Differentials and trends in emergency department visits due to alcohol intoxication and co-occurring conditions among students in a U.S. public university

doi:10.1016/j.drugalcdep.2017.10.029

Drug and Alcohol Dependence

Volume 183, 1 February 2018, Pages 89-95

https://doi.org/10.1016/j.drugalcdep.2017.10.029 Get rights and content

Highlights

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First study to link student emergency department (ED) medical records with the admission dataset.
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There was a rising trend in student ED visits involving alcohol intoxication.
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Variations observed in the rate of intoxication by campus-related factors.
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Nearly one fourth of student ED visits with alcohol intoxication involving injuries.

Abstract

Background

Few studies have explored the epidemiology of students presenting to the emergency department (ED) as a consequence of hazardous drinking. This study examined differentials and trends in ED visits following alcohol intoxication and co-occurring conditions among students presenting to a major U.S. university health system.

Methods

The ED electronic medical records from academic years 2010–2015 were queried for student visits and their records were linked to the university’s student admission datasets. Student alcohol-related visits were identified based on ICD-9 codes. Student characteristics and trends in the rate of alcohol intoxication per 100 ED student visits were analyzed. A random sample of 600 student clinical records were reviewed to validate diagnostic codes.

Results

There were 9616 student ED visits (48% males) to the ED of which 1001 (10.4%) visits involved alcohol intoxication. Two thirds of ED visits with alcohol intoxication had a co-occurring diagnosis, with injuries (24%) being the most common condition. The rate of alcohol intoxication varied greatly by student demographics and campus-related factors. There was a linear increase in the rate of alcohol intoxication from 7.9% in 2009–10 to 12.3% in 2014–15 (p < 0.01). The increase was greater among female students, students below 20 years of age, Asian students, and student athletes. In the sample reviewed, only two thirds of ED visits with alcohol intoxication were recorded by diagnostic codes.

Conclusion

The rate of ED visits following alcohol intoxication varied by student demographic characteristics and campus-related factors with a rising trend over the study period.

Introduction

Numerous studies have identified that excessive alcohol use is a problem in the general college age population. Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) from 2010 demonstrated an increase of 24.3% past-month alcohol users between 16 and 17 year olds and 18–20 year olds, and a 21.1% increase from 18 to 20 year olds to 21–25 year olds (SAMHSA, 2011). More specifically, 18–22 year olds enrolled full time in college had a higher prevalence of past month alcohol use (63.3% versus 52.4%), binge drinking (42.2% versus 35.6%), and heavy drinking (15.6% versus 11.9%) than those not enrolled in full time college. The most commonly presented direct and indirect outcomes of excessive alcohol consumption that are seen in the emergency department (ED) include trauma, injuries, mental health issues, assault, and death.

Alcohol intoxication continues to present a great burden for ED personnel and consumes a significant amount of ED resources. The 2006–2010 national statistics on alcohol-related ED visits and comorbidities reported a rising trend in the rate of alcohol-related ED visits among young people 20–24 years of age from 97 to 120 per 100,00. A significant proportion of ED visits in this age group had co-occurring injuries (38%) or mental health concerns (35%) (NIAAA, 2013). Data from the Drug Abuse Warning Network (DAWN), which captured ED data for alcohol abuse among minors 18–20 years of age, estimated approximately 95,166 visits occurred for underage drinking (alcohol alone or in combination with drugs) in 2005. In 2010, however, underage drinking resulted in 114,722 ED visits, or 848.7 visits per 100,000 in 2010. This corresponds to approximately 21% increase since 2005, showing the increasing prevalence of alcohol-related medical emergencies among those 18–20 years of age (SAMHSA, 2011).

Students are a unique population whose alcohol use and drinking behavior are dependent on a range of personal, inter-personal, and campus-related factors. It is well-established that white students, first year students (Wechsler et al., 1995), and students enrolled in fraternities/sororities (Lo and Globetti, 1995, Presley et al., 2002) have higher rates of episodic heavy drinking than other students, while students who are engaged in athletics have lower rates of risky drinking. In addition, the type of residence and the college size also affect the level of binge drinking (National Institutes of Health, 2002).

While binge drinking is common among college students, most studies on college drinking behavior are self-report surveys, which are subject to reporting bias. Due to legal and social concerns, students tend not to provide honest responses to sensitive questions related to their hazardous drinking behavior, especially when it involves the use of emergency care (National Institutes of Health, 2002). Thus, EDs are in a unique position to provide objective clinical and epidemiological data enabling monitoring of hazardous drinking in college-age students. In addition, given the complex challenges in addressing dangerous alcohol use among college students, characterizing students presenting to the ED for treatment of intoxication is useful in developing adequate and targeted interventions and responses. A clearer understanding of the change over time of ED visits related to alcohol intoxication overall and within each demographic, organizational, and academic sub-group can provide important information to monitor the effectiveness of intervention efforts and determine which student sub-groups should be targeted.

To date, only three US-based, published studies have examined alcohol use and related health consequences amongst college students presenting to hospital EDs (Turner and Shu, 2004, Wright et al., 1998, Wright and Slovis, 1996). These studies indicate that prevalence of ED visits involving alcohol use ranged from 13 to 16 per 100 ED visits, of which trauma was the most common co-occurring health consequence, accounting for 53% (Turner and Shu, 2004) or 69% (Wright et al., 1998) of the total visits. Younger students, freshmen, white, and undergraduate students were more likely than other students to visit ED for alcohol-related reasons. However, these studies had certain limitations, including a limited number of ED visits (n ≤ 1529) and a short study period (i.e., 1–2 years). Therefore, these studies were unable to delineate the trends over time in the use of a hospital ED following alcohol intoxication amongst student populations. Furthermore, the use of a single data source (i.e., ED data) does not adequately capture other important students’ characteristics such as academic programs, organizational affiliation, or extra-curricular activities.

The aim of this study was to examine demographic, organizational, and academic differentials and trends in alcohol intoxication and related health consequences that were identified from diagnostic codes documented in medical records among students who presented to an ED affiliated with a major public hospital in the U.S., through the combined use of the ED database and the University’s Student Information System. This study also evaluated the validity and accuracy of diagnostic codes documented in the patient medical records.

Section snippets

Study population and data sources

The current study was based on a cohort of students from a US public university who visited the university hospital ED during six academic years from 2009 to 10 to 2014–15. Data were created by linking three student datasets: ED’s Patient Registration System, University’s Student Information System (SIS), and the ED’s Clinical Data Repository (CDR).

The ED’s Patient Registration System is a reporting system of students visiting the university hospital ED. It generates a daily report of

Results

There were 9812 student visits to the ED during the study period. After excluding 196 visits with missing diagnoses, 9616 visits (48% males) by 7035 unique students were available for analysis. Over 88% of students were aged 18–24 years (median = 20.7 years), 21% were affiliated with a fraternity or sorority, and 1.7% were members of an athletic team. White students accounted for 60% of the total ED visits, followed by Asian and Pacific Islanders (8%), African American (7.8%), non-American

Significance of the study

To our knowledge, the current study is the first comprehensive evaluation of the differentials and trends in alcohol intoxication and co-occurring conditions among university students presenting to a university hospital ED. There was a significant linear increase in both the number and rate of recorded alcohol intoxication with a larger increase found among female students, students below 20 years of age, Asian students, and athletic students. This rising trend also mirrored the national

Contributors

CH conceived the dataset. AN conceived the study design, performed the analyses, and drafted the manuscript. All authors contributed to interpretation of the results and writing the manuscript. All authors approved the final version of the manuscript before submission. None of the original material contained in this manuscript has been submitted for consideration nor will any of it be published elsewhere.

Role of funding source

Nothing declared

Conflict of interest

All authors declare that they have no conflicts of interest.

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There were several other important interventions in this patient population. First, occult trauma is frequently encountered in patients with intoxication [19,20]. We observed that patients in 22% of encounters required at least one radiologic study, most often for trauma, and 16% required wound care.
Some contend that patients with acute alcohol or illicit substance intoxication should be treated in outpatient detoxification centers rather than in the ED. However, these patients often have underlying acute medical needs. We sought to determine the frequency of medical interventions required by ED patients with alcohol or illicit substance intoxication.
This was a prospective observational study of consecutive ED patients presenting to an urban tertiary care ED with altered mental status due to alcohol or illicit substance use. We performed data collection for patients deemed to be low-risk for complications, as defined by receiving care in an intoxication observation unit. Trained staff observed and recorded all medical interventions, including medications administered, diagnostic testing, procedures performed, and airway interventions. The incidence of agitation was recorded using the Altered Mental Status Scale (AMSS, ordinal scale from −4 to +4, where +4 is most agitated). The data analysis is descriptive.
This analysis included 2685 encounters (1645 unique patients; median age 39; 73% male) from January to May 2019. Average breath alcohol concentration was 0.20 g/dL (range 0.00–0.47). There were 89% encounters with alcohol intoxication, and in 17% encounters the patient was suspected or known to have drug intoxication (either alone or in conjunction with alcohol use). On arrival to the ED, 372 (14%) had agitation (AMSS +1 or higher) and 32 (1%) were profoundly agitated (AMSS +4). In total, 1526 (56%) received at least one intervention that could not be provided by a local detoxification or sobering facility. Of the study population, 955 (36%) received a sedating medication, 903 (34%) required physical restraints for patients or staff safety, 575 (21%) underwent imaging studies, 318 (12%) underwent laboratory testing, 367 (13%) received another intervention (IV access, EKG, splinting, wound care, etc). Additionally, 111 (4%) patients received an airway intervention (19 intubation, 23 nasal airway, 85 supplemental oxygen) and 275 (10%) required repositioning to protect the airway. There were 168 (6%) patients admitted to the hospital.
In this population of relatively low-risk ED patients with drug and alcohol intoxication, a substantial proportion of patients received medical interventions.
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In 2017, for example, the past month use of alcohol (62% vs 56.4%) and mixing alcohol with energy drinks (31.5% vs 26.7%) was higher among US college students as compared to non-college peers (National Institute on Drug Abuse, 2018). In addition, numerous studies have linked student harmful alcohol use to a host of negative personal and campus-wide problems including poor academic performances, high-risk sexual behavior, sexual assault, violence and aggression, serious injuries, driving while intoxicated, and traffic fatalities (Ngo et al., 2018a; NIAAA, 2013; Ansari et al., 2013; Beck et al., 2010; Hingson et al., 2009; Wechsler et al., 2002). Considering these issues, most universities have implemented strict alcohol policies on college campuses.
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Full length articleDifferentials and trends in emergency department visits due to alcohol intoxication and co-occurring conditions among students in a U.S. public university

Highlights

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study population and data sources

Results

Significance of the study

Contributors

Role of funding source

Conflict of interest

Alcohol use and related harm among older adolescents treated in an emergency department: the importance of alcohol status and college status

J. Stud. Alcohol

Treatment of alcohol intoxication at university health services: examining clinical characteristics, drinking patterns, and adherence with referral

J. Alcohol Drug Educ.

Admissions of patients with alcohol intoxication in the emergency department: a growing phenomenon

Swiss Med. Wkly.

Alcohol intoxication at a university hospital acute medicine unit – with special consideration of young adults: an 8-year observational study from Switzerland

Emerg. Med. J.

Burnout and alcohol abuse/dependence among U.S. medical students

Acad. Med.

Drinking to toxicity: college students referred for emergency medical evaluation

Addict. Sci. Clin. Pract.

The facilitating and enhancing roles Greek associations play in college drinking

Int. J. Addict.

Alcohol-related Emergency Department Visits and Hospitalizations and Their Co-occurring Drug-related, Mental Health, and Injury Conditions in the United States: Findings from the 2006–2010 Nationwide Emergency Department Sample (NEDS) and Nationwide Inpatient Samples (NIS)

High-risk Drinking in College: What We Know and What We Need to Learn; Final Report of the Panel on Contexts and Consequences

The burden of alcohol misuse on emergency in-patient hospital admissions among residents from a health board region in Ireland

Addiction

Full length article
Differentials and trends in emergency department visits due to alcohol intoxication and co-occurring conditions among students in a U.S. public university