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Alcohol detoxification policy Doncaster inpatients

Contents

  1. Introduction
  2. Purpose
  3. Scope
  4. Responsibilities, accountabilities and duties
  5. Understanding alcohol dependence
  6. Criteria for inpatient detoxification
  7. Procedure and implementation
  8. Training implication
  9. Monitoring arrangements
  10. Equality impact assessment screening
  11. Associated documents
  12. References
  13. Appendices

1 Introduction

Withdrawal symptoms occur when a person who is physically dependent on alcohol stops drinking or reduces their alcohol consumption.

Alcohol detoxification is a treatment provided to help control the physical and psychological symptoms that occur during the alcohol withdrawal process. Depending on the severity of withdrawals symptoms detoxification usually takes seven to 10 days.

2 Purpose

The purpose of this document is to set out the protocol that should be followed to ensure alcohol detoxification occurs safely and effectively.

3 Scope

This document is primarily intended for staff within New Beginnings inpatient drug and alcohol unit. Only staff with appropriate training and skills should be providing care to patients requiring an inpatient detoxification.

4 Responsibilities, accountabilities and duties

4.1 Service managers and modern matrons

  • Disseminate, implement and monitor implementation of the policy within areas of responsibility.
  • Facilitate, support and monitor staff in their responsibilities with regard to policy implementation and monitoring.
  • Identify and allocate resources in order to comply with this policy.
  • Make available appropriate and suitably maintained equipment, maintaining up to date medical devices inventories in all areas.
  • Promote incident reporting and audit requirements as specified within trust policies.
  • Facilitate an environment where incidents are reviewed in an open and positive manner, involving staff at all levels in improving practice and promoting organisational.
  • Report any issues, which may affect implementation to the attention of their assistant director.

4.2 Ward managers or team leaders

  • Facilitate effective local induction processes for all new starters.
  • Manage the process of releasing staff for training and updating at least annually in the skills relevant for their area, in line with the mandatory risk management training policy.
  • Maintain staff training records for the area, including temporary, bank and agency staff.
  • Proactively identify risks due to lack of training or resources to the manager, modern matron and service manager.

4.3 Clinical staff

  • Implement the protocol.
  • Report any issues which affect the effective implementation of this policy to their manager, for example, access to training or equipment.
  • Report all incidents as per the incident reporting.
  • Maintain a personal record of their own training.
  • Contribute to the review of incidents in an open and positive manner in order to improve practice and promote organisational learning.

4.4 Prescribers (medical staff or non-medical prescribers)

  • Comprehensive assessment of the client to ensure suitability for detoxification.
  • Assessment of the pharmacological requirements for detoxification.
  • Being available to provide advice.

Understanding alcohol dependence

5.1 Alcohol withdrawal syndrome

5.1.1 Symptoms of alcohol withdrawal

Common:

  • sweating
  • tachycardia
  • anxiety, agitation
  • nausea, vomiting
  • diarrhoea
  • tremor
  • insomnia
  • hallucinations in clear
  • consciousness

Less Common:

  • arrhythmias
  • hypertension

Severe withdrawals

  • seizures
  • delirium tremens

40% of individuals will develop an acute withdrawal syndrome upon stopping or significantly curtailing alcohol intake. The risk of withdrawal is not directly related to intake. Symptoms are seen within hours (typically 6 to 8) of the last drink and may develop before the blood alcohol level has fallen to zero. Symptoms outlined below may vary in severity, commonly peaking at 10 to 30 hours and usually subsiding by 40 to 50.

5.2 Withdrawal fits

Withdrawal fits can occur at 12 to 48 hours and are more likely if there is a previous history of withdrawal fits or epilepsy. Fits tend to be generalised tonic clonic (if focal, suspect other causes for example, head injury) and may occur in bouts. In 30% of cases, fits are followed by delirium tremens.

5.3 Severe withdrawal or delirium tremens (DT)

Severe withdrawal or delirium tremens usually develop after 72 hours but can be sooner. Clinical features include; marked tremor, confusion, disorientation, agitation, restlessness, fearfulness, visual and auditory hallucinations, delusions, autonomic disturbances, tachycardia, sweating, fever and dehydration. Risk factors include severe dependence, previous history of DT’s, older age, coexisting medical conditions such as infection.

5.4 Wernicke’s encephalopathy

Wernicke’s encephalopathy is a potentially fatal consequence of alcohol dependence. A presumptive diagnosis of Wernicke’s should be made in any patient detoxifying and experiencing any of the following:

  • confusion and apathy
  • drowsiness
  • coma or unconsciousness
  • hypothermia and hypotension
  • abnormal eye movements that may seem like a squint
  • double vision
  • poor balance
  • memory disturbance

Wernicke’s is a medical emergency and patients should be transferred for treatment to general hospital.

6 Criteria for inpatient detoxification

The majority of patients with alcohol dependence, including those with withdrawal symptoms, can be managed in the community but inpatient detoxification is usually required if the person:

  • is severely dependent on alcohol
  • is currently having (or has had ) severe withdrawal symptoms such as delirium tremens (DTs) or seizures
  • has significant co-morbid substance dependence
  • suffers with a serious medical or psychiatric co-morbid condition, liver dysfunction
  • is at risk of suicide or homicide
  • lacks social support or supervision in the community
  • has a history of failed community detoxifications
  • has significant cognitive impairment

7 Procedure and implementation

7.1 Assessment

Careful assessment of the patient is required to ensure safe and effective management. Assessment is important in establishing the safest place for the patient to complete an alcohol detoxification. If there are serious concerns about patients’ physical heath then alternative provision may need to be made such as through the general hospital.

The purpose of alcohol detoxification is to control withdrawals whilst avoiding side effects and to support the patient to successfully complete this treatment.

Assessment must include:

  • alcohol use by:
    • number of units
    • breathalyser reading(s)
    • severity of alcohol dependence questionnaire (SADQ) (appendix A)
    • past history of seizures and delirium tremens
    • withdrawal symptoms
  • mental health
  • social circumstances
  • physical health, physical health examination must be completed for inpatient admissions. This includes:
    • current and past
    • blood tests including full blood count, urea and electrolytes, liver function tests, clotting (International normalised ratio, INR)
    • a full set of baseline physical and neurological observations documented on the trust charts
    • examination of cardiovascular, neurological and gastrointestinal and respiratory systems

Please refer to policy and appendix B minimum standards for the physical assessment and examination of inpatient in mental health and learning disabilities services.

Plan following detoxification including relapse prevention. If not already engaging with drug and alcohol services please consider referral.

7.2 Pharmacological management of alcohol detoxification

Benzodiazepines are the treatment of choice in the management of alcohol withdrawal.

Dosage should be individually titrated and will depend on severity of dependence, withdrawal severity, gender, body mass index (BMI), general health and liver function.

Chlordiazepoxide is the drug of choice as it has a long half-life, slow absorption and lower abuse potential. Alternatively if chlordiazepoxide is unavailable diazepam may be used. For example for a 30mg chlordiazepoxide starting regime use 10mg starting dose regime; for 40mg to 50mg chlordiazepoxide regime use 15 to 20mg diazepam regime.

Special caution is necessary in the case of older people, severe liver impairment (for example, cirrhosis) as the metabolism of benzodiazepines may be reduced and lead to over-sedation. Lorazepam or oxazepam may be suitable alternatives to diazepam or chlordiazepoxide if there are concerns especially if signs of liver dysfunction or failure.

Extra medication (referred to as PRN (as needed medication)) will be prescribed routinely. This allows for extra medication to be administered if required. Usually this will be prescribed as doses of 5 to 10mg of chlordiazepoxide with an additional maximum 40mg to 60mg in 24 hours. A clinical institute withdrawal assessment of alcohol (CIWA, revised version is CIWA-Ar) must be completed prior to administering PRN medication. The reason for administering the medication must be written in the patients notes

7.3 Monitoring

7.3.1 Starting the detoxification

  • Patients should be breathalysed and the first dose of the benzodiazepine given if there are signs of withdrawals or serial readings show a falling alcohol concentration and there is no evidence of alcohol intoxication.
  • A high breathalyser reading with no signs of intoxication may indicate a high level of tolerance. In this situation treatment will be necessary when there are signs of withdrawals. Failure to do so will result in withdrawals becoming severe quickly.
  • Observations should be completed which includes:
7.3.1.1 Routine observations
  • pulse
  • blood pressure
  • respiratory rate
  • oxygen saturations
  • temperature
  • neurological observations on admission
  • physical observations will be carried out twice a day for the first three days then once a day during the detoxification

Following this, physical observations will be continued if there any concerns. These observations should be recorded on the trust documentation and always calculated using the early warning score. The early warning score is an escalation tool used to alert clinical staff to the need to contact a doctor, or emergency services, for patients who give cause for concern due to a sudden or deteriorating illness. Please refer to appendix C and policy, resuscitation manual.

Patients should be orientated and reassured that any distressing symptoms will eventually settle. An explanation of the symptoms and their relationship to alcohol withdrawals should be given.

Patients will be reviewed daily by nursing staff. During the first two days the patient will be reviewed by medical staff to ensure the detoxification regime is correct.

Staff to also to monitor for potential signs of Wernicke’s (see below for signs and symptoms.

7.3.1.2 Assessment of alcohol scale
  • The CIWA-Ar will be used to monitor withdrawal symptoms. See appendix D.
  • The CIWA-Ar measures 10 items with a maximum score of 67. A CIWA-Ar score of, 10 indicates mild withdrawal, 10 to 20 moderate and more than 20, severe.
  • This will be completed twice a day during the first three days. If scores continues to be high (for example, 15 and above) then the CIWA- Ar should be repeated until the score reduces (to below 10).
  • If the CIWA-Ar remains high, please contact medical staff or the prescriber for advice.
  • A score above 15 indicates a risk of severe alcohol withdrawals. The regime should be reviewed using clinical judgement. Consider changing the medication as below.
  • A one off extra dose of Chlordiazepoxide may be required (between 10mg to 20mg or is CIWA-Ar is high then use of PRN indicated.
  • The medication regime increased by 50% (for example 30mg instead of 20mg of Chlordiazepoxide), with a maximum of 40mg in a single dose.
  • The regime may need altering to slow down the rate of reduction (for example, repeat the previous day’s regime).

7.4 Vitamin supplements

Alcohol dependence can lead to poor diet and impaired absorption resulting in vitamin deficiencies. Oral thiamine is poorly absorbed in alcohol dependent patients.

For the majority of patients identified as requiring an inpatient detoxification prophylactic treatment with parental thiamine (Pabrinex) is routinely recommended for those patients with a high risk of developing thiamine deficiency for example, those with severe alcohol dependence, history of seizures or delirium tremens, diarrhoea, vomiting, physical illness, malnourished, poor diet and weight loss.

In the UK, Pabrinex is the only parenteral high potency B-complex vitamin therapy available. Two ampoules contain thiamine hydrochloride 250mg in combination with ascorbic acid 500mg, nicotinamide 160mg, pyridoxine hydrochloride 50mg and riboflavin 4mg.

Administer one pair of Pabrinex ampoules (thiamine 250mg) once daily intra-muscularly for the first three days of the detoxification. Pabrinex is administered only by trained nursing staff.

Please refer to the standard operating procedure for the administration of the high dose intra muscular vitamin supplement.

7.4.1 Oral vitamin prophylaxis

Oral vitamins are sufficient for patients with a lower risk of developing complications. This group include mild alcohol dependence (patients who could be detoxed at home for example), no weight loss, good diet. Thiamine 100mg three times daily is prescribed during the detoxification. Consider recommending to the general practitioner (GP) continuation of thiamine 50mg long term if there is evidence of cognitive problems.

7.4.2 Treatment of suspected or diagnosed Wernicke’s encephalopathy

Wernicke’s encephalopathy is a medical emergency. If suspected an assessment of the client must be made immediately to consider transfer to a medical ward. As well as examining the client for Wernicke’s an assessment should include possibilities of co morbid physical health problems for example, infection, dehydration, head injury and so on.

7.4.3 Risk of anaphylaxis with Pabrinex

This should not preclude the use of parenteral thiamine in patients where this route of administration is required, particularly those at risk of Wernicke’s where treatment with thiamine is essential.

Facilities for treating treatment for anaphylaxis Is available in all inpatient areas including adrenaline, oxygen and resuscitation equipment.

The risk of anaphylaxis is very low and even less when given intramuscular injection (IM). The cases documented actually occurred for Parentrovite, which Pabrinex replaced. Four reports were documented for 1million pairs of ampoules used Intravenous (IV) and one report per 5 million pairs of ampoules when used IM.

7.4.4 Alcohol related seizures

Most seizures are self-limiting. With careful assessment and monitoring withdrawal seizures can be avoided when detoxifications are planned adequately.

NICE guidance recommends IV lorazepam first line. Mental health wards cannot support the use of IV medicines. NICE guidance recommends the use of buccal midazolam or rectal diazepam in a community setting.

NICE guidance recommends treatment of prolonged seizures (seizures lasting more than 5 minutes).

During the seizure, monitor and maintain the airway as best possible. If the patient is in the convulsive phase of the seizure, and the airway is not compromised the seizure should be left to run its course. Monitor patient and maintain a safe environment at all times.

If the seizure lasts more than 5 minutes administer Buccal Midazolam 10mg (or 10mg Rectal Diazepam) as prescribed. Repeat after 10 minutes if the seizure continues

In the recovery phase of a seizure the patient may be placed in the recovery position where the patient’s physical observations should be taken using the airway, breathing, circulation, disability, exposure (ABCDE) approach.

If the patient does not recover as expected, or there are concerns with the physical observations call an ambulance via (9)999. If the patient recovers well and physical observations raise no concerns the patient should be discussed with medical staff as soon as possible.

8 Training implications

8.1 All

  • How often should this be undertaken: On induction to unit.
  • Length of training: Varies.
  • Delivery method: Face to face.
  • Training delivered by whom: Supervisor.
  • Where are the records of attendance held: Electronic staff record (ESR).

A variety of means such as:

  • team brief
  • weekly newsletter
  • trust wide mail drop
  • trust wide email
  • team meetings
  • special meetings
  • one to one meeting or supervision
  • group supervision
  • posters
  • practice development days
  • CPD sessions
  • local induction

The training needs analysis (TNA) for this policy can be found in the training needs

Analysis document which is part of the trust’s mandatory risk management training policy located under policy section of the trust website

All staff using this policy will receive training on induction to the unit by their supervisor and line manager. Training will involve the assessment and management of alcohol detoxifications as per this policy. Staff will receive ongoing training and support through supervision, clinical meetings and when reviewing incidents.

Staff will also be made aware of the policy and its contents in the following ways:

  • dissemination of policy to all staff through service manager, line managers and supervisors
  • policy contents to be covered during local induction for new staff members
  • issuing of the policy to be an agenda item on staff meetings
  • a copy of the policy will be available for staff to view on the trust web site

9 Monitoring arrangements

9.1 Evidence of dissemination of policy

  • How: Minutes of clinical meetings.
  • Who by: Service managers.
  • Reported to: Care group director.
  • Frequency: Once

7.2 Implementation of policy by staff

  • How: Clinical audit.
  • Who by: Business division using this policy.
  • Reported to: Clinical effectiveness committee.
  • Frequency: Yearly

10 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

10.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

10.1.1 Indicate how this will be met

No issues have been identified in relation to this policy.

10.2 Mental capacity act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

10.2.1 Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act 2005 (section 1).

12 References

13 Appendices

13.1 Appendix A Severity of alcohol dependence questionnaire

13.2 Appendix B Physical health examination template

13.3 Appendix C Early warning score

13.3 Appendix d Clinical institute withdrawal assessment of alcohol scale, revised (CIWA-Ar)

Document control

  • Version: 2.
  • Unique reference number: 102.
  • Ratified by: Clinical policies review and approval group.
  • Date ratified: 6 October 2020.
  • Name of originator or author: Consultant psychiatrist.
  • Name of responsible individual: Executive medical director.
  • Date issued: 27 November 2020.
  • Review date: October 2023.
  • Target audience: All managers with responsibilities derived from
    the policy and all clinical staff with direct service user contact.
  • Description of changes: Minor changes to practices including dose ranges, observations and structure.

Page last reviewed: April 30, 2024
Next review due: April 30, 2025

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