Dr Karen Williams Consultant General and Addiction Psychiatrist, Mental Health Liaison Team 2gether NHS Trust

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1 Detox in the General Hospital: challenges and opportunities Dr Karen Williams Consultant General and Addiction Psychiatrist, Mental Health Liaison Team 2gether NHS Trust

2 Alcohol detox regimes Clomethiazole drips Clomethiazole tablets Carbamazapine only detoxes Chlordiazepoxide plus Carbamazapine Chlordiazepoxide only detoxes Symptom led detoxes Those using SADQ, readiness and APQ Not forgetting the Pabrinex/Parenterovite and thiamine

3 Who gets Detoxed? In clinical need with co-morbid physical health problems Those who are prepared and are motivated to change To uncover co-morbid mental health problems In a planned way, in appropriate environment, those committed to change Those who would be dangerous to discharge Vulnerable adults and under 16s People who ask for detox

4 Current detox job: the setting Gloucestershire Hospitals NHS Foundation Trust 2 hospitals, 8 miles apart Approx 1000 beds and 50 wards 2100 registered nurses and 800 doctors (NB turnover!) planned and emergency admissions 2012/3 2.5 gastro-enterology wards 2 Eds and 2 acute admissions units 2WTE Alcohol liaison nurses, 1 alcohol worker?how many guidelines, protocols and procedures

5 The demand: 2012/13 figures alcohol related admissions (allegedly reduced from ) in ED attendances at outpatients 256 deaths (Current Alcohol liaison team referrals: 38 inpatient and 18 outpatient referrals per month)

6 The situation in WTE alcohol liaison nurses recruited in March WTE alcohol worker Some input from part-time MHLT doctor Hospital Alcohol detoxification guidelines introduced and rewritten since 2002 F1 and F2 education Some enthusiastic specialists eg liver specialist nurse, gastroenterologists, addiction psychiatrists

7 The gastroenterology audit Poor detection of alcohol problems: AUDIT Poor assessment/history taking CIWA not being used Inappropriate random detox doses Long stays Low referral rate to ALT/aftercare WKS being missed, random pabrinex doses Low motivation to change

8 NICE CG 100 Published June 2010 Due for revision in 2015 People with or assessed at risk of DT/seizures offer admission Advice on under 16 s and vulnerable adults Advice on medication Symptom triggered detox regime

9 In summary A small band of professionals knew how to detoxify people There were an awful lot of health professionals who didn t/wouldn t There were a lot of alcohol related admissions, many of which were not being managed well The hospital was not compliant with NICE CG 100 nor indeed its local guidelines We thought things needed to change

10 Implementing the symptom led detox Multidisciplinary meeting: Gastroenterologist, pharmacist, alcohol liaison nurse, alcohol specialists Updated the detox Policy; introduce symptom led detox for first 24 hours, followed by a reduction regime based on need, use of CIWA. All incorporated in a detox booklet Introduction of action cards for people who don t read guidelines

11 EDUCATION, EDUCATION, EDUCATION!! Pharmacist and ALT nurse led sessions on wards Alcohol awareness days in both Post Grad centres Much work by ALT nurses targeted at ACU, ED and gastroenterology wards F1, F2, CTs in medicine and Emergency medicine, nurses, pharmacists

12 Problems The alcohol detox booklets were not ordered No-one told the doctors where the booklets were The old regime was used instead The nurses and doctors got confused by paperwork and using the prescriptions Some people just rebelled.. Don t expect anyone to read NICE Guidelines The Chlordiazepoxide supply ran out

13 But.success with Proper Pabrinex regimes Less violence and aggression on the ACUAs Shorter stay Less chlordiazepoxide medication used. Less complications: DTs, fits and WKS Even the surgeons started using it! Added benefit of accommodation worker for the homeless

14 Next steps Alcohol booklet with diazepam and chlordiazepoxide version Hopefully as idiot proof as possible with even more prompts Re-audit of regimes More education especially about the medication uses and reduction in aggression and lengths of stay

15 Top tips Get a committed Gastroenterologist on board and get the support of the ward managers and sisters Make friends with the pharmacists Have enthusiastic and confident ALT nurses who can educate Provide education on the wards and units not just the classrooms Use your ALT nurses to support and monitor staff Make your paperwork as idiot proof as possible Provide feedback to wards on length of stay, drug usage, security staff