Resource utilization and outcomes of intoxicated drivers.

Abstract

The high risk behavior of intoxicated drivers, impaired reaction time, lack of seat belt use, and increased incidence of head injury raises questions of whether pre-hospital use of alcohol leads to a higher injury severity score and worse clinical outcomes. We therefore compared intoxicated and non-intoxicated drivers of motor vehicle crashes with respect to outcome measurements and also describe the resources utilized to achieve those outcomes at our Level 1 trauma center.
Retrospective descriptive study (Jan 2002-June 2007) of our trauma registry and financial database comparing intoxicated drivers with blood alcohol levels (BAC) > 80 mg/dl (ETOH > 80) with drivers who had a BAC of 0 mg/dl (ETOH = 0). Drivers without a BAC drawn or who had levels ranging from 1 mg/dL to 80 mg/dL were excluded. Data was collected on demographic information (age, gender, injury severity score or ISS), outcome variables (mortality, complications, ICU and hospital LOS, ventilator days) and resource utilization (ED LOS, insurance, charges, costs, payments). Statistical analysis: p < 0.05 vs. ETOH > 80; stratified chi square.
Out of 1732 drivers, the combined study group (n = 987) of 623 ETOH = 0 and 364 ETOH > 80 had a mean age of 38.8 +/- 17.9, ISS of 18.0 +/- 12.1, and 69.8%% male. There was no difference in ISS (p = 0.67) or complications (p = 0.38). There was a trend towards decreased mortality (p = 0.06). The ETOH = 0 group had more patients with a prolonged ICU LOS (>/= 5 days), ventilator days (>/= 8 days), and hospital LOS (> 14 days) when compared to the ETOH > 80 group (p < 0.05). The ETOH > 80 group tended to be self pay (4.9% vs. 0.7%, p < 0.5) and less likely to generate payment for hospital charges (p < 0.5). Hospital charges and costs were higher in the ETOH = 0 group (p < 0.5).
The data suggests that intoxicated drivers may have better outcomes and a trend towards reduced mortality. They appeared to be less likely to have prolonged hospital LOS, ICU LOS, and ventilator days. We also observed that intoxicated drivers were more likely to be self-pay, less likely to have charges > $50K, and less likely to pay >/= 90% of the charges. Further research using multivariable analysis is needed to determine if these apparent outcomes differences are driven by acute intoxication, and the tendency for endotracheal intubation and ICU admission, rather than injury severity.

Full text

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RESEARCHOpen Access
Resource utilization and outcomes of intoxicated
drivers
Robert A Cherry1*, Pamela A Nichols1, Theresa M Snavely1, Lindsay J Camera2, David T Mauger2
Abstract
Background: The high risk behavior of intoxicated drivers, impaired reaction time, lack of seat belt use, and
increased incidence of head injury raises questions of whether pre-hospital use of alcohol leads to a higher injury
severity score and worse clinical outcomes. We therefore compared intoxicated and non-intoxicated drivers of
motor vehicle crashes with respect to outcome measurements and also describe the resources utilized to achieve
those outcomes at our Level 1 trauma center.
Methods: Retrospective descriptive study (Jan 2002-June 2007) of our trauma registry and financial database
comparing intoxicated drivers with blood alcohol levels (BAC) > 80 mg/dl (ETOH > 80) with drivers who had a BAC
of 0 mg/dl (ETOH = 0). Drivers without a BAC drawn or who had levels ranging from 1 mg/dL to 80 mg/dL were
excluded. Data was collected on demographic information (age, gender, injury severity score or ISS), outcome
variables (mortality, complications, ICU and hospital LOS, ventilator days) and resource utilization (ED LOS,
insurance, charges, costs, payments). Statistical analysis: p < 0.05 vs. ETOH > 80; stratified chi square.
Results: Out of 1732 drivers, the combined study group (n = 987) of 623 ETOH = 0 and 364 ETOH > 80 had a
mean age of 38.8 ± 17.9, ISS of 18.0 ± 12.1, and 69.8%% male. There was no difference in ISS (p = 0.67) or
complications (p = 0.38). There was a trend towards decreased mortality (p = 0.06). The ETOH = 0 group had more
patients with a prolonged ICU LOS (≥ 5 days), ventilator days (≥ 8 days), and hospital LOS (> 14 days) when
compared to the ETOH > 80 group (p < 0.05). The ETOH > 80 group tended to be self pay (4.9% vs. 0.7%, p < 0.5)
and less likely to generate payment for hospital charges (p < 0.5). Hospital charges and costs were higher in the
ETOH = 0 group (p < 0.5).
Conclusions: The data suggests that intoxicated drivers may have better outcomes and a trend towards reduced
mortality. They appeared to be less likely to have prolonged hospital LOS, ICU LOS, and ventilator days. We also
observed that intoxicated drivers were more likely to be self-pay, less likely to have charges > $50K, and less likely
to pay ≥ 90% of the charges. Further research using multivariable analysis is needed to determine if these
apparent outcomes differences are driven by acute intoxication, and the tendency for endotracheal intubation and
ICU admission, rather than injury severity.
Background
The prevalence of motor vehicle crashes remains a major
public health concern and is a leading cause of morbidity
and mortality in the United States. There were 38,588
fatalities and 1,746,000 injuries associated with motor
vehicle crashes that were reported by police in 2006 [1].
Many of these motor vehicle crashes are alcohol-related
and accounted for 13,470 fatalities [2]. The National
Highway Traffic Safety Administration (NHTSA) has
reported that 20% of fatal crashes in 2005 involved drunk
drivers (BAC of ≥ 80 mg/dL) [3]. According to NHTSA,
alcohol-related crashes account for $51.1 billion or 22%
of the economic costs. Approximately 75% of these costs
involve crashes in which a driver or non-occupant had a
BAC of at least 100 mg/dl. The high percentage of intoxi-
cated drivers is therefore a major driver of the socio-
economic costs involving motor vehicle crashes.
Moreover, there have been a number of studies that
have found an association between drinking and driving
and an increased risk for motor vehicle injury [4-6]. The
* Correspondence: rcherry@psu.edu
1Penn State Milton S. Hershey Medical Center, Department of Surgery, Shock
Trauma Center, Hershey, Pennsylvania 17033, USA
Full list of author information is available at the end of the article
Cherry et al. Journal of Trauma Management & Outcomes 2010, 4:9
http://www.traumamanagement.org/content/4/1/9
© 2010 Cherry et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

Page 2

Insurance Institute for Highway Safety reported that a
BAC as low as 20 mg/dL increases the likelihood of a
crash while operating a motor vehicle [5]. The probabil-
ity of a crash increases significantly at 50 mg/dL and
rises rapidly at levels greater than 100 mg/dL. Even
among people who are 55 years and older, drinking his-
tory (12 or more drinks prior to death) is associated
with fatality from a motor vehicle crash [7].
The incidence of alcohol-impaired driving, and the
risk of injury from alcohol-related motor vehicle crashes,
is also strongly associated with binge drinking [8,9].
Other predictors for a recurrent motor vehicle crash
included age < 32 years old, male sex, nighttime crash,
and a BAC > 50 mg/dl [6]. Drivers who tested positive
for blood alcohol are noncompliant with seat belt use
[10-13] and are more likely to have suffered a head
injury [11,13,14].
The high risk behavior of intoxicated drivers, impaired
reaction time, lack of seat belt use, and increased inci-
dence of head injury all raises the question of whether
pre-hospital use of alcohol leads to a higher injury
severity score, and therefore worse clinical outcomes.
We therefore compared intoxicated and non-intoxicated
drivers of motor vehicle crashes with respect to out-
come measurements and also describe the resources uti-
lized to achieve those outcomes at our Level 1 trauma
center.
Methods
This was a retrospective descriptive study conducted at
our Level 1 trauma center from January 2002 through
June 2007. Adult trauma patients who were 18 years of
age and older, operated a motor vehicle, and involved in
a crash were identified using our trauma registry (Col-
lector, Digital Innovation, Forest Hill, Maryland). Drivers
were identified and differentiated from passengers based
on EMS and/or emergency department records. Patients
with documented blood alcohol tests were identified by
accessing the electronic medical record (Cerner Cor-
poration, Kansas City, Missouri). There is mandatory
reporting of all suspected or confirmed cases of alcohol
intoxication to the Pennsylvania Department of Trans-
portation. At our institution, blood alcohol concentra-
tions are obtained on suspected cases of alcohol
intoxication if the laboratory finding might affect thera-
peutic decision-making or result in a referral to a drug
and alcohol counselor.
We compared intoxicated drivers with alcohol concen-
trations > 80 mg/dl (ETOH > 80) with drivers who had
alcohol concentrations of 0 mg/dl (ETOH = 0). Drivers
without an ETOH level drawn or who had results ran-
ging from 1 mg/dl to 80 mg/dl were excluded from the
study. The legal limit for blood alcohol concentrations
in Pennsylvania is 80 mg/dL. Patients without a blood
alcohol concentration drawn and inter-facility transfers
were excluded.
Data was collected on outcome measurements such as
mortality, complications, ICU and hospital length of stay
or LOS, and ventilator days. Resource utilization was
assessed by obtaining variables on time spent in the
emergency department (ED), insurance type, inpatient
charges, medical costs, and payments made (PMT).
Information on discharge destination from the ED and
the hospital was also collected. The Cochran-Mantel-
Haenszel Chi-square test, stratified by age, gender, and
injury severity score (ISS), was used to compare the
ETOH > 80 group against the ETOH = 0 group with
respect to these outcomes.
All analyses were carried out using SAS Version 9
(SAS Institute Inc., Cary, NC). All p values < 0.05 were
used to denote significant differences between groups.
The Cochran-Mantel-Haenszel Chi-square test, stratified
by age, gender, and injury severity score (ISS), was used
to compare the ETOH > 80 group against the ETOH =
0 group with respect to these outcomes and odds ratios
were calculated for binary outcomes. Both stratified and
unstratified odds ratios with 95% confidence intervals
were constructed. The study protocol was approved by
the Institutional Review Board at the Penn State Milton
S. Hershey Medical Center.
Results
There were 1,732 adult drivers of motor vehicles identi-
fied during the study period who were evaluated at our
trauma center. The combined study group consisted of
623 patients with a BAC of 0 mg/dL (ETOH = 0 group)
and 364 patients with a BAC > 80 mg/dL (ETOH > 80
group). Collectively, these patients had a mean age of
38.8 ± 17.9 years, an ISS of 18.0 ± 12.1, and were 69.8%
male. There was no significant difference is ISS among
the two groups (p < 0.66), but the ETOH > 80 group
was younger and had more men (p < 0.05).
The ETOH = 0 group tended to have a prolonged ED
LOS (≥ 220 minutes, see Table 1). The ETOH > 80
group was more likely to be admitted to the ICU (41.3%
vs. 33.7%, p < 0.05) and intermediate care unit (18.2% vs.
16.1%, p < 0.05) from the ED, and the ETOH = 0 group
was more likely to go to the operating room (Table 2).
Despite fewer admissions to the ICU, the ETOH = 0
group had significantly prolonged ICU LOS (≥ 5 days),
ventilator days (≥ 8 days), and hospital LOS (> 14 days)
when compared to the ETOH > 80 group (p < 0.05)
(Table 2). There was no significant difference in the
number of deaths for the ETOH > 80 group, but there
was a trend towards decreased mortality (p = 0.06).
The ETOH > 80 group tended to be self pay (4.9% vs.
0.7%, p < 0.5) and less likely to generate payment for
hospital charges (p < 0.5) (Table 3). Of note, hospital
Cherry et al. Journal of Trauma Management & Outcomes 2010, 4:9
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charges and medical costs were significantly higher in
the ETOH = 0 group (p < 0.5). The ETOH > 80 group
was significantly more likely to go home (76.5% vs.
65.6%) and less likely to be discharged to a skilled nur-
sing facility (1.5% vs. 5.2%) and a rehabilitation center
(15.7% vs. 25.6%) (Table 4).
Discussion
Our study describes several unexpected observations
among intoxicated drivers with respect to resource utili-
zation and outcome measurements. These results under-
score several areas requiring further discussion,
including the burden that alcohol misuse and abuse may
place on hospital resource utilization, and whether alco-
hol intoxication is a potential predictor of clinical out-
come. In addition, the financial implications that
intoxicated drivers have on our Level 1 trauma center
becomes more of an issue after reviewing the data in
this study.
Although our study did not specifically control for ISS,
the data did not show differences in ISS between BAC >
80 and BAC = 0 groups. The groups were also compar-
able in that there were no differences in complications
or mortality. Nevertheless, there have been conflicting
reports in the literature with regards to injury severity
for occupants involved in alcohol-related motors vehi-
cles crashes. Ward and his colleagues, for instance,
studied 1,198 trauma patients with evidence of alcohol
use and found no difference in the severity of injury
compared with those with a negative blood alcohol con-
centrations [15]. In another study, Smink and associates
also found no difference in the mean ISS scores between
drivers who test negative for alcohol, and those who do
not [16]. On the other hand, Brown et. al. found that
ISS was significantly higher for occupants of vehicles
that were operated by intoxicated drivers with a blood
alcohol concentrations of 100 mg/dl [17]. Honkanen
and his associates also found a positive correlation
between injury severity and intoxication among injured
occupants of motor vehicles [18].
The issue that emerges is whether there are outcome
differences between intoxicated drivers regardless of ISS.
Shih and his colleagues investigated 923 injured drivers
involved in motor vehicle and motorcycle crashes in
which 421 of them had BAC ≥ 50 [19]. Drivers with a
BAC ≥ 50 had a significantly higher ISS. However, after
a logistic regression analysis, a BAC ≥ 50 was not asso-
ciated with severe injury as defined by an ISS ≥ 9 or
mortality. However, alcohol intoxication (BAC ≥ 50) was
a predictor of morbidity. In the Washington State study
by Mueller, BAC > 50 mg/dL was also found to be a
predictor for morbidity [20]. Age greater than 54 years
old and BAC > 50 mg/dL did not predict mortality.
Perhaps one of the more provocative studies was per-
formed by Koval and associates. They performed a
recent retrospective study of 67,021 patients in which
Table 1 Outcome measurements of intoxicated vs. non-
intoxicated drivers
ED ≥ 220
min.
≥ 5days
ICU LOSVent days
≥ 8
Hospital LOS
> 14 days
ETOH = 025.6%*, 159/
598
22.5%, 78/346 13.5%, 49/364
19.0%*, 118/
621
10.5%*, 65/
618
5.0%, 18/361
17.8%*, 111/
623
11.5%, 42/364ETOH >
80
* - p < 0.05 vs. ETOH > 80
ED - emergency department
ICU - intensive care unit
Vent - ventilator
LOS-length of stay
ETOH = 0-blood alcohol level of 0 mg/dL
ETOH > 80
blood alcohol level > 80 mg/dL
Table 2 Post emergency department destination
ICUMedical/Surgical Unit Intermediate Care UnitORMorgue
ETOH = 0
ETOH > 80
Total
33.7%, n = 209
41.3%, n = 150
359
28.0%, n = 174
21.8%, n = 79
253
16.1%, n = 100
18.2%, n = 66
166
22.1%, n = 137
17.9%, n = 65
202
0.2%, n = 1
0.8%, n = 3
4
ICU - intensive care unit
OR - operating room
LOS- length of stay
ETOH = 0 - blood alcohol level of 0 mg/dL
ETOH > 80
blood alcohol level > 80 mg/dL
Table 3 Financial variables of intoxicated vs. non-
intoxicated drivers
Self-payCharges >
$50K
ETOH =
0416416
Costs >
$25K
25.5%, 106/
416
PMT/Charge >
0.9
28.4%*, 118/4160.7%*, 3/29.6%*, 123/
ETOH >
80
4.9%, 10/
203
20.8%, 42/202 18.1%, 38/
202
16.3%, 33/202
* - p < 0.05 vs. ETOH > 80
PMT - payment
ETOH = 0 - blood alcohol level of 0 mg/dL
ETOH > 80
blood alcohol level > 80 mg/dL
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38.3% were drivers involved in a MVC [11]. The stron-
gest predictor for mortality was ISS. Other risk factors
cited were male sex and age. Most notably, “protective
factors” included the presence of alcohol and the use of
safety devices. Other published reports also suggest that
alcohol intoxication may be protective. For example,
outcomes after MVC and isolated severe traumatic
brain injury are significantly different depending upon
the level of ETOH and not simply upon the presence or
absence of serum ETOH [21,22].
One should not necessarily infer from the data
described in our study, however, that intoxication is
protective for drivers involved in a motor vehicle crash.
This study is limited in that logistic regression analysis
was not performed. The culling of additional numerical
or categorical predictor variables to determine the prob-
ability of occurrence is certainly desirable. We believe
that a multivariable analysis to determine outcomes dif-
ferences would best be performed as a prospective study
because of the limitations inherent in a retrospective,
registry-based investigation. The prospective collection
of variables such as vehicle speed and type, daytime vs.
nighttime vehicle operation, seat belt use, airbag deploy-
ment, driver experience, and distractions (ex. number of
occupants) would also be valuable. For these reasons,
we have categorized this report as a retrospective
descriptive study. Apparent associations due to differ-
ences between groups must therefore be interpreted
with caution.
Responsibility demands a critical analysis of these
observations looking for alterative explanations that
require further investigation. For instance, there were an
increased number of admissions to the ICU and IMC
among the ETOH > 80 group despite no differences in
ISS. This contradiction could be explained if a dispro-
portionate number of intoxicated patients required
endotracheal tube intubation and a short ICU length of
stay due to binge drinking. Patient care would therefore
be driven by medical necessity and not by injury sever-
ity. The shorter ICU and hospital LOS found in the
ETOH > 80 is consistent with this line of reasoning.
This argument would suggest that some ICU and IMC
admissions among patients with an ETOH > 80 may
have been unnecessary. On the other hand, one would
have expected to find differences in injury severity score
among the two groups if this were the case. Of note,
patients with an ETOH = 0 were more likely to go to
the operating room and may have been more seriously
injured than what was captured by ISS. This might
explain why the ETOH > 80 group had fewer admis-
sions to the ICU, and a reduced incidence of prolonged
mechanical ventilation.
In our data, ED LOS was also notably shorter in the
ETOH > 80 group. The overall relationship between
LOS and alcohol intoxication is conflicting in the litera-
ture. Brotman and associates found that hospital length
of stay among trauma patients who tested positive for
alcohol was similar to those who tested negative [23]. In
contrast, Mueller found that drivers under the influence
of alcohol had longer hospital stays after adjusting for
age, gender, and injury severity [20].
We also observed that the ETOH > 80 group was
more likely to be self-pay, more likely to be admitted to
the ICU and IMC, and less likely to pay for the charges
associated with their medical care. Our trauma center is
therefore less likely to recover operating costs when car-
ing for intoxicated drivers. If these findings are consis-
tent at other institutions, then the additional services
rendered may represent another financial burden for
trauma centers, especially those that are already finan-
cially troubled. Of note, Mueller and colleagues has
already shown that hospital charges in Washington
State were greater for drinking drivers when compared
to nondrinking divers [20].
There are several other limitations of this study. It is a
retrospective study and contains some missing data ele-
ments that are inherent to trauma registries in general.
There is also a possibility that patients with a BAC = 0
are less likely to be admitted to the hospital than intoxi-
cated patients. This would result in a relatively greater
resource utilization among patients with an ETOH > 80.
In addition, patients who are discharged directly from
the ED are not considered state qualifiers for inclusion
in the registry. This may have an impact on ISS between
groups, especially if BAC = 0 patients are disproportio-
nately discharged. In addition, because only those
Table 4 Most common discharge destinations
HomeRehabilitation Center Skilled Nursing Facility Legal AuthorityAMA Hospital TransferPsychiatric
Facility
ETOH = 0
ETOH > 80
Total
65.6%, n = 395
76.5%, n = 264
659
25.6%, n = 154
15.7%, n = 54
208
5.2%, n = 31
1.5%, n = 5
36
0.2%, n = 1
2.0%, n = 7
8
0.5%, n = 3
1.5%, n = 5
8
1.0%, n = 6
0.3%, n = 1
7
0.2%, n = 1
1.5%, n = 5
6
AMA - against medical advice
ETOH = 0 - blood alcohol level of 0 mg/dL
ETOH > 80
blood alcohol level > 80 mg/dL
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patients that were considered registry qualifiers in our
state were included, we do not know the actual number
of patients that may have been treated and released,
with or without a trauma evaluation. Therefore, we do
not know the actual ICU days per patient for either
group. Furthermore, alcohol screening was not manda-
tory for all drivers and might introduce a selection bias
into the methodology. Finally, since this is a single cen-
ter study, our findings may not necessarily reflect those
seen at other trauma centers.
Further research is needed in this area. For instance,
population-based studies that investigate the outcomes
of all drivers in a region, including those dead at the
scene, would be valuable. Investigations may also be
conducted that carefully control for injury mechanism,
such as speed, impact location, type of vehicle, and seat
belt/air bag protection. Future studies should also con-
sider selecting a primary outcome parameter of interest.
For example, propensity scores could be developed and
used to predict the need for intubation and prolonged
mechanical ventilation based on age, gender, ISS, abbre-
viated injury score for the head, Glasgow Coma Score,
admission blood pressure and arterial pO2(or oxygen
saturation), and the presence or absence of rib fractures.
Intoxicated patients could then be case-matched with
unintoxicated patients having similar propensity scores
and assessed for the incidence of intubation and pro-
longed mechanical ventilation. The sample size needed
for such a study is probably too small to be conducted
at any single institution.
Conclusions
Drivers of motor vehicle crashes with a BAC > 80 mg/
dL who presented at our trauma center were observed
to have better outcomes compared with drivers having
no evidence of alcohol use. Intoxicated drivers were
described as having lower ICU admission rates, hospital
and ICU length of stay, ventilator days, and inpatient
charges. Those drivers were also more likely to be dis-
charge to home. The appearance of improved outcomes
in intoxicated drivers may have been driven by acute
intoxication, and the tendency for endotracheal intuba-
tion and ICU admission, rather than injury severity.
Further studies are needed to corroborate these observa-
tions at other trauma centers.
Additional note
The authors are pleased that an invited editorial by Dr.
Uli Schmucker [24] has been included with this article.
Many of his remarks have been considered during the
course of our clinical investigation. We agree with his
assessment that further research is needed to determine
if acute alcohol intoxication has an impact on trauma
outcomes.
Acknowledgements
Poster presentation at Sixty-Seventh Annual Meeting of the American
Association for the Surgery of Trauma in Maui, Hawaii, September 24-27,
2008.
Author details
1Penn State Milton S. Hershey Medical Center, Department of Surgery, Shock
Trauma Center, Hershey, Pennsylvania 17033, USA.2Penn State Milton S.
Hershey Medical Center, Public Health Sciences, Hershey, Pennsylvania
17033, USA.
Authors’ information
RAC: Study concept and design. RAC, PAN, TMS: Acquisition of data. RAC,
DTM, LJC: Analysis and interpretation of data. RAC: Drafting of the
manuscript. RAC, PAN, TMS, LJC: Critical revision of the manuscript for
important intellectual content. DTM, LJC: Statistical analysis. RAC, PAN, TMS:
Administrative, technical, and material support. All authors have read and
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 28 December 2009 Accepted: 5 August 2010
Published: 5 August 2010
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