A score is born.
A staggering 88,000 people in the US die each year from alcohol-related causes. But that number is just a fraction of emergency department visits caused by drinking—nearly 5 million in 2014.
Some wind up in the ED after a rare episode of overindulgence, while others are daily drinkers experiencing additional problems like homelessness. All of them are kept in the ED until they appear sober, have no other complications, and can go home safely. It’s a seemingly straightforward process.
But certain patients present a conundrum for providers, says Jason Hack, MD, a professor of emergency medicine. “The descriptions of both intoxication and sobriety are very broad and ill-defined and mean different things to different people,” he says. “A more accurate description is to detect if someone has alcohol-induced impairment and identify when it resolves.”
Hack, who’s the director of the Division of Medical Toxicology, says providers have a tool that measures the severity of a patient’s withdrawal, but nothing to gauge the degree of their impairment. This opens up two scenarios, both undesirable: in the first, a patient is held against their will and forced to a blood alcohol level of zero, putting them in potentially life-threatening alcohol withdrawal. In the second, the hospital lets the patient go too soon, when they’re still impaired, and they get hurt or harm someone else. Hack saw an opening. “How do you determine when somebody is at their maximal functioning?” he says. “Nobody really knew.” Thus the HII score was born.
Hack’s Impairment Index is a five-part test that, he says, can span providers and shifts, because it objectively quantifies how well a patient performs tasks like speaking clearly, walking steadily, or following a moving object with their eyes.
Justin Benoit, MD, MS, an assistant professor of emergency medicine at the University of Cincinnati College of Medicine, evaluated HII alongside other tools in 2016 and found that “Jason’s [scoring system]really works the best.”
Lamenting the subjective way his ED evaluates patients for intoxication, Benoit says he hopes more researchers will take a look at HII. “I don’t think people fully appreciate this problem and all of its consequences,” he says. “We deal with it all the time, and we don’t have a good tool and everybody’s just kind of winging it.”
Hack says the HII score has been used in the Rhode Island Hospital ED for four years as well as other centers across the US; he’s now developing an HII app for mobile devices that health care centers can integrate with their EHRs. The chance to improve care for underserved patients drew Hack to emergency medicine, he says, and those who are chronically intoxicated are among the most vulnerable.
“I feel really strongly,” he adds, “that to the extent that we can care for them, that we do it well.”
