SGEM#313: Here Comes A Regular to the ED

Date: December 18th, 2020 Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020 Guest Skeptic: Dr. Hasan Sheikh is an emergency and addictions physician in Toronto and a lecturer at the University of Toronto. He holds a Masters in Public Administration from the Harvard Kennedy School of Government. Hasan was on an SGEM Xtra last year discussing the Canadian Association of Emergency Physician's (CAEP) position statement on Dental care in Canada. "The Canadian Association of Emergency Physicians believes that every Canadian should have affordable, timely, and equitable access to dental care." CAEP has put out other position statements. The most recent is on sick notes for minor illness. For a list of other positions statements from CAEP click on this LINK. Case: A 45-year-old male with no fixed address is found by a bystander with decreased level of consciousness (LOC) on the street. Emergency Medical Services (EMS) is called, and the patient is brought to the emergency department (ED). An empty bottle of vodka is found on the patient, and the decreased LOC is suspected to be due to alcohol intoxication. It is the patient’s fifth visit to the ED in the last two weeks with a similar presentation. The patient is observed over many hours, their LOC improves, and they are discharged after demonstrating that they can ambulate safely. Background: A leading driver of morbidity and mortality worldwide is alcohol (1). Alcohol consumption is attributed to approximately 5% of all global deaths. This works out to an estimated 3 million deaths due to alcohol (2). Alcohol was the single greatest risk factor for ill health worldwide among people aged 15–49 years according to the 2016 Global Burden of Disease Study (3). There are more hospital admissions in Canada for alcohol-attributable conditions than for myocardial infarction (4). There is a cost associated with alcohol related harms. In Canada, that number is around $14.6 billion a year with $3.3 billion in health care costs (5). Alcohol related ED visits has also increased more than four times greater than the overall rate of ED visits (6). This trend of increasing alcohol related ED visits is not unique to Canada. It has also been reported in England, Australia and the US (7-9). Clinical Question: What is the one-year overall mortality rate for adults with frequent visits to the ED for alcohol related reasons? Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020 Population: Adults aged 16-105 years of age who made frequent ED visits for alcohol related reasons (two or more ED visits in a year). Excluded: Data inconsistencies, not Ontario residents, Age < 16 or > 105 or death at discharge Exposure: Patients with ED visits for alcohol-related mental and behavioural disorders, using the ICD-10-CA code of F10. This includes simple intoxication and withdrawal Comparison: Comparisons were made between groups of frequent ED users for alcohol-related reasons, including those that visited the ED twice in a year, 3-4 times in a year, and greater than four times in a year Outcome: Primary Outcome: One-year mortality, adjusted for age, sex, income, rural residence, and presence of co-morbidities Secondary Outcomes: Mental and behavioural disorders, diseases of the circulatory system, diseases of the digestive system, and external causes of morbidity and mortality (e.g., accidents, including accidental poisoning, accidental injuries, injuries, intentional self-harm, assault) with frequency >5%. Cause of death using alcohol-attributable ICD-10-CA codes as well as ICD-10-CA codes for death by suicide. Authors’ Conclusions: “We observed a high mortality rate among relatively young,