CORRECTIONAL HEALTHCARE WEBINAR

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1 1 CORRECTIONAL HEALTHCARE WEBINAR 2 Managing Alcohol Withdrawal in the Correctional Setting February 29, Michelle Foster Earle President OMNISURE CONSULTING GROUP, LLC 401 Congress Ave., Suite 1540 Austin, Texas (800)

2 4 Jeffrey E. Keller, MD, FACEP President, Badger Correctional Medicine Idaho Falls, ID Susan Laffan, RN, CCHP-RN, CCHP-A Correctional Health Care Specialist Toms River, NJ Lorry Schoenly, PhD, RN, CCHP-RN Correctional Healthcare Risk Consultant OmniSure Consulting Group 5 Objectives Describe methods to spot alcohol withdrawal potential during intake screening Outline best practices for patient treatment and patient safety during alcohol withdrawal Evaluate alcohol withdrawal situations to identify risk reduction strategies 6 Disclaimer Risk management support provided by OmniSure Consulting Group, LLC is not intended nor should be construed as the rendition of legal or medical advice, nor intended to replace legal or medical advice. Information provided by OmniSure and our panelists are for illustrative purposes only and is not intended to dictate or replace company policy. OmniSure is a separate risk management consulting firm only, not the insurance company. 2

3 7 Disclosures This educational activity is not commercially supported The planners and presenter have no conflict of interest to declare No off-label use will be discussed by the presenters Criteria for successful completion Attendance for the entire activity Completion of the participant evaluation 8 POLL QUESTION 9 Alcohol Intoxication in Corrections Alcohol implicated in more than half of all incarcerations Over 2/3rds of inmates are substance involved Prison and jail inmates seven times more likely to have a substance disorder than general population 3

4 10 Legal Liability Risks in Alcohol Withdrawal Screening for withdrawal potential Maintaining patient safety Managing withdrawal symptoms Stabilizing complications Seeking tertiary care solutions 11 Case #1 45 year old male arrested on DUI Stated on screening drink a 12 pack beer/day BAC 0.14 The next day he is tremulous and nauseated HR-120 BP-166/96 R-22 T-98.8 Pulse Ox-96% on room air 12 Alcohol Withdrawal: Initial Screening Questions How often do you drink alcohol? How much alcohol do you drink? What type of alcohol do you drink? When was the last time you consumed alcohol? Have you ever had shakes, tremors, or seizures when you stopped using alcohol? 4

5 13 Signs and Symptoms of Alcohol Withdrawal Restlessness, irritability, anxiety, agitation Anorexia, nausea, vomiting Tremors and/or seizure activity Elevated pulse rate, blood pressure and temperature Insomnia, nightmares, intense dreaming Poor concentration, impaired memory and judgment Increased sensitivity to sound, light and tactile sensations Hallucinations: auditory, visual, and tactile Delusions, delirium with disorientation to time/place/person/situation Fluctuation in level of consciousness 14 Alcohol Withdrawal Timeline Time After Last Drink Symptoms Peak 6-12 hrs Tremors, N/V, anxiety, HTN hrs 6-48 hrs Tachycardia, fever, seizures varies hrs Hallucinations varies 3-5 days Delirium Tremens varies 15 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) Standardized Validated Symptom Rating Scale Documents assessment of withdrawal progression Can be used to determine withdrawal treatment 5

6 16 CIWA-Ar Scale: 10 Symptom Categories Nausea and vomiting Auditory disturbances Anxiety Disorientation Tremors Visual Disturbances Agitation Skin temperature Tactile disturbances Headache 17 On-Going Withdrawal Assessments Critical for determining condition changes Comparison over time CIWA-Ar continuation Vital signs an important component Use changing scores to guide care and provider notification 18 Case Study #1 (continued) 12 hours later sent to the medical unit Sweating Tremors noted in arms and legs HR-150 BP-172/104 R-16 T Pulse Ox- 94% on room air 6

7 19 POLL QUESTION Alcohol Withdrawal Treatment Agents Benzodiazepines are the mainstay of the alcohol detoxification Other agents have been used Phenobarbital Carbamazepine Clonidine Benzodiazepine Options No one benzo is proven better than any other Long-acting benzos probably better Valium, Librium have the longest half-lives Ativan, Serax have shorter half-lives, but also can be used Xanax should not be used 7

8 22 Dosage Schedules Fixed Dosage Symptom Triggered Dosage Fixed Dosage Every patient receives the same dose of medication. Extra doses can be given as needed Doses reduced over 3-5 days. Fixed Dosage Schedule Loading Dose: Day One: Day Two: Day Three: Day Four: Valium 20mg Valium 20mg BID Valium 20mg AM 10mg PM Valium 10mg BID Valium 10mg BID 8

9 Fixed Dosage Advantages Simple No scoring needed Best for small jails Disadvantages Many patients will get more than needed Some patients will get less than needed Symptom Triggered Dosage Doses given in response to symptom severity Requires symptom scoring system, like the CIWA-Ar Patients need evaluated at least twice a day Some patients will receive no medication Some patients will receive a lot Symptom Triggered Treatment Assessment Score CIWA-Ar >15 CIWA-Ar 8-15 CIWA-Ar < 8 Treatment Valium 20mg Rescore in 2-3 hours Valium 10mg Rescore in 6 hours No treatment Rescore in 12 hours 3 Consecutive Scores < 8 Done 9

10 Symptom Triggered Treatment Advantages Tailors benzo dose to the patient Less total benzos will be used overall Disadvantages Requires medical personnel to do scoring Medical personnel re-evaluate patients daily Can only be done in jails with medical personnel present Additional Treatment: Vitamin Therapy Thiamine (B-1) Wernicke s encephalopathy Thiamine 100mg PO at onset of therapy Multivitamins One MVI PO daily for 14 days 30 Pause for Thoughts 10

11 31 Case # 2 38 year old female; 7 months pregnant States at intake screening no drug use occasional alcohol use Day 4, observed talking to self and hyperactive Strikes another inmate with a dinner tray causing a laceration Said my baby told me to do it Falls from upper bunk BP-162/102, P-128, R-24, T- 99.7, PO- 96% Refused medication You are trying to poison me! Sent to ED for evaluation and treatment 32 Patient Safety Issues: Seizures Lower tier/lower bunk Clear clutter and non-necessary equipment/furniture Access medical for symptoms or condition change Patient Safety Issues: Hydration and Nutrition 33 Monitored for intake and output Monitor nausea and vomiting Provide extra fluids IV fluids may be needed Monitoring vital signs for hypovolemic shock 11

12 34 Patient Safety Issues: Protection Medical and correctional staff educated De-escalation techniques Recognition in behavior changes Communicating observations Protection for self harm Protection for harm to and from others 35 Patient Safety: Pregnancy Consider both mother and baby in withdrawal management Symptoms that may affect the fetus Nausea & Vomiting Dehydration Hypertension Seizures Patient Safety Issue: Increased Suicidal Risk 36 Mental health issues may emerge in withdrawal process Sobriety increases reality of incarceration Increased Suicide Risk 12

13 Patient Safety Issues: Protective Housing 37 Protective Housing Options Infirmary Medical Observation Unit Mental Health Unit Step-down Medical Unit Special Needs Unit Suicide Watch Cells 38 Case #3 46 year old male - did not sleep last night Talking to the shower head in morning No prior symptoms Admitted to the jail a week ago Denied drug or alcohol use Taking citalopram (Celexa) for depression BP-165/100, HR-136, RR-24, T-99.8 Thinks he is at home- trying to turn on TV 39 Case #3 (Continued) Psychiatric nurse practitioner evaluation On-call psychiatrist Diagnosis: Acute psychosis Haldol Injection Repeated in 4 hours Collapses and dies 8 hours later 13

14 40 POLL QUESTION 41 Delirium vs. Psychosis This patient was not psychotic, he was delirious Delirium: a syndrome of disorientation, confusion and hallucinations caused by a medical condition Untreated Delirium Tremens has a mortality of as much as 30% 42 Delirium vs. Psychosis Alcoholics sometimes lie at booking and deny alcohol Delirium Tremens occurs at day 3-6 Delirium can be mistaken for psychosis because delirious patients act crazy If you think about the diagnosis, delirium can be distinguished from psychosis 14

15 43 Delirium vs. Psychosis Delirium Sudden onset Disoriented Visual hallucinations Sick (abnormal vital signs, look sick) Psychosis No sudden change Oriented No visual hallucinations Not sick 44 Partnering with Security Staff Alcohol Delirium is preceded by: Not sleeping Not eating Pacing Security staff may see these signs where medical personnel may not 45 Pause to Ponder 15

16 Best Practices for Alcohol Withdrawal Management Screen for alcohol withdrawal for all intakes Use a standardized assessment tool to determine withdrawal progression and initiation of treatment Be sure custody and healthcare staff understand symptoms of withdrawal and how to initiate action Have a standardized treatment plan symptom triggered or fixed dose Activate safety measures for withdrawing or potentially withdrawing inmates Send severe cases for higher level monitoring and treatment Case Outcomes Case 1 45 Year Old Male DUI Case 2 7 Month Pregnant Female Case 3 Misdiagnosed delirium 48 Summary Inmates may hide level of alcohol use during intake Consider alcohol withdrawal when evaluating erratic behavior Alcohol withdrawal may not follow a traditional timeline Follow a standard treatment plan involving benzodiazepines, vitamin therapy, nutrition and hydration Take patient safety seriously 16

17 49 Resources CIWA-Ar Form: Bayard, M., McIntyre, J., Hill, K. R., Woodside, J. (2004). Alcohol Withdrawal Syndrome. American Family Physician, 69 (6), Carlson, H. B., Kennedy, J. A. (2006). The treatment of alcohol and other drug withdrawal syndromes in persons taken into custody. In Puisis, M. Ed. Clinical Practice in Correctional Medicine, 2 nd Ed. Philadelphia: Mosby Elsevier. The National Center on Addiction and Substance Abuse at Columbia University. (2010). Behind Bars II: Substance Abuse and America s Prison Population. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from report2010behindbars2.pdf To Receive CE Credit from California Board of Registered Nurses 50 Complete online participant evaluation Link will be provided to download certificate and slide set 51 Correctional Healthcare Risk Reduction Services Quarterly Webinar Series E-New Alerts Mailing List Sign-up 17

18 52 Join Us In San Antonio! NCCHC Updates in Correctional Health Care CSI: Claim Scene Investigation for Risk Reduction Preconference Session Sunday, May 20 1:30pm 5:00pm Michelle Foster, ARM Catherine Knox, MN, RN, CCHP-RN Lorry Schoenly, PhD, RN, CCHP-RN Todd Wilcox, MD, MBA, CCHP-A 53 Next Webinar Containing Infections in Jails and Prisons: Focus on TB and MRSA Wednesday, June 27, pm Central Sue Smith, MSN, RN, CCHP-RN Correctional Nurse Specialist Columbus, OH Lorry Schoenly, PhD, RN, CCHP-RN Correctional Healthcare Risk Consultant OmniSure Consulting Group 54 CORRECTIONAL HEALTHCARE WEBINAR 18

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