Intervention to decrease leaving without treatment among intoxicated emergency department patients

Approximately 15% of the >4000 patients presenting each year to our emergency department (ED) with a chief complaint or discharge diagnosis related to alcohol were leaving without treatment (LWT). If they are not clinically sober at the time of departure, these patients are at risk for falls or other injury. Our goal was to create an intervention to decrease this rate of early departure.

A stakeholder group identified the reasons why intoxicated patients were leaving without treatment, concluding that the primary reason patients left was there was no process in place for evaluating and caring for these patients who potentially had impaired decision-making capacity. The group created a worksheet for the triage nurse to identify and manage patients presenting with intoxication and impaired decision-making or ambulation, with protocols to keep the patient in a supervised area. We performed a before and after analysis, evaluating 12 months before and 12 months after the protocol was initiated, with the primary outcome being the rate of intoxicated patients who left without treatment. We also measured the recidivism rate (the rate of return to the ED within 24 h after departure) and the ED length of stay (LOS).

After the intervention was initiated, the percentage of intoxicated patients who left without treatment decreased from 15.0% to 7.4% LWT (p < 0.001). Among patients who stayed until discharge during the intervention period, the 24-hour recidivism was 9.4%, compared to 22.6% for those who left without treatment (p < 0.001). This difference in recidivism rates for each group was the same before and after the intervention, but fewer patients left without treatment after. For those patients with alcohol-related visits, the ED LOS was statistically significantly longer in the intervention phase, by a mean of 42 min for all patients (p < 0.001), as well as by a mean of 24 min for those who stayed to be dispositioned (p = 0.031).

Providing a standardized process for caring for acutely intoxicated patients leads to fewer patients leaving the ED before discharge. Patients who stay to the completion of treatment have a lower recidivism rate within 24 h after leaving than those in the leaving without treatment category.