emergency department: A systematic review and meta analysis.

Patient or visitor perpetrated workplace violence (WPV) has been reported to be a common occurrence within the ED. No universal definition of violence or recording of such events exists. In addition ED staff are often reluctant to report violent incidents. The true incidence of WPV is therefore unclear. This systematic review aimed to quantify WPV in EDs. The association of WPV to drug and alcohol exposure was explored. The databases MEDLINE, Embase, PsycInfo and the Cochrane Library were searched from their commencement to 10 March 2016. MeSH terms and text words for ED, violence and aggression were combined. A meta-analysis was conducted on the primary outcome variable-proportion of violent patients among total ED presentations. A secondary meta-analysis used studies reporting on proportion of drug and alcohol affected patients occurring within the violent population. The search yielded a total of 8720 records. A total of 7235 were unique and underwent abstract screening. A total of 22 studies were deemed relevant according to inclusion and exclusion criteria. Retrospective study design predominated, analysing mainly security records and incident reports. The rates of violence from individual studies ranged from 1 incident to 172 incidents per 10 000 presentations. The pooled incidence suggests there are 36 violent patients for every 10 000 presentations to the ED (95% confidence interval 0.0030-0.0043). WPV in the ED was commonly reported. There is wide heterogeneity across the study methodology, definitions and rates. More standardised recording and reporting may inform preventive measures and highlight effective management strategies.