Focused use of drug screening in overdose patients increases impact on management (original) (raw)

Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 145 No. 5152 (2015)

Summary

Drug poisoning is a common cause for attendance in the emergency department. Several toxicology centres suggest performing urinary drug screens, even though they rarely influence patient management.

STUDY OBJECTIVES: Measuring the impact on patient management, in a University Emergency Department with approximately 40 000 admissions annually, of a rapid urinary drug screening test using specifically focused indications. Drug screening was restricted to patients having a first psychotic episode or cases demonstrating respiratory failure, coma, seizures, a sympathomimetic toxidrome, severe opiate overdose necessitating naloxone, hypotension, ventricular arrhythmia, acquired long QT or QRS >100 ms, and high-degree heart block.

METHODS: Retrospective analysis of Triage® TOX drug screen tests performed between September 2009 and November 2011, and between January 2013 and March 2014.

RESULTS: A total of 262 patients were included, mean age 35 ± 14.6 (standard deviation) years, 63% men; 29% poisoning with alcohol, and 2.3% deaths. Indications for testing were as follows: 34% were first psychotic episodes; 20% had acute respiratory failure; 16% coma; 8% seizures; 8% sympathomimetic toxidromes; 7% severe opioid toxidromes; 4% hypotension; 3% ventricular arrhythmias or acquired long QT intervals on electrocardiogram. A total of 78% of the tests were positive (median two substances, maximum five). The test resulted in drug-specific therapy in 6.1%, drug specific diagnostic tests in 13.3 %, prolonged monitoring in 10.7% of methadone-positive tests, and psychiatric admission in 4.2%. Overall, 34.3% tests influenced patient management.

CONCLUSIONS: In contrast to previous studies showing modest effects of toxicological testing, restricted use of rapid urinary drug testing increases the impact on management of suspected overdose patients in the ED.

References

  1. Montague RE, Grace RF, Lewis JH, Shenfield GM. Urine drug screens in overdose patients do not contribute to immediate clinical management. Ther Drug Monit. 2001;23(1):47–50.
  2. Perrone J, De Roos F, Jayaraman S, Hollander JE. Drug screening versus history in detection of substance use in ED psychiatric patients. Am J Emerg Med. 2001;19(1):49–51.
  3. Tijdink JK, van den Heuvel J, Vasbinder EC, van de Ven PM, Honig A. Does on-site urine toxicology screening have an added diagnostic value in psychiatric referrals in an emergency setting? Gen Hosp Psychiatry. 2011;33(6):626–30.
  4. Wu AH, McKay C, Broussard LA, Hoffman RS, Kwong TC, Moyer TP, et al.; National Academy of Clinical Biochemistry Laboratory Medicine. National academy of clinical biochemistry laboratory medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department. Clin Chem. 2003;49(3):357–79 (revised & updated 2005)
  5. Lukens TW, Wolf SJ, Edlow JA, Shahabuddin S, Allen MH, Currier GW, et al. Clinical Policy: critical issues in the diagnosis and management of the adult Psychiatric patient in the Emergency Department. Ann Emerg Med. 2006;47:79–99.
  6. Kellermann AL, Fihn SD, LoGerfo JP, Copass MK. Impact of drug screening in suspected overdose. Ann Emerg Med. 1987;16(11):1206–16.
  7. Schiller MJ, Shumway M, Batki SL. Utility of routine drug screening in a psychiatric emergency setting. Psychiatr Serv. 2000;51(4):474–8.
  8. Belson MG, Simon HK, Sullivan K, Geller RJ. The utility of toxicologic analysis in children with suspected ingestions. Pediatr Emerg Care. 1999;15(6):383–7.
  9. Fortu JM, Kim IK, Cooper A, Condra C, Lorenz DJ, Pierce MC. Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: results and use. Pediatr Emerg Care. 2009;25(6):387–92.
  10. Belson MG, Simon HK. Utility of comprehensive toxicologic screens in children. Am J Emerg Med. 1999;17(3):221–4.
  11. Jolivet P, Vuille G, Kehtari R. “Extensive” toxicologic research in emergencies: a luxury or a necessity? Rev Med Suisse Romande. 2003;123(4):235–7.
  12. Brett AS, Rothschild N, Gray R, Perry M. Predicting the clinical course in intentional drug overdose. Implications for use of the intensive care unit. Arch Intern Med. 1987;147(1):133–7.
  13. Ingram DN, Bosse GN, Womack EP, Jortani S. Evaluation of a urine screen for acetaminophen. J Med Toxicol. 2008;4(2):96–100.
  14. Fabbri A, Marchesini G, Morselli-Labate AM, Ruggeri S, Fallani M, Melandri R, et al. Comprehensive drug screening in decision making of patients attending the emergency department for suspected drug overdose. Emerg Med J. 2003;20(1):25–8.
  15. Langdorf MI, Rudkin SE, Dellota K, Fox JC, Munden S. Decision rule and utility of routine urine toxicology screening of trauma patients. Eur J Emerg Med. 2002;9(2):115–21.
  16. Inuzuka S, Hayashida M, Nihira M. An investigation of drug abuse and the utility of toxicology screening for use in emergency centers. Nippon Ika Daigaku Zasshi. 1997;64(4):344–52.
  17. Fabbri A, Ruggeri S, Marchesini G, Vandelli A. A combined HPLC-immunoenzymatic comprehensive screening for suspected drug poisoning in the emergency department. Emerg Med J. 2004;21(3):317–22.
  18. Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol 2009;47(4):286–91.
  19. Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66–76.

Most read articles by the same author(s)