Emergency department wait times in concordance with blood alcohol content and subsequent alcohol use disorder

Methods

We conducted a cross-sectional analysis of the 2019–2021 NHAMCS. This dataset is a nationwide collection on the utilization of ambulatory care services in noninstitutional and short-stay EDs in the United States. Federal, military, and Veterans Administration hospitals were excluded from these surveys. Each ED is randomly assigned a 4-week reporting period in which there is a random collection of patient data and characteristics. Each hospital was trained in data collection, was verified for eligibility, and aided in creating a collection plan prior to participation in the survey. This study was not submitted for ethics review to an Institutional Review Board oversight because it did not meet the regulatory definition of human subject research as defined in 45 CFR 46.102(e) of the Department of Health and Human Services’ Code of Federal Regulations.

Results

After excluding nonresponses, our sample consisted of 6,558 patients who fell into the criteria of the top three levels of ED triage who presented with M or S ICD-10 codes, representing approximately 18.4 million ED visits between 2019 and 2021 after applying sampling weights. Our sample consisted of a majority of individuals identifying as White (n=3,339, 66.7 %), followed by Black/African American (1,041, 19.6 %) and Hispanic (454, 10.4 %; Table 1). There were slightly more males than females (51.0 and 49.0 %, respectively). A large majority were from metropolitan areas (5,032, 83.5 %). Further, 5,032 (83.5 %) of patients presented at EDs with a residency program. Among those, 180 presented with a history of AUD – 35 of whom presented with a BAC+ upon admission. Among those without a previous history of alcohol misuse (5,738, 96.9 %), 92 presented with a BAC+.

The mean wait times were 28.94 min (SE=0.91) for the AUD-/BAC- group, 29.22 min (SE=7.52) for the AUD+/BAC- group, 10.51 min (SE=1.70) for the AUD-/BAC+ group, and 17.82 min (SE=3.97) for the AUD+/BAC+ group (Table 2). The mean wait times were 27.22 min (SE=1.14) for individuals identified as White, 27.77 min (SE=1.61) for Black/African American, 32.79 min (SE=8.93) for Asian, 41.44 min (SE=14.99) for AI/AN, 31.72 min (SE=3.86) for Hispanic, and 18.14 min (SE=3.83) for Other/multiracial. The mean wait time for individuals listed as males was 27.07 min (SE=1.26) and for females was 29.90 min (SE=1.36). EDs with a residency program reported a mean wait time of 30.32 min (SE=1.56), whereas those without a residency program reported a mean wait time of 27.87 min (SE=1.12).

Discussion

Our findings showed that the ED wait times among individuals presenting with muscular or skeletal injuries with a recorded history of AUD who were BAC- at the time of triage were not significantly different from those without a history of AUD. Our binary regression models show that individuals who were BAC+ upon entry to the ED had shorter wait times regardless of AUD history – and only those who were AUD-/BAC+ had shorter wait times in the adjusted regression models. These results may show that potential stigma toward individuals with AUD within EDs may not apply to wait times.

The shorter wait times among individuals who enter EDs with a BAC+ status may be due to alcohol toxicity or alcohol withdrawal syndrome – which may require immediate attention [14], 15]; however, other factors may also play key roles in this finding. A white paper for the American Academy of Emergency Medicine (AAEM) entitled “Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder,” highlights that individuals entering the ED as BAC+ are often involved in incidents involving serious trauma including motor vehicle collisions, physical violence, and suicide attempts – often requiring prompt attention [15]. Further, a publication by Sarkar et al. [16] entitled “Clinical Practice Guidelines for Assessment and Management of Patients with Substance Intoxication Presenting to the Emergency Department,” states that individuals presenting in EDs who are BAC+ may be being escorted by law enforcement authorities, which would likely require immediate attention. They also state that safety for medical personnel and other patients may be at risk due to increased likelihood of agitation or violence and that prompt treatment may reduce potential harm.

Further, results from our study showed a decrease in wait time in BAC+ patients regardless of triage level, for M and S ICD-10 codes. The lower mean wait times for those with BAC+ admission status, regardless of AUD status or race/ethnicity, shows a correction in ED decision-making compared to a study from Goldfarb et al. [17] to address these patients in a more timely manner Although the reason for the shorter wait times cannot be discerned from our analysis, the progress shown here can be applied in a cross-specialty toward all types of injuries to any potential biases employed by healthcare providers and current practices when dealing with individuals under the influence of alcohol and to ensure that the quality of care does not differ from patient to patient. Although patients who are BAC+ are being attended to in a timelier manner within EDs, this may also reflect healthcare workers potentially trying to remove the potential of risky behavior in the waiting room, regardless of concern for treatment. By prioritizing patients with a BAC+, patients experiencing worse injuries may be delayed in seeing a provider. Therefore, along with BAC, we encourage healthcare workers to consider injury severity, altered mental status, and additional comorbidities to determine patient priority to admission.

Our findings regarding wait times and ethnoracial groupings were contrary to previous research in that within our study there were no significant differences between White, Black, and Hispanic groups. A 10-year study utilizing the NHAMCS from 2006 to 2015 showed that the overall wait time decreased in populations with mental health and SUDs; however, when controlling for AUD and mood disorders, Black patients were reported to have an increased wait time compared to White patients. Conversely, Hispanic patients had shorter wait times than White patients with preexisting anxiety or drug use disorders [18]. A separate study from 2023 utilizing NHAMCS data showed that among individuals presenting to an ED who had been diagnosed with an SUD, Black patients had significantly longer wait times than White patients [17]. Notably, individuals included in the ‘Other/race not listed’ category had significantly shorter wait times compared to White patients in both the binary and adjusted models, whereas AI/AN patients had longer mean wait times – nearly 14 min – although they were not statistically significant, likely due to the small sample size.

Conclusions

Overall, our study showed no significant difference in ED wait times between individuals with and without a history of AUD, although those presenting under the influence of alcohol had shorter wait times. This indicates that the history of AUD does not delay being seen. However, shorter wait times for those entering the ED as BAC+ may be due to their immediate need for treatment due to toxicity or alcohol withdrawal syndrome, having more severe injuries related to intoxication, or the need to be seen promptly due to agitation or aggressive behavior to prevent harm to medical personnel or patients.