Protocol for discharge to Community Alcohol Detoxification Name……………………………………………….. UR no……….………….…………………………… AFFIX ID LABEL Patients requesting an admission purely for an Alcohol Detoxification should be directed to community Services via their G.P. and not admitted unless medically unwell. Guidelines for doctors to the correct procedure in organising a tail-end detoxification in the community for patients who have completed a number of days of the detoxification regime as an inpatient. Please involve the Alcohol Liaison Team at as early a stage as possible – Fax Referral Form (Pg.5) to 6748. Patient Inclusion Criteria 1 2 3 Alcohol dependent individuals requiring medication to safely stop alcohol use. Patient expressing wish to abstain from alcohol. Patient medically fit for discharge and has completed 3 days of detoxification in hospital setting. 4 5 NO history of delirium tremens on this admission. 6 Patient willing to engage in Alcohol Liaison Team follow up as out-patient. 1 2 YES Initials NO significant acute medical/mental health problems. Procedure Assess patient inclusion criteria. YES Initials Does the patient want to continue the detox and willing to engage in support? Yes No If “Yes” go to point 3. If “No” discharge patient with no detox medication and advise to keep drinking at a steady level. Advise pt to see own G.P. if wishes to detox in future. 3 Complete with patient the “Patient Contract and consent Form” information sheet (On page 3 of this protocol). Write down the patients Regime on Page 4 (“Your Medication Regime”) and give this page to the patient. 4 Clinician completes a TTO prescription for the remaining days of detoxification. On the Hospital’s IDS system select the order set "Medicine- Chlordiazepoxide discharge regime”. This IDS set will include 7 days of Thiamine 50mg QDS and Vitamin B Co Strong 2 BD. 5 Fax G.P Letter notifying the management plan upon discharge. 6 Mon – Fri 9-5: Inform Alcohol Liaison Team on Bleep 552 or Tel 6572 to arrange Outpatient appointment with Alcohol Liaison Nurse. Out Of Hours: Inform Alcohol Liaison Team (6572) leaving patient’s name and telephone number and give patient information leaflet. (N.B. If patient is unwilling to commit to follow up post discharge question patient’s motivation to stop drinking.) A Whitfield/J Plumley Feb. 2010 1 ALCOHOL WITHDRAWAL REGIME Name……………………………………………….. UR no……….………….…………………………… AFFIX ID LABEL A TTO can only be dispensed following completion of Day 3 Day Chlordiazepoxide dosage 1 20mg qds (Inpatient) 2 20mg qds (Inpatient) 3 20mg qds (Inpatient) 4 15mg qds 5 10mg qds 6 5mg qds 7 Plus Chlordiazepoxide 20mg PRN, max 140mg daily. Halve doses for elderly. If withdrawal symptoms severe or past history of withdrawal fits, consider higher starting dose e.g. 30mg or 40mg qds and suitability for community detox If withdrawal seizures occur, give Diazepam PR or IV Parenteral B vitamins: - consider in coma/delirium from alcohol withdrawal - Pabrinex 2 pairs every 8 hours for 3 days if incipient or established Wernicke’s*; 1 pair once daily for 3 days if high risk without Wernicke’s* Thiamine: 50mg qds po Vitamin B complex: 2 tablets bd po for 10 days 5mg bd * PATIENTS AT RISK OF WERNICKE’S INCLUDE those with significant weight loss, poor diet, peripheral neuropathy, severe withdrawals or past history of severe withdrawals. * WERNICKE’S IS CHARACTERISED IN 80% OF CASES BY CONFUSION ONLY - do not wait for full syndrome i.e. ataxia, opthalmaplegia & confusion Example Mr Green is admitted to UHSM following a seizure following abruptly stopping his alcohol consumption. He does not experience any delirium tremens and is deemed medically fit for discharge on Day four (March 22nd) of his detoxification on Chlordiazepoxide. The patient wishes to complete the detox and appears motivated to remain abstinent from alcohol upon discharge. The clinician needs to write a day by day TTO prescription as follows: Drug Dose Route Chlordiazepoxide 5mg Capsules Chlordiazepoxide 5mg Capsules Chlordiazepoxide 5mg Capsules Chlordiazepoxide 5mg Capsules 15mg Oral 10mg Oral 5mg Oral 5mg Oral Frequency Days Supply FOUR 1 times daily FOUR 1 times daily FOUR 1 times daily TWO times 1 daily GP to continue No Pharmacy No No No Mr Green’s other medication (including Thiamine and Vitamin B Co Strong) are also written on the TTO. An Appointment is made to see the Alcohol Liaison Nurse on 23rd March in the Emergency Department which Mr Green agrees to attend. A G.P. letter is faxed detailing the treatment plan. A Whitfield/J Plumley Feb. 2010 2 Tail-End Detoxification Patient Contract and Consent Form Name……………………………………………….. UR no……….………….…………………………… Patient to read and sign this form: AFFIX ID LABEL 1. You (The Patient) agree to complete your detoxification in the community 2. The detoxification procedure has been explained to you Please tick if you understand the following: The physical and psychological aspects of alcohol withdrawal, severity, duration and intensity of symptoms. The approaches to managing alcohol withdrawal symptoms e.g. good fluid intake, small regular meals, sleep, hygiene etc. The pharmacological aspects of detoxification including effects, side effects, cautions and contradictions of medications used. The dangers of continuing alcohol use during the detoxification and its interaction with medication used. The risks associated with using other drugs of abuse e.g. opiates, benzodiazepines during withdrawal and during subsequent sobriety. The importance of continued psychological/ pharmacological interventions to maintain abstinence from alcohol. 3. You agree to the following conditions: o You will not drink alcohol during the agreed period of detoxification. o You will take all medication as prescribed and agreed with you, your doctor and the Alcohol Team. o You will make a follow-up appointment with relevant community services to support you during and after your detoxification to ensure ongoing sobriety. My appointment is with ___________________________________________ On ______________ At __________________________________________ Signed (patient) _________________________ Date __________________ Signed (Health Care Professional) __________________ Date ___________ A Whitfield/J Plumley Feb. 2010 3 Please write the Librium Prescription on this page for the patient to take home with them. Name……………………………………………….. UR no……….………….…………………………… AFFIX ID LABEL Standard Tail-End Detoxification Medication Regime Name of Capsules: Chlordiazepoxide (Librium) 5mg Day 1 Morning 20mg Lunch 20mg Tea 20mg Bedtime 20mg 2 20mg 20mg 20mg 20mg 3 20mg 20mg 20mg 20mg 4 15mg 15mg 15mg 15mg 5 10mg 10mg 10mg 10mg 6 5mg 5mg 5mg 5mg 7 5mg Nil Nil 5mg Total 74 capsules Your Medication Regime Name of Capsules: Chlordiazepoxide (Librium) 5mg Day/ Date 1(In Hospital) Morning Lunch Tea Bedtime 2(In Hospital) 3(In Hospital) 4 5 6 7 Total A Whitfield/J Plumley Feb. 2010 4 Alcohol Liaison Team Care Facilitator Referral Form Patient’s name: D.O.B: Ethnicity: Date of admission: Address: Date of referral: Gender: Consent given? Postcode: M Y F N Phone number: Referral Source (Ward and Name): Presenting problem: Expected length of stay: GP Details: Please Fax to 6748 A Whitfield/J Plumley Feb. 2010 5