Hospitalized patients and alcohol: who is being missed?

Research and clinical experience have shown that alcohol use disorders are neither sufficiently identified nor addressed in hospitalized patients. This study sought to quantify and localize these missed opportunities. The setting was an urban medical center with a Level 1 trauma designation. The only eligibility requirement was a Blood Alcohol Level (BAL) greater than 300 ng/dl upon hospital admission, a "nonsubtle" value more than three times the legal intoxication limit. Charts [58] were retrospectively reviewed for treating service (medical, trauma services, or psychiatric) and evidence of psychological signs or behavioral symptoms of withdrawal. Also assessed were the presence or absence of withdrawal monitoring, withdrawal prophylaxis orders, inpatient addictions consultation, and referral for addictions aftercare. Numerous patients with admission BALs >300 failed to be identified as needing assessment for alcohol-related disorders. Patients admitted to medical or psychiatric services were significantly more likely to be diagnosed than those on trauma services (P =.02). Patients on medical or psychiatric services were also more likely to be assessed for withdrawal and referred for after-care (P <.0001) than those cared for on trauma services. The delivery of care for alcohol-related disorders was deficient, particularly for patients with traumatic injuries, even among patients severely intoxicated at admission. Failure to identify such patients represented a missed opportunity to address this vital contributor to trauma. It is suggested that both the origins of this shortfall and its resolution depend not just upon trauma providers but upon the entire medical system.