Self-discharge during treatment for acute recreational drug toxicity: an observational study from emergency departments in seven European countries

Abstract

Background Self-discharge is a risk factor for readmission and excess mortality. We assess the rate of self-discharge from the emergency department (ED) among presentations for acute recreational drug toxicity and identify factors associated with self-discharge. Methods From the Euro-DEN Plus database of presentations to the ED with acute recreational drug toxicity, we extracted data from 11 centres in seven European countries from 2014 to 2017. Self-discharge was defined as taking one’s own discharge or escaping from the ED before being medically cleared. We used multiple logistic regression analyses to look for factors associated with self-discharge. Results Among 15,135 included presentations, 1807 (11.9%) self-discharged. Self-discharge rates varied from 1.7 to 17.1% between centres. Synthetic cannabinoids were associated with self-discharge, adjusted odds ratio 1.44 (95% confidence interval 1.10–1.89), as were heroin, 1.44 (1.26–1.64), agitation, 1.27 (1.10–1.46), and naloxone treatment, 1.27 (1.07–1.51), while sedation protected from self-discharge, 0.38 (0.30–0.48). Conclusion One in eight presentations self-discharged. There was a large variation in self-discharge rates across the participating centres, possibly partly reflecting different discharge procedures and practices. Measures to improve the management of agitation and cautious administration of naloxone to avoid opioid withdrawal symptoms may be approaches worth exploring to reduce self-discharge.

Drug users coming to European emergency departments: general basic approach and recommendations for safe discharge

“…Most drug intoxications that come or are brought to the hospital have several common denominators: they are usually mixed intoxications of several legal (energy drinks or alcohol, which is present in nearly half of the cases attended by EDs) and illegal substances and, in general, they are not serious and do not usually require hospital admission [7,8]. Nearly two out of every three patients attending the ED are discharged following a brief period of observation in the ED and, even, up to 12% of patients are left without being seen or discharged against medical advice [7]. In all cases, even the least severe, close monitoring of vital signs (including temperature) is essential during ED stay to detect early ventilatory or circulatory dysfunction.…”

“…Conversely, treatment of intoxicated patients is basically supportive and addressed to the control of symptoms. It includes treatment of agitation (mainly with intravenous benzodiazepines), aggressive management of hyperthermia, investigation of the presence of cardiovascular and neurological symptoms, and hospital admission for patients with mental disorders who require psychiatric care (16%) [7]. Prior to discharge, every patient should receive proper medical advice to avoid further episodes of adverse events related to drug consumption.…”

“…One of the main challenges that emergency physicians face with drug users who come to the ED is the clinical variations arising from polydrug use that occurs in toxicological syndromes (38.8% in EUroDEN-Plus) [7]. It is important to not only achieve rapid identification of a toxicological syndrome, but this must also be followed by the implementation of specific treatment.…”

“…Therefore, a closer relationship between EDs and epidemiological and toxicology and poison centers must be promoted. As an example, the European Monitoring Center for Drug and Drug Addiction [1,2] is currently provided with data recorded by EuroDEN-Plus centers for some of its reports [7,8], helping to better understand the full picture of healthcare problems generated by drug consumption. Finally, as emergency medicine is a reality in most European countries (and will be throughout all of Europe in the short term), emergency physicians will have to develop areas of superspecialization.…”