GUIDELINES FOR DETOXIFICATION TRIAGE USING THE 48 HOUR OBSERVATION BED ALGORITHM. Steven Kipnis, MD, FACP, FASAM Medical Director, NYS OASAS

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1 GUIDELINES FOR DETOXIFICATION TRIAGE USING THE 48 HOUR OBSERVATION BED ALGORITHM Steven Kipnis, MD, FACP, FASAM Medical Directr, NYS OASAS 1

2 Definitin Detxificatin is defined as: A medical regimen Cnducted under the supervisin f a physician t systematically reduce the amunt f the addictive substance in a patient s bdy There shall be a physician, nurse practitiner and/r physician's assistant under the supervisin f a physician, n staff sufficient hurs t perfrm the initial medical examinatin f all patients and t prescribe any and all necessary pharmaclgical medicatins necessary t secure safe withdrawal. Prvide reasnable cntrl f active withdrawal symptms and/r avert life threatening medical crisis related t the addictive substance. 2

3 Substances that Require Detxificatin Include: Ethyl alchl Opiates (herin, cdeine, methadne, etc) Sedative Hypntics (barbiturates, benzdiazapines, etc) Cannabinids (marijuana, hash, etc)* Stimulants (ccaine, amphetamines, etc)* Hallucingens (LSD, PCP, etc)* Armatic Petr-chemical inhalants* *require alchl, piates r sedatives t be present fr cnsideratin f admissin as the withdrawal des nt require this level f medical interventin. 3

4 Principles f Detxificatin: Detxificatin alne is rarely adequate treatment fr AOD dependencies. When using medicatin regimens r ther detxificatin prcedures, clinicians shuld use nly prtcls f established safety and efficacy. Clinicians must advise patients when prcedures are used that have nt been established as safe and effective. During detxificatin, prviders shuld cntrl patients' access t medicatin t the greatest extent pssible. Initiatin f withdrawal shuld be individualized. 4

5 Principles f Detxificatin: Whenever pssible, clinicians shuld substitute a lngacting medicatin fr shrt-acting drugs f addictin. The intensity f withdrawal cannt always be predicted accurately. Every means pssible shuld be used t amelirate the patient's signs and symptms f AOD withdrawal. Discharge planning shuld start at the time f admissin. The medical team is respnsible fr a minimum f ne nte per day and shuld clearly delineate the state f the patient, the prgress that the patient is shwing and future medical plans. 5

6 Principles f Detxificatin: Patients shuld begin participating as sn as pssible in fllw-up supprt therapy such as peer grup therapy, family therapy, individual cunseling r therapy, 12-step recvery meetings and AOD recvery educatinal prgrams. 6

7 Detxificatin Tday 7

8 Detxificatin (Crisis) Services in New Yrk A. Medically Managed Detx: Services ffered in acute inpatient hspital settings t patients requiring the mst intensive level f service. Fr patients with medical r psychiatric cmplicatins. B. Medically Supervised Withdrawal Inpatient: Services ffered in an inpatient r residential setting t thse requiring 24 hur supervisin/supprt. C. Medically Supervised Withdrawal - Outpatient: General detxificatin ffered in an utpatient setting t thse with stable scial supprt. D. Medically Mnitred Withdrawal : Detx fr patients in mild withdrawal r situatinal crisis in residential setting. N Medicaid reimbursement. 8

9 Detxificatin Prviders in New Yrk (Fee fr Service Medicaid) SFY 2004/2005 SFY 2005/2006 Service Categry # f Prviders Ttal Medicaid # f Prviders Ttal Medicaid Medically Managed Detx (Hspital DRG Detx) 200 $318,345, $327,999,448 Medically Supervised Withdrawal - Inpatient (nn-hspital) 10 $21,673, $22,454,193 Medically Supervised Withdrawal - Outpatient (Hspital) 3 $354,076 1 $7,369 Medically Supervised Withdrawal - Outpatient (nn- Hspital) 4 $92,788 4 $372,898 Ttal 217 $340,465, $350,833,908 9

10 Detxificatin Tday 10

11 NYS Detx Facts: 85% f Detx in NYS is dne in Hspitals Nte: Other states use hspital-based detx primarily fr medically r psychiatrically cmplicated cases. 60% - 80% f detx cases in NYS hspitals are billed t Medicaid as uncmplicated cases 80% f all hspital cases are nt linked t fllw-up treatment 44% f all hspital detx Medicaid cases end up back in detx 11

12 The Opiate Patient Prblem A significant percentage f the peple wh present fr hspitalbased detxificatin in New Yrk State are diagnsed as requiring uncmplicated piate detxificatin. Many f these individuals receive multiple detx episdes withut cnnecting with apprpriate pst-detxificatin treatment. The majrity f individuals wh receive piate detxificatin services in hspitals relapse t the use f illicit piates rather quickly. Gruber et al, Drug Alchl Depend 2008;94(1-3): mnth methadne maintenance with cunseling was mre effective than 21 day methadne detxificatin in reducing herin and alchl use. When a lng-term piate addicted patient relapses and uses illicit piates after a detx episde, he/she is at increased risk fr accidental verdse death, since the detx experience can reduce the individual s piate tlerance. 12

13 Detxificatin Tmrrw 13

14 The Right: Service Setting Linkage 14

15 Principles f Detxificatin Refrm Patient Centered Integrate Best Practices Develp and Supprt Linkages Services are Adequately and Apprpriately Funded Cllabratin and Cperatin amng Stakehlders 15

16 Observatin Bed A unit f service bed which prvides intensive assessment and treatment f withdrawal where the patient has cntinuus evaluatin fr up t 48 hurs. At 24 and 48 hurs, determinatins are made as t the indicated level f care and the patient culd be transferred t a lwer level. The care given in the bservatin bed is equal t the medically managed level f care. 16

17 Medically Managed Withdrawal and Stabilizatin Services are designed fr patients wh are acutely ill frm alchl-related and/r substance-related addictins r dependence, including the need fr medical management f persns with severe withdrawal r risk f severe withdrawal symptms, and may include individuals with r at risk f acute physical r psychiatric c-mrbid cnditin. This level f care includes the 48 hur bservatin bed. 17

18 Medically Supervised Withdrawal and Stabilizatin Inpatient Medically supervised inpatient services are apprpriate fr persns wh are intxicated by alchl and/r substances, wh are suffering frm mild t mderate withdrawal, cupled with situatinal crisis and have nt experienced withdrawal cmplicatins in the past. Patients wh have stabilized in a medically managed detxificatin service shuld be cnsidered fr medically supervised inpatient r utpatient services. 18

19 FORMULATION OF NEW GUIDELINES St. Luke s Rsevelt mdel IPRO mdels ASAM Patient Placement Criteria OASAS Medical Advisry Panel Outpatient Detx prviders OASAS Internal Wrkgrup 19

20 Old Way The patient cmes int the emergency rm. Frm the emergency rm the patient is admitted directly t the Detxificatin / DRG unit. The patient stays, n average, 3 5 days. Linkage t the next level f treatment is incnsistent. 20

21 New Way If an indicated level des nt exist in the lcal area, the patient shuld be placed in the next higher level f care. Medically mnitred prgrams can be used as a linkage prgram fr patients that are stabilized and d nt require medicatin adjustment (ther than fllwing a taper schedule) r a high degree f medical supervisin. 21

22 Prir t Admissin A Determinatin is Made: Outpatient vs Inpatient Detxificatin An piate dependent patient can be stabilized in the emergency department using buprenrphine and then admitted t: an utpatient detxificatin unit a methadne prgram a private physician t cmplete the piate detxificatin prgram (tapering f buprenrphine and linkage t behaviral treatment) An piate dependent patient can be stabilized in the emergency department and then referred t a methadne prgram fr either methadne r buprenrphine stabilizatin and then detxificatin r maintenance. Which level f inpatient service the 48 hur Observatin bed, Medically Managed level f care r the Medically Supervised bed. 22

23 The patient wh is admitted t the hspital is assessed by a member f the detx medical team: Prir t admissin, At 24 hurs; and again At 48 hurs 23

24 Example #1 28-year-ld man cmes int the emergency rm and requests detx. Alchl use f 2 t 3 six packs per day. He denies ther drug use. He denies significant withdrawal in the past. At present he is in mild withdrawal. He cmes in with his significant ther and lives with her in a safe envirnment. 24

25 The patient shuld be admitted t Outpatient Detxificatin Services if (all required): The patient is able t fllw instructins. The patient has adequate supprt t help manage the utpatient detxificatin prcess. The histry f substance use is reliable. Risk f seizures, hallucinatins, delirium tremens and severe psychiatric disrders are assessed as minimal. Withdrawal screening scres are mildly t mderately elevated (CIWA less than 15, COWS, etc). Mild withdrawal frm sedatives that are nt mixed with alchl. Fr piate withdrawal, buprenrphine, methadne r nn-piate medicatin is assessed as sufficient t adequately treat the withdrawal. If utpatient withdrawal is nt available, then patient can be admitted int a medically supervised bed. 25

26 Example #2 28-year-ld man cmes int the emergency rm and requests detx. Herin use: 4 6 bags per day. He denies ther drug use. At present he is in mild withdrawal after nt using fr 24 hurs. He cmes in with his significant ther and lives with her in a safe envirnment. 26

27 Admit t an utpatient detxificatin service. Admit t a methadne prgram fr stabilizatin and taper r maintenance. Start buprenrphine and hand ff t a: Private physician; Methadne prgram; 822 OASAS utpatient prgram; r Hspital Medical clinic: If appintment available next day; If medicatin can be used; and If linkage can be set up. 27

28 28-year-ld man cmes int the emergency rm and requests detx. Herin use: 4 6 bags per day. He uses ccasinal sedatives He drinks less than a 6 pack per day. He denies significant withdrawal frm all drugs ther than the piates. At present he is in mild withdrawal after nt using fr 24 hurs. Example #3 He cmes in alne. He lives by himself in a mtel. He des nt wrk. He has n available transprtatin. He has n family in the area. 28

29 The patient shuld be admitted t Outpatient Detxificatin Services if (all required): NO The patient is able t fllw instructins. The patient has adequate supprt t help manage the utpatient detxificatin prcess. NO The histry f substance use is reliable. Risk f seizures, hallucinatins, delirium tremens and severe psychiatric disrders are assessed as minimal. Withdrawal screening scres are mild t mderately elevated (CIWA less than 15, COWS, etc). Mild withdrawal frm sedatives that is nt mixed with alchl r ther drugs. Fr piate withdrawal, buprenrphine r nn-piate medicatin is assessed as sufficient t adequately treat the withdrawal. 29

30 The patient shuld be admitted directly int a Medically Supervised Inpatient Level f Service bed (all required): Principal diagnsis reflecting psychactive substance use disrder. Recrd must clearly substantiate the presence f psychactive substance disrder. Patient vluntarily accepts detxificatin services. Patient des nt meet criteria fr medically managed detxificatin service r utpatient detxificatin services. Risk f seizures, hallucinatins, delirium tremens and severe psychiatric disrders are assessed as minimal. Evidence f acute intxicatin r withdrawal symptms, with n evidence f ther changes in mental status. 30

31 The patient shuld be admitted directly int a Medically Supervised Inpatient Level f Service bed (all required): Withdrawal exhibits symptms such as: tremrs, irritability, sweating, change in vital signs (pulse> 100, bld pressure higher than 160/100, temperature higher than 100.9F), anrexia, nausea, vmiting, diarrhea, cramping abdminal pain, gse flesh r tearing. Vital signs are determined t be indicated fr arund the clck mnitring. Plus requires at least ne f the fllwing: Histry f inability t cmply with utpatient detxificatin services; Mild psychiatric symptms present which d nt need an acute psychiatric interventin; Medical disrders d nt require acute interventin; and Hme envirnment des nt supprt utpatient detxificatin. 31

32 Example #4 28-year-ld man cmes int the emergency rm and requests detx. His herin use: 4 6 bags per day. He uses ccasinal sedatives. He drinks 3 6- packs per day. He denies significant withdrawal frm the piates, but is nt sure abut alchl. There is a questin f a seizure in the past. 32

33 Example #5 28-year-ld man cmes int the emergency rm and requests detx. At present he is in withdrawal after nt using fr 24 hurs. Pulse 110, significant tremr, BP 170/110 with mild rthstatic changes. He has nt eaten in 2 days due t diarrhea and vmiting. He cmes in alne, lives by himself in a mtel, des nt wrk and has n family in the area. He has been thrugh inpatient and utpatient detx and rehab ver the last year. Medically he thinks he may have had a high sugar in the past (ER 310 glucse). 33

34 Admissin Criteria t the 48 Hur Bed Admissin requires 1, 2, 3, and 4 plus at least ne ther criterin frm 5 16: 1. Principal diagnsis reflecting psychactive substance use disrder. 2. Recrd must clearly substantiate the presence f psychactive substance disrder. 3. Patient vluntarily accepts detxificatin services. 4. Nature f substance use requires inpatient supervised withdrawal services and there is dcumentatin f the inability t utilize utpatient services. 34

35 Admissin Criteria t the 48 Hur Bed 5. Evidence f acute intxicatin r withdrawal symptms. A. As evidenced by at least ne f the fllwing: 1. Exhibits at least tw withdrawal symptms such as: tremrs, irritability, sweating, change in vital signs (pulse> 100, bld pressure higher than 160/110 r lwer than 90/60, temperature higher than 100.9F), unstable vital signs, CIWAr>15, anrexia, nausea, persistent vmiting, persistent diarrhea, cramping abdminal pain, seizures, gse flesh r tearing. 2. Changes in mental status/ cnfusin/ disrientatin/ stupr 3. Hallucinatins visual, auditry, tactile 4. Severe psychmtr agitatin which is expected t imprve ver the curse f detxificatin 6. Substance induced md disrder with danger t self r thers must specify nature f danger ther than cntinued substance use. 7. Inadequate nutritin that cmprmises bdily functins where family/cmmunity supprt cannt be relied n. 35

36 Admissin Criteria t the 48 Hur Bed 8. Patient is presently suffering frm a significant medical disrder related t substance use that can be managed by the detxificatin service. 9. Patient is presently suffering frm a significant psychiatric r cgnitive disrder (may r may nt be related t the substance use) that can be managed by the detxificatin service. 10. Patient has ther medical disrders that are stated t be dangerus t the patient during detxificatin if nt mnitred (insulin dependent diabetic, hypertensin, COPD, etc). 11.Patient has a prir histry f delirium tremens. 36

37 Admissin Criteria t the 48 Hur Bed 12.Patient has a prir histry f withdrawal seizures under similar circumstances. 13.Frequent vital sign mnitring every 1-2 hurs needed t insure safe withdrawal (assessment and detx medicatin management). 14.Dcumented need fr intravenus fluids t stabilize vital signs r crrect electrlyte abnrmalities. 15.BAC >.30 with limited intxicatin (absence f symptms and signs f intxicatin shwing marked tlerance). 16.Parenteral medicatins fr withdrawal with dcumentatin that patient is unable t tlerate ral fluids and/r medicatins. 37

38 24 Hurs Later The Medical Team member reassesses the patient: Buprenrphine and librium prtcls Intravenus fluids required Vital signs stabilizing Mildly elevated CIWA and COWS Ptassium 3, Glucse 190 Cntinue in 48 hur bed 38

39 At 48 Hurs Des the patient fit the medically supervised level at this time? Des the patient still meet the medically managed (48 hur bservatin bed) criteria? Can the patient be discharged t an utpatient methadne clinic fr cntinued piate taper (buprenrphine r methadne)? Can the patient be admitted t an 822 utpatient prgram and have the buprenrphine slwly tapered (medicatin management prtcls)? Can the patient be admitted t a methadne r 822 t be maintained n the buprenrphine dse? 39

40 AT THE MEDICALLY MANAGED LEVEL OF SERVICE Requires all f the fllwing: Medical therapy which is supervised by a physician (can be carried ut by the medical team) in rder t stabilize the patient s medical cnditin is still indicated; Daily physician attendance is still indicated; Vital signs at least every 6 hurs r mre ften are still indicated; Implementatin f individualized treatment plan is started; and Medicatin administratin (detxificatin medicatins such as Librium) t prevent r mdify withdrawal is still being adjusted and mnitred. 40

41 AT THE MEDICALLY MANAGED LEVEL OF SERVICE Requires at least ne f the fllwing: CIWA greater than 12; Seizures within the past 24 hurs; Delirium tremens within the past 24 hurs; Hallucinatins within the past 24 hurs; Acute interventin needed fr c-ccurring medical disrder; Acute interventin needed fr c-ccurring psychiatric disrder; Severe withdrawal that cannt be handled at a lwer level f care (cntinued vmiting, cntinued diarrhea, abnrmal vital signs) requiring intravenus medicatin and/r fluids; r Pregnancy. 41

42 Once the patient s level f care determinatin is made, the patient stays at that level until discharge Realistically patient culd mve frm MMW t MSW and back t MMW Billing and cding nightmare Fair 42

43 Discharge Criteria fr the Inpatient Medically Managed r Medically Supervised Patient All are required: Patient cntrl and stability is acceptable fr less restrictive treatment. Cmpletin f prescribed treatment. Patient is ff all medicatins that were used fr detxificatin EXCEPT: if the plan is fr the patient t be maintained n buprenrphine r methadne with apprpriate referral; r if the patient has been stabilized n a sedative with apprpriate referral t an utpatient detx service r anther OASAS level f care (inpatient rehab, 822) where the medicatin can be slwly tapered. 43

44 Discharge Criteria fr the Inpatient Medically Managed r Medically Supervised Patient Discharge plan includes: Withdrawal identified as reasn fr admissin is reslved. Other c-ccurring prblems are stable/imprved and fllw up is arranged as necessary. Nursing and scial wrk ntes supprt discharge plans and instructins as utlined in physician s discharge nte. Scial and/r envirnmental supprt exists r can be prvided. Vital signs have nrmalized. Withdrawal screening tl (CIWA, COWS, etc) is nw in nrmal range. Patient is able t maintain ral nutritinal intake. Linkage t the next apprpriate level f care has been cmpleted and dcumented in the chart. 44

45 The Warm Hand-Off The transfer f care frm ne service t anther has been recgnized as key t breaking the cycle f Detx, Detx, Detx. We shuld seek t establish a persnal cntact between ur patient and the next caregiver. A name f wh t ask fr is a minimum and direct cmmunicatin shuld be used if pssible. THINK CONNECTION. 45

46 The Medical Nte The 816 regulatin states: The frequency f prgress ntes shall be based n the cnditin f the patient. In a medically supervised utpatient withdrawal and stabilizatin service, prgress ntes shall be dcumented n less ften than nce per visit; in medically managed, nce per shift, and in all ther withdrawal and stabilizatin services, prgress ntes shall be dcumented n less ften than nce per shift fr the first five days and n less ften than nce per day thereafter. Interpretatin: Applies t nursing and/r cunseling Medical team ntes shuld be at a minimum nce per day 46

47 The Medical Nte What are we lking fr in the nte? IPRO lks at quality and utilizatin: Quality issues lk at the prvisin f safe, effective medical treatment. Utilizatin issues ccur when there is pr dcumentatin f what is being dne (what services are being delivered t justify the present level f care). A nte shuld include: Subjective findings; Objective findings (vital signs, evidence r lack f withdrawal signs and symptms); Interpretatin f the abve; and The plan f actin 47

48 Pearls D what is best fr the patient. Err n the side f safety. Dcument, dcument, dcument. 48

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