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Impact of Alcohol Screening for Traumatic Brain Injury Patients Being Admitted to Neurosurgical Intensive Care Unit.

Background

In 2010, there were more than 2.5 million traumatic brain injury (TBI) cases in the United States. It was reported that these cases resulted in indirect medical costs of approximately $76.4 billion. (1) Alcohol-related deaths from excessive alcohol consumption among working adults mn at 9.8% of the total deaths in the United States. Traumatic brain injuries related to alcohol consumption in the general population affect between one-half and two-thirds of the TBI patients who are admitted to a trauma 1 designated hospital. (2) The results of 15 studies at trauma 1 designated hospitals reported estimates of alcohol-related visits ranging from 26.2% to 62.5%. Yet, the rate of alcohol screening is less than 50% for all trauma patients who present to the emergency department (ED). (3) With these data points, there is a very high probability that TBI patients will have a comorbidity of alcohol consumption symptoms and a worsening TBI upon admission to the neurosurgical intensive care unit (NICU) from the hospital's ED. (3)

One of the challenges for caring of TBI patients in the NICU is that, if the patients are not screened for alcohol upon arrival to the unit, it takes 24 to 48 hours to evaluate whether the patient's symptoms are related to a worsening TBI or other etiologies, such as alcohol consumption, of these symptoms (4,5) Without the differentiation of these symptoms, providers must be prepared for the worst-case scenario of an increased intracranial pressure from a possible brain herniation. (6,7) Another potential issue with unscreened alcohol patients in the ED is that alcohol intoxicated patients score lower on the ED's Glasgow Coma Scale (GCS), mostly for the level of consciousness. On the other hand, subsequently in the NICU, this score has significantly improved, and patients were more awake as they were sobering from alcohol. (8) This information may falsely suggest that the time lapse between the ED and admission to NICU changed the acuity of the TBI rather than only sobering from alcohol. (8) In a 2012 study, authors found that, because of these changes in GCS scores, the treatment path and management were changed. (9) Alcohol screening in the ED provides crucial information that can change the treatment path if it were known that patients had been intoxicated. (9)

Another assessment tool to prognosticate for a TBI treatment plan is the Abbreviated Injury Scale (AIS). It is based on the location of the injury, mechanism of the injury, and level of consciousness. If the patients are too intoxicated or have other substances on board, the AIS score could be misleading for the prognostication. If alcohol or toxicology screenings were done, the treatment path could be adjusted upon intake to the NICU. (10,11) Bedside nursing must be aware of these potential symptom conflicts because they are responsible for administering the screening tests and other assessment tools.

Therefore, because of these potential comorbidities of alcohol intoxication and a worsening TBI upon intake to the NICU, the first objective of this study was to determine the prevalence of alcohol screening for all TBI patients entering the NICU. The second objective for this study was to determine the relationship between alcohol screening with age, sex, GCS, AIS scores, and an emergent decompressive craniotomy. The third objective was to determine whether alcohol screening was related to the length of stay (LOS) at the hospital.

Methods

This is a retrospective study using descriptive statistics on the TBI patients' alcohol screening correlated with age, sex, emergent decompressive craniotomy, ED's GCS and AIS scores, and LOS. The LOS was reviewed to determine whether alcohol screening had any effect on the overall LOS. This quantitative study used a 12-month sample of TBI patients admitted to a trauma 1 designated hospital's ED in the US Pacific Northwest. The target population was taken from the 2012 Trauma Registry after obtaining the approval of the hospital's institutional review board. The criteria for inclusion in the sample were adults who were older than 18 years, female and male, and diagnosed with a TBI.

Sample and Procedures

The sample was based on TBI patients admitted to the trauma 1 designated ED in a hospital in the Pacific Northwest in the year 2012. The 2012 trauma registry used for this study had the patients' identification removed; it only included age, sex, alcohol screen status, blood alcohol level, GCS, AIS, emergent decompressive craniotomy, and LOS. Patients were categorized as screened for alcohol versus not screened based on laboratory results. Emergent decompressive craniectomy was extracted as a yes/no procedure from the records.

Measures

Severity of head injury was categorized using the AIS (1, mild; 2, moderate; 3, serious; 4, severe; 5, critical; 6, unsurvivable). The AIS has been found to be a valid and reliable scale for assessing head injury in TBI patients. (12)

GCS is based on 3 categories: eye response (1, no response, to 4, normal), verbal response (1, no response, to 5, nonnal), and motor response (1, no response, to 6, response), with a GCS score of 15 describing a fully functional person. (11) Total GCS responses are then categorized as follows: 14 to 15, normal state to mild; 10 to 13, mild to moderate; 6 to 9, moderate to severe; and 3 to 5, comatose. Both the AIS and GCS are used to prognosticate mortality in TBI patients. (8,13) Length of stay was operationalized as the number of days in the hospital including the day of admission and the day of discharge.

Data Analysis

Descriptive statistics, Pearson correlation for normally distributed continuous outcomes, and [chi square] analyses for categorical outcomes were used to determine the relationship between alcohol screening of TBI patients with age, sex, GCS and AIS scores, emergent decompressive craniectomy, and LOS. Where statistical significance was of interest, the .05 level of probability was used as the basis for evaluating the result. All statistical analyses were conducted in SPSS software (version 23).

Results

Overall, 1591 patients had complete data on the variables of interest. Traumatic brain injury patients' mean (SD) age was 51.41 (21.2) years; women were older (mean [SD], 56.64 [22.1] years) than men (mean [SD], 48.99 [20.3] years). Overall alcohol screening was done 80% (1273) of the time by laboratory. This was significantly higher than the national rate of 15% to 39% for all trauma patients. (14,15)

There was a greater number of TBI men (N = 1088) than women (N = 503) in the overall sample. Men were screened more often than women, with the difference being only greater than 6%. Men were more frequently screened for alcohol compared with women, 68.3% (1088) versus 31.6% (503), respectively ([chi square](1) = 7.86, P [less than or equal to] .001). Age was also related to alcohol screening (r = 0.23, P < .001) where younger patients were less likely to be screened.

The distributions of AIS scored by alcohol screen are shown in Table 1. Because of the large differences in the sample sizes, the percent columns are the most informative. The distribution for the total group of patients is provided as a reference point, and it can be seen that the AIS moderate diagnosis was the most frequent result. Patient distributions across screening (screened vs not screened) were similar to the overall distribution with only minor differences, except on the moderate diagnosis where there was an almost 10-percentage-point difference between the screened and not-screened patients (Table 1; 35.6% and 26.2%, respectively). A [chi square] analysis between the 2 groups on the AIS scores resulted in a statistically significant difference ([chi square] (5, N = 1591)= 14.77,/' = .01), where those with high AIS (critical) scores were less likely to be screened. The result was almost entirely due to the AIS moderate difference of 10 percentage points. Table 1 shows that the most frequent alcohol screened was AIS 2 (moderate) or 35.6% and the second most screened was AIS 4 (severe) or 22.8%.

Glasgow Coma Scale category 14-15 was the highest overall at 48.0%. The second highest ranking for TBI patients was no GCS at 33.1% rate. The third ranking was GCS 3-5 at 10.3%. The least frequent screening done by GCS was 10-13 and 6-9 at 4.6% and 4.0%, respectively. Alcohol screening was related to the ED's GCS ([chi square] (12) = 22.13, P = .04), where midrange scores were less likely to get screened. Emergent decompressive craniotomy ([chi square] (1) = 1-94, P = .16) and LOS (r = -0.04, P = .14) were not associated with alcohol screening.

Discussion

When the patient arrives at the NICU without being screened for alcohol, providers do not know whether the patient's clinical presentations of agitation tachycardia and hypertension are a result from alcohol or from an increasing cerebral edema. The provider must assume the worst-case scenario of an increasing cerebral edema that could result in death. Cerebral edema increases the intracranial pressure leading to a brain herniation that may require an emergent decompressive craniotomy.

Research shows that the reasons for not screening for alcohol are not clearly identified and may be due to multiple factors, such as staffing, time, and presumptions. (14,16-18) Recent research has shown that 15% to 39% of all trauma patients are being screened for alcohol. (14,19) However, because of the high risk of unnecessary treatments in the upstream healthcare departments such as the intensive care unit or acute care floors, alcohol level screening should be a requirement in the ED intake activity. The risk for not screening and identifying alcohol intoxication has a measurable impact on a positive patient outcome and has been discussed in various research studies addressing the impact of upstream care for the TBI population. (8,19,20)

Screening for alcohol level in the ED can be challenging due to environmental factors and acuity levels of the illness. However, if alcohol screening is not done, these patients' hospital course could be complicated because of the comorbidity of alcohol withdrawal and a TBI. There is limited literature addressing the issue of TBI patients being not screened for alcohol at the time of admission. On the basis of this study, there is a systemic bias related to sex, age, AIS, and GCS at the time of admission. It has been shown that men are screened 3 times more than women, which demonstrates a systemic bias and profiling based on sex due to societal perceptions. (21) Younger patients were less likely to be screened. Contributing elements could be social and legal implications for employment. (21,22) Two studies reported that younger and female patients are less likely to be screened for alcohol use because of fear of offending and lack of privacy in the ED environment. (16,18)

Previous research has shown that, generally, patients with unsurvivable and mild AIS scores were not screened for alcohol. (12) Patients who have a low (3-5) to mild (6-9) range of GCS were the least screened most probably because of the assumption of a poor prognosis. (12) One study suggested that the reason for not screening in the severe head injury patients was due to the legal implications from the sequela of medical problems resulting in delays of treatment. However, the same study cited other studies suggesting that alcohol-screened patients testing positive were overtreated, not undertreated. (8)

There are too many variables that are unseen and unpredictable based on retrospective data. Not screening this population for alcohol could have negative effects on the TBI population. This could be minimized if there were a set of protocols in place, mandating that all the trauma patients be screened for alcohol in the ED. This simple test could provide needed information for the providers who will be taking care of this population when they are admitted to the intensive care unit. Although our study did not find a relationship between screening for alcohol and LOS or urgent decompressive craniotomy, having this information would minimize the need for other diagnostic tests that may lower the overall cost of the hospital stay.

Study Limitations

The limitation of this study is that it was retrospective and did not include data to establish the rationale for not screening for blood alcohol level at the ED intake. In some of the cases for urgent decompressive craniectomies, the patients did not have a GCS taken in the ED because of the severity of their injury; therefore, obtaining blood alcohol screening in the ED may not have been feasible. Alcohol and TBI patients present a complex clinical manifestation. This complexity of both illnesses could be minimized and addressed before the acute phase of both illnesses. The details of the barriers to screening are not yet clear, but subsequent care is impacted based on the lack of ED screening.

Conclusions

This retrospective study results indicate that women, younger patients, and patients with midrange GCS scores and unsurvivable and mild AIS scores could be impacted by a systemic bias to not conduct an alcohol screen based on how the patients present to the ED. An updated ED's triage process and screening tool used by bedside nursing is recommended to allow for a targeted 100% alcohol screening rate for all trauma patients to eliminate this systemic bias. Traumatic brain injury patient care in the first 5 days is critical due to the possibility of a cerebral edema stroke as a sequela to the TBI. When other illnesses are added to this critical period, it poses many challenges for the providers and bedside nurses. With this complexity of illnesses, an appropriate diagnosis and treatment can be very costly. An incorrect or limited diagnosis could lengthen the hospital stay because of the sequela of the critical illnesses. This study showed that this level l trauma center designated hospital did well compared with the nationwide alcohol screening survey. However, level 1 trauma center designated hospitals should be standardized so that every trauma patient who is admitted to the ED is screened for alcohol level. Additional training for bedside nursing in the NICU to differentiate alcohol or substance abuse symptoms from a worsening TBI should be mandated. A nationwide standard practice for alcohol level screening would change how critical care is optimized for these patients.

Questions or comments about this article may be directed to Chong (Sherry) Cheever, MSN ANP-BC PhD(c). She is Lead Nurse Practitioner, Neurosurgical Intensive Care Unit, Harborview Medical Center, Seattle, WA.

Celestina Barbosa-Leiker, PhD, is Associate Dean for Research Director, Program of Excellence in Addiction Research, College of Nursing, Washington State University, Spokane, WA.

The authors declare no conflicts of interest.

DOI: 10.1097/JN N.0000000000000345

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TABLE 1. Total Group Alcohol Screening and Correlation
to AIS, GCS, and Demographics

                                 Screened

                 Total Group       Yes           No
                 (N = 1591)    (N = 1274)     (N = 317)

AIS Scale         n      %      n       %      n     %

Mild             70     4.4     59     4.6    11    3.4
Moderate         536    33.7   453     35.6   83    26.2
Serious          326    20.5   258     20.3   68    21.5
Severe           372    23.4   291     22.8   81    25.6
Critical         281    17.6   209     16.4   72    22.7
Unsurvivable      6     0.4     4      0.3     2    0.6

                                 Screened

                 Total Group       Yes           No
                 (N = 1591)    (N = 1274)     (N = 31)

GCS              100% Total    80% Yes        20% No

GCS 14-15        763     48    594     46.6   169    35
GCS 10-13        73     4.6     66     5.2     7    2.2
GCS 6-9          63      4      52     4.1    11    3.5
GCS3-5           164    10.3   145     11.4   19     6
GCS not done     528    33.1   417     32.7   111    35

Correlation to alcohol screen
  Age                          [r.sub.s] = 0.23, P<.001
  GCS                          [r.sub.s] = 0.103, P<.001
  AIS                          [r.sub.s] = 0.095, P<.001
  Craniotomy                   [r.sub.s] = 0.035, P = .16
  LOS                          [r.sub.s] = -0.04, P = .14
  [chi square]
  AIS                          [chi square] = 14.77, P = .01
  GCS                          [chi square] = 22.13, P = .04
  Sex                          [chi square] = 7.86, P = .01

Abbreviations: AIS, Abbreviated Injury Scale;
GCS, Glasgow Coma Scale; LOS, length of stay.
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Article Details
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Author:Cheever, Chong (Sherry); Barbosa-Leiker, Celestina
Publication:Journal of Neuroscience Nursing
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2018
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