The authors have declared that no competing interests exist.
Conceived and designed the experiments: CMD. Performed the experiments: CMD TJC. Analyzed the data: CMD TJC. Contributed reagents/materials/analysis tools: CMD. Wrote the paper: CMD TJC. Statistical analysis: CMD.
Statistics from the National Trauma Data Bank imply that discretionary blood alcohol and urine drug testing is common. However, there is little evidence to determine which patients are appropriate for routine testing, based on information available at trauma center arrival. In 2002, Langdorf reported alcohol and illicit drug rates in Trauma Activation Patients.
This is a retrospective investigation of alcohol and illicit drug rates in consecutive St. Elizabeth Health Center (SEHC) trauma patients. SEHC Trauma Activation Patients are compared with the Langdorf Activation Patients and with the SEHC Trauma Nonactivation Patients. Minimum Rates are positive tests divided by total patients (tested and not tested).
Alcohol and illicit drug rates were significantly greater for Trauma Activation Patients, when compared to Nonactivation Patients. At minimum, Trauma Activation Patients are likely to have a 1-in-3 positive test for alcohol and/or an illicit drug. This substantial rate suggests that Trauma Activation Patients, a readily discernible group at trauma center arrival, are appropriate for routine alcohol and illicit drug testing. However, discretionary testing is more reasonable for Trauma Nonactivation Patients, because minimum rates are low.
It is clear that American trauma leadership endorses alcohol and drug testing. The National Trauma Data Bank (NTDB), sponsored by the American College of Surgeons Committee on Trauma, is the largest database of trauma center admissions in the United States
Discretionary, non-universal, alcohol and drug testing appears to be the typical practice. A review of results from the NTDB, after excluding not-applicable patients, shows that only 39% underwent alcohol testing and 26% had urine toxicology testing
One problem with alcohol and drug reporting in trauma patients is that the description of the parent trauma population is commonly nebulous. Examples include “3,312 trauma patients came to our facility”
Several investigators support a notion of select urine toxicology testing in trauma patients
Although the positive alcohol rate in a study by Blondell was 29.3%,
The St. Elizabeth Health Center (SEHC) Institutional Review Board waived the need for informed consent. The SEHC Institutional Review Board approved the study and the data were deidentified and analyzed anonymously.
This is a retrospective study of consecutive patients evaluated by the trauma services at SEHC, an urban Level I trauma center, from June through the end of August in 2010. SEHC patients consist of Trauma Activation Patients and Trauma Nonactivation Patients. SEHC alcohol and illicit drug rates in consecutive Trauma Activation Patients were computed and compared with the Langdorf Trauma Activation Patients
SEHC Trauma Center Admissions consisted of the combined SEHC Trauma Activation Patients and the SEHC Trauma Nonactivation Patients. SEHC Trauma Activation Patients included those with a Trauma Team status or Trauma Alert status. Trauma Team Activations were employed for physiologic or anatomic indicators and Trauma Alert Activations were implemented for high-risk blunt trauma mechanisms. Trauma Activation Patients were evaluated by the trauma services immediately upon emergency department arrival. Trauma Nonactivation Patients were other patients initially evaluated by the emergency department physician with a request for consultation and admission to the Trauma Service.
Violent mechanisms of injury included gunshot wounds, stab wounds, and interpersonal blunt trauma assaults. For the SEHC patients, clinical traits and outcomes were obtained from the trauma registry which participates in the NTDB. Blood alcohol results were from the Trauma Registry and urine toxicology results emanated from the medical records. Blood alcohol was considered positive when any measurable level was present. Using Siemen's Advia 1800 instrumentation, blood alcohol concentrations were computed based on alcohol dehydrogenase and nicotinamide adenine dinucleotide reactions. When a patient's urine drug screen was positive for an amphetamine, cannabinoid, cocaine, or phencyclidine, an illicit drug was considered as present. Using Siemen's Advia 1800 instrumentation, illicit drugs were initially identified by an enzyme multiplied immunoassay technique. Positive screens were confirmed using gas chromatography mass spectrometry for cocaine and thin layer chromatography for the other illicit drugs.
Trauma activation criteria are compared with the American College of Surgeons Committee on Trauma, Trauma Center Triage criteria
A Minimum Alcohol Rate and Minimum Illicit Drug Rate were computed as the number of positive tests divided by the number of total patients in the cohort (tested and not tested). This computation produces a minimum alcohol or illicit drug positive rate for the parent population. A Tested Alcohol Rate and Tested Illicit Drug Rate were calculated by dividing the number of patients with a positive alcohol or toxicology screen by the number of patients in the cohort who were tested. Tested Rates exclude those not tested from the trauma cohort denominator, thus creating a potential sampling bias that can produce a distorted alcohol or illicit drug positive rate for the parent population.
SAS System for Windows, release 9.2 (SAS Institute Inc., Cary, NC, USA) was used to perform the statistical analysis. Interval data are presented as the mean and standard deviation. Nonparametric data are presented as the mean and range. We considered P<0.05 to represent statistical significance.
From June through August 2010, 338 consecutive SEHC Trauma Activation Patients were evaluated. Injury traits and outcomes are in
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47 | 13.9% |
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283 | 83.7% |
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99 | 29.3% |
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40.5±20.6 | |
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13.2 (3–15) | |
|
10.6 (1–57) | |
|
20 | 5.9% |
|
5.0±8.1 |
SEHC, St. Elizabeth Health Center; Violent mechanism: gunshot wound, stab wound, or assault.
Study | # Pts. | # Tested | % Tested | # (+) | Minimum Rate |
Tested Rate |
SEHC | 338 | 295 | 87.3% | 78 | 23.1% | 26.4% |
Langdorf | 170 | 144 | 84.7% | 48 | 28.2% | 33.3% |
Both | 508 | 439 | 86.4% | 126 |
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|
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SEHC | 338 | 185 | 54.7% | 53 | 15.7% | 28.6% |
Langdorf | 170 | 144 | 84.7% | 40 | 23.5% | 27.8% |
Both | 508 | 329 | 64.8% | 93 |
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|
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SEHC | 338 | 480/676 | 71.0% | 113 | 33.4% | |
Langdorf | 170 | 288/340 | 84.7% | 71 | 41.8% | |
Both | 508 | 768/1016 | 75.6% | 184 |
|
SEHC, St. Elizabeth Health Center; # Pts., number of patients; # Tested, number of patients tested; % Tested, percent of patients tested; # (+), number of positive tests.
ACS Trauma Center Triage | Langdorf | SEHC |
Glasgow Coma Score <14 | Yes | yes |
systolic blood pressure <90 | Yes | yes |
respiratory rate <10 or >29 | Yes | yes |
penetrating injury head, neck, torso, or proximal extremity | Yes | yes |
flail chest | Yes | yes |
≥2 proximal long-bone fractures | Yes | yes |
crushed, degloved, or mangled extremity | No | yes |
amputation proximal to wrist or ankle | Yes | yes |
suspected pelvic fracture | Yes | yes |
open or depressed skull fracture | No | yes |
Paralysis | Yes | yes |
trauma with burns | Yes | yes |
high-risk blunt trauma mechanism | Yes | yes |
ACS, American College of Surgeons; SEHC, St. Elizabeth Health Center.
Comparisons of Trauma Activation Patients and Trauma Nonactivation Patients in the SEHC study are in
Activations | Non Activations | P-value | |||
n = 338 | n = 234 | ||||
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|||||
violent | 47 | 13.9% | 16 | 6.8% | 0.008 |
fall | 82 | 24.3% | 156 | 66.7% | 0.0001 |
motor vehicular crash | 93 | 27.5% | 29 | 12.4% | 0.0001 |
|
41±21 | 59±26 | 0.0001 | ||
13 (3–15) | 15 (10–15) | 0.0001 | |||
11 (1–57) | 8 (2–26) | 0.0001 | |||
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20 | 5.9% | 1 | 0.4% | 0.001 |
5±8 | 4±4 | 0.0001 | |||
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blood alcohol | 295 | 87.3% | 43 | 18.4% | 0.0001 |
urine drug | 185 | 54.7% | 47 | 20.1% | 0.0001 |
78 |
|
11 |
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0.0001 | |
53 |
|
14 |
|
0.0003 |
SEHC, St. Elizabeth Health Center; Violent mechanism: gunshot wound, stab wound, or assault.
SEHC Trauma Center Admissions (combined SEHC Trauma Activation Patients and SEHC Trauma Nonactivation Patients) and NTDB Trauma Center Admissions results are in
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Study | # Pts. | # Tested | % Tested | # (+) | Minimum Rate |
Tested Rate |
SEHC | 572 | 338 | 59.1% | 89 | 15.6% | 26.3% |
NTDB 2010 |
650,858 | 252,781 | 38.8% | 98,517 | 15.1% | 39.0% |
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SEHC | 572 | 232 | 40.6% | 67 | 11.7% | 28.9% |
NTDB 2010 |
590,221 | 155,039 | 26.3% | 65,247 | 11.1% | 42.1% |
SEHC, St. Elizabeth Health Center; NTDB, National Trauma Data Bank.
SEHC Trauma Center Admissions are SEHC Trauma Activation Patients combined with SEHC Trauma Nonactivation Patients.
# Pts., number of patients; # Tested, number of patients tested; % Tested, percent of patients tested; # (+), number of positive tests.
Data from Table 13 in 2010 Report excludes Not Applicable patients.
Data from Table 14 in 2010 Report excludes Not Applicable patients.
Commonly, the literature describes trauma-associated alcohol and drug rates for patients “undergoing alcohol and/or urine toxicology testing”. However, the patient traits of those with and without testing, i.e., selection biases, are typically not elucidated. When reviewing the trauma literature for alcohol and illicit drug rate results, potential sampling bias and errors need consideration. Specifically, determine whether a) the traits of the trauma cohort are clear, b) all patients were tested, and c) all patients were included in the analysis. A Minimum Alcohol or Illicit Drug Rate is computable if the trauma patient cohort undergoes select alcohol or illicit drug testing, yet the analysis includes all patients (tested and not tested) in the trauma cohort denominator. This computation produces a minimum, lowest possible, alcohol or illicit drug positive rate for the parent population.
The Langdorf study and a subset of SEHC patients provide a retrospective review of consecutive Trauma Activation Patients from two Level I trauma centers. Based on these investigations, Trauma Activation Patients are likely to have a 1-in-4 positive test for blood alcohol, a 1-in-5 positive test for an illicit drug, and a 1-in-3 positive test for alcohol and/or an illicit drug (
Of the patients positive for an illicit drug in the SEHC study of Trauma Activation Patients, cannabinoid and cocaine were relatively common, amphetamines were infrequent, and phencyclidine was nonexistent. Other trauma studies have also shown that cocaine
Alcohol testing rates were approximately 85% in the Langdorf and SEHC studies of Trauma Activation Patients (
The illicit drug-testing rate was approximately 85% in the Langdorf study of Trauma Activation Patients (
A comparison of Trauma Activation Patients and Trauma Nonactivation Patients in the SEHC study is elucidating (
It is clear that United States trauma leadership embrace blood alcohol and urine drug testing. The inclusion of alcohol and drug testing in the NTDB and the submission of data by trauma directors support this notion. Discretionary (non-universal) blood alcohol and urine toxicology testing is a common practice in trauma centers. The blood alcohol-testing rate was 60% for the Trauma Center Admissions (combined Trauma Activation Patients and Trauma Nonactivation Patients) in the SEHC study (
In the two studies of Trauma Center Admissions (combined Trauma Activation and Nonactivation Patients), the testing rate for alcohol was lower in the NTDB study (38.8%) when compared to the SEHC study (59.1%). However; of those tested, more NTDB Trauma Center Admissions patients were positive (39.0%) than those in the SEHC study (26.3%). This demonstrates how sampling bias might influence the alcohol-positive Tested Rate. The Minimum Rates for alcohol in the two Trauma Center Admissions (SEHC and NTDB) studies were lower in comparison to those for the two Trauma Activation Patients cohorts (SEHC and Langdorf).
An examination of the illicit drug rates in the two Trauma Center Admissions studies reveals comparable issues. The testing rate was lower in the NTDB (26.3%), when compared to the SEHC study of Trauma Center Admissions (40.6%). However; of those tested, the NTDB positive rate was higher (42.1%), when compared to the SEHC study (28.9%). This suggests that there is likely variance in patient selection and exclusion between the two investigations. This finding also implies that selection biases can influence illicit drug Tested Rates. It is germane that London, following an analysis of the NTDB, demonstrated that trauma patient drug testing is decreasing
The comparison of SEHC Trauma Activation Patients with SEHC Trauma Nonactivation patients shows higher alcohol and illicit drug Minimum Rates for Activation Patients. Of note, SEHC Activation Patients, in comparison to Nonactivation Patients, had greater violent mechanisms, more motor vehicular crashes, fewer falls, lower age, lower GCS, and higher injury severity (
Langdorf proposed a multifaceted set of rules, based on time of injury, mechanism of injury, and patient age, as to when toxicology screening should or should not be performed
Although this is a retrospective study, it is an analysis of consecutive trauma patients who either did or did not undergo blood alcohol testing or urine drug screening. We consider the trauma registry to be a reliable database. However, data accuracy and quality from a retrospective database source is lower, when compared to a prospective, dedicated database. The determination of patients consuming a narcotic or sedative prior to their trauma event may have been elucidating. Our study uses discretionary, non-universal, alcohol and urine drug testing. Thus, an accurate rate for the parent population is uncertain.
Alcohol and illicit drug minimum rates are significantly greater for Trauma Activation Patients, when compared to Trauma Nonactivation Patients. Trauma Activation Patients are likely to have, at least, a 1-in-4 positive test for blood alcohol, a 1-in-5 positive test for an illicit drug, and a 1-in-3 positive test for alcohol and/or illicit drug. Optional alcohol and urine toxicology testing is a common practice in American trauma centers. However, guidelines for testing or not testing, based on information available at trauma center arrival, are not established. The data in this report indicate that Trauma Activation Patients have substantial exposure to alcohol and illicit drugs. This suggests that Trauma Activation Patients, a readily discernible group at trauma center arrival, are appropriate for routine alcohol and illicit drug testing. The relatively low alcohol and illicit drug rates in Trauma Nonactivation Patients imply that discretionary testing is more reasonable.